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10270644-DS-14 | 10,270,644 | 21,729,328 | DS | 14 | 2152-06-24 00:00:00 | 2152-06-24 18:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Celebrex / prednisone / Codeine / Tetanus Vaccines & Toxoid /
Sulfa (Sulfonamide Antibiotics) / flu vaccine / Indocin /
lactose
Attending: ___.
Chief Complaint:
s/p Fall, Laceration
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ lady hx AFib on Coumadin, CAD, and HTN who
p/w a fall at approx 21:45 ___.
Patient says she was sitting down at her kitchen table and got
up to get her medication when she tripped over the leg of a
chair and fell. She says she wasn't looking where she was going
and landed knees first. She also hit her head against a
bookcase. Denies any LOC, neck pain, or back pain. She uses a
cane at baseline and has to watch where she's going a lot in
order to navigate around safely.
She denies any dizziness, light-headedness, chest pain, dyspnea,
abdominal pain, dysuria or urinary frequency, fevers or chills.
She denies feeling confused at all but she lives by herself. She
has had a couple of other falls down in ___. She now c/o a
headache, ___, throbbing in nature, non-radiating, alleviated
by ice, exacerbated by external pressure.
In the ED initial vitals were: 98.5 70 120/80 18 98% RA
- Labs were significant for h/h 11.0/___, WBC 9.9 with 70.9%
neutrophils, u/a with WBC 25, INR 2.2,
- CT head no acute intracranial process
- knee radiograph without any fractures
- CXR showed mild pulmonary edema with moderate cardiomegaly
- Patient with chills in the ED
- Patient was given ctx and morphine and admitted to medicine
for observation given age and comorbidities
Vitals prior to transfer were: 98.6 91 136/61 18 96% RA
On the floor, initial VS were 98.1 132/57 84 97% RA. She was no
longer complaining of any pain and stated the morphine really
helped.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
ATRIAL FIBRILLATION
CORONARY ARTERY DISEASE w/ normal EF
HYPERTENSION
VALVULAR HEART DISEASE
OBESITY
OBSTRUCTIVE SLEEP APNEA not on CPAP
ANEMIA
OSTEOARTHRITIS
SKIN CANCERS
BILATERAL CATARACTS s/p bilateral lens implants
MACULAR DEGENERATION
VITAMIN D DEFICIENCY
HYPERLIPIDEMIA
B KNEE OA
H/O CONCUSSION
Social History:
___
Family History:
Bleeding disorder of unknown type in son and daughter. Father
stroke in his ___. Rheumatoid arthritis in sister. MI in aunt.
Physical Exam:
ADMISSION EXAM:
Vitals - T 98.1 BP 132/57 HR 84 O2 97% RA
GENERAL: elderly woman lying in bed, NAD
HEENT: bandages around forehead, clean and dry, left eye with
significant periorbital ecchymoses and lid edema, MMM
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: 2+ peripheral edema bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ upper and lower extremity,
sensation intact lower extremities
SKIN: scattered echymoses over lower extremities
DISCHARGE EXAM:
Vitals- T 98.1 BP 132/57 HR 95 O2 18 95% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, no subconjuntival hemorrhage, the left
pupil is lengthened, has bandages around forehead, clean and dry
with just some mild bleeding at site of stitches, left eye with
significant periorbital ecchymoses and lid edema, MMM,
oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Irregular rate and rhythm, with ___ murmur
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, swollen legs bilaterally
with 1+ pitting edema to thigh, chronic venous stasis changes in
lower legs, no cords or calf tenderness
Neuro- CN II-XII intact, strength ___ upper, ___ in lower
extremities, sensation intact lower extremities
Skin- scattered echymoses over lower extremities
Pertinent Results:
ADMISSION LABS:
___ 11:02PM ___ PTT-35.0 ___
___ 11:02PM NEUTS-70.9* ___ MONOS-7.1 EOS-1.0
BASOS-0.4
___ 11:02PM WBC-9.0 RBC-4.02* HGB-11.9* HCT-38.0 MCV-95
MCH-29.5 MCHC-31.3 RDW-14.0
___ 11:02PM GLUCOSE-137* UREA N-14 CREAT-0.9 SODIUM-142
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-31 ANION GAP-13
DISCHARGE LABS:
___ 11:45AM GLUCOSE-152* UREA N-11 CREAT-0.8 SODIUM-139
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-32 ANION GAP-12
___ 11:45AM CALCIUM-9.1 PHOSPHATE-3.1 MAGNESIUM-2.0
___ 11:45AM WBC-9.9 RBC-3.69* HGB-11.4* HCT-34.9* MCV-95
MCH-30.9 MCHC-32.7 RDW-13.8
___ 11:45AM ___ PTT-35.6 ___
MICROBIOLOGY:
___ 02:50AM URINE RBC-1 WBC-25* BACTERIA-FEW YEAST-NONE
EPI-2
___ 02:50AM URINE BLOOD-NEG NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG
___ 02:50AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ Urine Culture: Pending
IMAGING:
Bilateral Xray knee: (___)
IMPRESSION:
No acute fracture seen. Small joint effusion on the right.
___ CXR:
IMPRESSION: Moderate cardiomegaly with mild pulmonary vascular
congestion.
___ CT head:
IMPRESSION: No acute intracranial abnormalities identified.
ON DISCHARGE:
___ 11:45AM BLOOD WBC-9.9 RBC-3.69* Hgb-11.4* Hct-34.9*
MCV-95 MCH-30.9 MCHC-32.7 RDW-13.8 Plt ___
___ 11:45AM BLOOD Glucose-152* UreaN-11 Creat-0.8 Na-139
K-3.8 Cl-99 HCO3-32 AnGap-12
___ 11:45AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.0
___ 11:45AM BLOOD ___ PTT-35.6 ___
Brief Hospital Course:
ID: ___ yo woman with h/o afib, CAD, htn, and HLD who presents
with mechanical fall and facial laceration.
ACTIVE ISSUES:
#Fall: Given patient's baseline weakness and decreased mobility
(osteoarthritis and uses cane at home to ambulate) as well as
decreased night vision with cataracts, her fall was believed to
be mechanical. Patient completely recalled event and denied any
dizziness, lightheadedness, confusion or LOC, making syncopal
event unlikely. At baseline, patient ambulates independently
with cane. ___ evaluated the patient and felt that she was safe
for discharge home with home ___ and rolling walker.
#Head strike/ facial laceration: Patient reported head strike
with nearby shopping cart. No loss of consciousness or mental
status changes. CT Head showed no intracranical hemorrhage or
fracture. She was noted to have decreased Hgb 11.9 (baseline
13.1), but had no evidence of ongoing hemorrhage. Her INR on
admission was 2.2. Her pain was well controlled on Tylenol.
#Pyuria: Patient was noted to have pyruia on UA. She received 1
dose of ceftriaxone in the ED. She denied any dysuria or
hematuria. She did endorse occasional increased frequency
although this was in the setting of lasix use. Her pyuria most
likely represented assymptomatic bacturia and she did not
receive any additional antibiotics.
#CAD: Patient with nonobstructive disease from prior cardiac
cath and normal EF in echo from ___ (per cardiology notes). On
this admission, found to have mild pulmonary edema on CXR and
lower extremity swelling, but edema is baseline per patient and
she has no dyspnea, JVD elevation, or crackles on exam. No
orthopnea or PND or dyspnea on exertion at home.
#Chronic venous insufficiency: She was noted to have ___
pitting edema in her lower extremities, which is baseline per
pt. She was continued on her home lasix and compression
stockings.
CHRONIC ISSUES:
#Afib: CHADS2 score of 2 (age, hypertension). She was continued
on her outpatient warfarin dose. Her INR on day of discharge was
2.0. She was continued on her home atenolol and diltiazem
(switched to short-acting while inpatient).
#HLD: She was continued on her home atorvastatin.
#Bilateral knee pain: The patient complained of bilateral knee
pain on admission. Bialteral knee x-rays showed no acute
fracture and small R knee effusion.
TRANSITIONAL ISSUES:
[] Pt with have home ___
[] Please assess for signs and symptoms of possible UTI given
pt's history of frequency
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diphenoxylate-Atropine 1 TAB PO HS:PRN diarrhea
2. Atenolol 75 mg PO DAILY
3. Diltiazem Extended-Release 300 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU QHS
5. Warfarin 3 mg PO 5X/WEEK (___)
6. Warfarin 1.5 mg PO 2X/WEEK (MO,TH)
7. Atorvastatin 10 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. potassium chloride 10 mEq oral daily
10. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
Discharge Medications:
1. Atenolol 75 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU QHS
4. Furosemide 40 mg PO DAILY
5. Warfarin 1.5 mg PO 2X/WEEK (MO,TH)
6. Diltiazem Extended-Release 300 mg PO DAILY
7. Diphenoxylate-Atropine 1 TAB PO HS:PRN diarrhea
8. potassium chloride 10 mEq oral daily
9. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
10. Warfarin 3 mg PO 5X/WEEK (___)
11. Acetaminophen 650 mg PO TID
do not take more than 4 g per day
12. rolling walker
Diagonosis: Osteoarthritis ICD 9 715.9
Prognosis: good/excellent
Length of needs: lifetime
Reason why pt needs: ambultation
what: rolling walker
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary:
Mechanical Fall
Asymptomatic pyruia
Secondary:
CAD
Afib
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted for a fall believed to be caused by
mechanical tripping. You were evaluated by physical therapy who
felt that you were safe to go home and recommended walking with
the assistance of a stardard rolling walker. Please remember to
keep your appointments. Your urine had bacteria in it. Given
that you did not have any burning or pain when you urinated, we
decided to not continue antibiotics. When you follow up with
your primary care doctor, please be sure to let them know if you
develop any of these symptoms.
Followup Instructions:
___
|
10270706-DS-12 | 10,270,706 | 21,972,631 | DS | 12 | 2161-04-14 00:00:00 | 2161-04-15 19:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypoglycemia
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
Ms ___ is an ___ year old ___ speaking female, who
presents from ___ (nursing home) for
hypoglycemia.
Around noon on day of admission, staff at her nursing home
noticed she had become less responsive and was unable to move
her extremities. Finger stick was 96. She had just been
administered SC heparin for DVT prophylaxis. Given concern for
a stroke, paramedics were called. When they arrived, her
glucose was apparently low and glucagon was administered. An IO
was placed in the left leg and an amp of D50 was administered.
She was brought to the ED, where blood sugar was noted to be 16.
She received another amp of D50. Glucose improved transiently
but again came down to 40. Intravenous dextrose (D10W) was
started. She had improvement, but several additional
hypoglycemic episodes.
Her white count was noted to be 15,000, and a lactate was 4.0.
Her blood pressure remained normotensive. Her temperature was
99.6. She had a CT head and abdomen/pelvis which revealed no
infectious focus. She does have ulcers of dorsum of both lower
extremities which were treated with keflex 2 weeks prior; these
are dry and non-seeping. Recently she also had a diagnosis of
DVT after a hospitalization in ___ for left hip fracture,
for which an ORIF was performed. She was started on coumadin
and completed a course of coumadin on ___. Since then, she
has been transitioned to SC heparin for prophylaxis. There is
no history of hypoglycemia prior to this episode; she has no
known history of diabetes; there is no reason to suspect
surreptious insulin use. She does not use ___ herbal
medications. She denies dry skin, fevers, changes in bowel
movements. She has lost 10 lbs of weight while at the nursing
home following the hip fracture and surgery. Review of systems
otherwise negative.
Endocrine was consulted who recommended several lab tests,
include C-peptide, sulfonylurea level, beta-hydroxybutyrate.
She was admitted to the MICU given her recurrent hypoglycemia
for management and further workup. At time of transfer, her
vitals revealed a HR of 88, a temp of 99.6, SaO2 of 98% on RA.
Past Medical History:
Dementia
Hypertension
GERD
Osteoporosis
Ulcers on Dorsi of feet
left hip ORIF ___ c/b DVT
Social History:
___
Family History:
NC
Physical Exam:
On admission:
HR 85, BP 150/70, RR 12, 98% RA, RR 12
In General, she is an active, alert ___ female, who is
oriented to person, but is unaware why she is in the hospital.
She has an underlying diagnosis of dementia, but is able to
answer questions pleasantly and appropriately via her
grand-daughter, who interprets. Occasionally she is agitated.
Cardiovascularly, she has a normal JVP, with a normal rate and
regular rhythm.
Pulmonary exam reveals clear lungs bilaterally.
Abdomen is soft, nontender, and nondistended with normoactivel
sounds and no palpable masses.
Extremity exam is remarkable for subacute dorsal ulcers on both
feet that are black and non-seeping, and dry.
Discharge PE:
PE:
VS: 98.7 131/83 (110-130/74-82) 79 (79-86) 20 98RA FSG 106-148
General: well appearing, eldery ___ female
CV: SEM loudest at USB, RRR, S1 S2
lungs: clear to auscultation b/l, good air movement, no wheezes,
rhonchi, crackles
abdomen: soft, nontender, nondistended, +BS
extremities: dry ___, no ___ edema, 2+ DP pulses
feet: dorsal ulcers on both feet; black scab now peeling off
with remnants of collagenase seen, no purulence noted
Neuro: moving all extremities spontaneously, able to follow
commands
Pertinent Results:
Admission labs:
___ 01:40PM BLOOD WBC-14.6* RBC-3.87* Hgb-11.5* Hct-36.4
MCV-94 MCH-29.6 MCHC-31.5 RDW-14.1 Plt ___
___ 01:40PM BLOOD Neuts-90.8* Lymphs-5.4* Monos-3.6 Eos-0.2
Baso-0.1
___ 01:40PM BLOOD Plt ___
___ 12:21AM BLOOD ESR-95*
___ 03:41AM BLOOD ESR-85*
___ 01:40PM BLOOD Glucose-99 UreaN-18 Creat-0.6 Na-142
K-4.2 Cl-106 HCO3-23 AnGap-17
___ 01:40PM BLOOD ALT-19 AST-30 AlkPhos-124* TotBili-0.3
___ 01:40PM BLOOD Albumin-3.9 Calcium-9.6 Phos-3.4 Mg-2.2
___ 12:21AM BLOOD %HbA1c-5.5 eAG-111
___ 12:21AM BLOOD TSH-0.16*
___ 03:41AM BLOOD Free T4-1.3
___ 12:21AM BLOOD Cortsol-9.9
___ 03:41AM BLOOD CRP-54.7*
Discharge labs:
___ 07:50AM BLOOD WBC-6.4 RBC-4.33 Hgb-12.6 Hct-41.4 MCV-95
MCH-29.1 MCHC-30.5* RDW-14.4 Plt ___
___ 07:50AM BLOOD ___ PTT-31.2 ___
___ 07:50AM BLOOD Glucose-132* UreaN-17 Creat-1.1 Na-139
K-4.6 Cl-108 HCO3-19* AnGap-17
___ 07:50AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.2
___ 03:41AM BLOOD PROINSULIN-PND
___ 07:20PM BLOOD C-PEPTIDE-PND
___ 07:20PM BLOOD SULFONAMIDES-PND
___ 07:20PM BLOOD INSULIN-PND
___ 07:20PM BLOOD BETA-HYDROXYBUTYRATE-Test Name
___:
Plain films of feet:
FINDINGS: AP, lateral, and oblique views of the feet are
obtained. There are mild degenerative changes. There are no bony
erosions to suggest
osteomyelitis or periostitis. However, bone scan or MRI would be
more
sensitive for this finding if clinically indicated.
Studies:
CT head
IMPRESSION: No evidence of acute intracranial process.
CT abd/pelvis:
IMPRESSION:
1. No evidence of acute intra-abdominal process based on this
somewhat
limited exam.
2. Significant fecal loading extending all the way to the
rectum.
3. Compression fracture of L3 of unknown age.
CT abdomen/pelvis:
IMPRESSION:
1. No evidence of acute intra-abdominal process based on this
somewhat
limited exam.
2. Significant fecal loading extending all the way to the
rectum.
3. Compression fracture of L3 of unknown age.
CT head:
IMPRESSION: No evidence of acute intracranial process.
Plain films pelvis:
IMPRESSION: Status post ORIF of a left proximal femoral fracture
without
evidence of hardware complications. No new acute fracture noted.
CXR:
IMPRESSION: Mild retrocardiac atelectasis.
Brief Hospital Course:
___ year old ___ female with acute, recurrent hypoglycemia in
the setting of leukocytosis, lactatemia, low grade temperatures,
and potential infectious focus.
# Hypoglycemia: Pt presented from nursing home with severe
hypoglycemia to ___. Despite several doses of D50 blood sugars
remained ___ at ED. She does not have history of DM, does
not take insulin or hypoglycemic agents, and does not have
history of hypoglycemia. She was started on D10 drip which was
continued in ICU untiil sugars were consistently in 100s. Drip
was stopped and sugars remained in normal range. She was
tolerating po without difficulty. Endocrine was curbsided in ED
who recommended sending pro-insulin, sulfonylurea, C-peptide,
beta-hydroxybutyrate levels. TSH and cortisol were checked
given concern for panhypopituitarism. AM cortisol was wnl; TSH
was low but free T4 within normal range. There was some
suspicion that she ___ have accidentally been administered
insulin at rehab, which the rehab denied. Possible infectious
causes were investigated but CXR and U/A were unremarkable.
Blood cultures were sent, which are both no growth to date. EKG
was unremarkable. Only possible source of infection were ulcers
on dorsum of both feet which were treated per below.
While on the floor, the patient's blood sugars were checked
every four hours initially, then spaced out to q8h. The patient
maintained her sugars between 85-200. After discharge, it was
found that the patient's c-peptide levels were elevated. The
patient's grand daughter and the patient's PCP were both
contacted, as there is concern that the patient ___ have an
insulinoma. The patient was scheduled for an appt to see an
endocrinologist at ___ on ___. The patient's grand
daughter was cautioned re: the signs and symptoms of
hypogylcemia and instructed to give the patient juice and
immediately bring her to the ED for evaluation.
# leukocytosis: The patient presented with an elevated white
count and lactate; an ifectious work-up was negative, except for
the ulcers on her feet b/l (see below). It was thought that her
white count could have been due to hypoglycemic state. She was
ultimately started on bactrim/keflex for presumed cellulitis.
However, on transfer to the floor, the decision was made to d/c
antibiotics, as the patient remained afebrile. The patient is
also s/p ORIF--> there was a thought of posisbly having infected
hardware in the setting of elevated CRP/ES; however, plain film
of the hip was negative for any acute hardware complications.
Her CRP and ESR should be repeated as an outpatient.
# Cellulitis: Pt had an ulcer on dorsum of each feet with dried
blood; no active purulent draiange. While in the MICU, it was
noted that the surrounding skin was erythematous and warm to
touch. After lactate had normalized, she was started on bactrim
and keflex for cellulitis. Inflammatory markers (ESR, CRP) were
checked which were elevated.
While on the floor, the patient was seen by podiatry who
recommended wet to dry dressing for the R ulcer, and collagenase
for ulcer. A plain film of her feet were both negative for
osteomyelitis or any fractures. Because the patient was
afebrile with white count normalizing, the patient's antibiotics
were discontinued. It was thought that her initial elevated
white count could be a stress response to the state of
hypoglycemia.
.
# foot ulcers: While in the MICU, it was initially thought there
was some surrounding erythema that could be consistent with
cellulitis around each foot ulcer, and the patient was started
on Bactrim/Keflex. On the floor, the patent had plain films of
her feet which were normal. Podiatry was consulted and
recommended collagenase to the L ulcer and wet to dry dressings
to the R foot ulcer. Ultimately, the patient's Bactrim/Keflex
were both stopped.
.
# Dementia: The patient was continued on her home exelon.
.
# Osteoporosis: The patient is s/p hip fracture complicated by
DVT s/p 3 months of coumadin. The patient was continued on
heparin SC while in patient, as well as calcium and Vitamin D.
# HTN: The patient is on lasix at home. While in house the
patient's Lasix was held. She was instructed to restart her
Lasix as an outpatient. This should also be followed up as an
outpatient.
Transitional Issues:
- The patient was found to have an elevated C-peptide, which
suggests that there was endogenous insulin secretion; she will
have to have an endocrine evaluation, including imaging, to
assess for an insulinoma. The patient's PCP was contacted with
this information, as was the patient's grand daughter ___.
The patient was made a follow-up appt with ___ for further
work up of this insulinoma on ___. The patient's
granddaughter was also cautioned about the signs/symptoms of
hypoglycemic events and that fast administration of sugar is
necessary, as well as immediately calling an ambulance and
bringing the patient to the emergency room for evaluation.
- The patient will need to have a CRP/ESR repeated as an
outpatient.
- The patient is not currently on a bisphosphonate in the
setting of her recent hip fracture. This is something that
should be followed up as an outpatient.
Medications on Admission:
Enlive 198 ml BID
heparin SC TID
calcium with Vit D 600mg/200IU
docusate 100 mg BID
rivastigmine 3 mg BID
senna 2 tabs BID
oxycodone 10 mg TID
lasix 20 mg daily
Discharge Medications:
1. Enlive Liquid 0.037-1.04 gram-kcal/mL Liquid Sig: One Hundred
___ (198) mL PO twice a day.
2. Caltrate 600 + D 600 mg(1,500mg) -400 unit Tablet, Chewable
Sig: One (1) Tablet, Chewable PO once a day.
3. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
4. rivastigmine 3 mg Capsule Sig: One (1) Capsule PO twice a
day.
5. senna 8.6 mg Tablet Sig: Two (2) Tablet PO twice a day.
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. collagenase clostridium hist. 250 unit/g Ointment Sig: One
(1) Appl Topical DAILY (Daily): please apply to L foot ulcer.
Disp:*1 tube* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnosis:
hypoglycemia
dementia
secondary diagnosis:
status post hip fracture
history of deep vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you while you were hospitalized
at ___. You were admitted to the hospital because you were
found to have a low blood sugar. We gave you fluids to help
increase the levels of sugar in your blood.
We also initially gave you some antibiotics for the ulcers on
your feet. However, because you were doing well, we decided to
stop these antibiotics.
The physical therapists also evaluated you and recommended
___ hour care at home.
We made the following changes to your medications:
START collagenase once daily to left foot ulcer
STOP oxycodone for pain control
Please follow up with both your primary care doctor and the feet
specialists (podiatrists). Please see below for your
appointments.
Followup Instructions:
___
|
10270870-DS-16 | 10,270,870 | 20,855,253 | DS | 16 | 2129-04-08 00:00:00 | 2129-04-08 16:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old right handed man with history of
HTN, HLD, DM II, aortic stenosis s/p porcine valve, CAD s/p DES
who presents as a code stroke for an episode of vertigo and
abnormal vision. Patient was in his usual state of health until
4:30pm this afternoon. He was watching a movie when suddenly,
his vision was "off." He has difficulty describing it, but says
it was not blurry, no diplopia, but seemed "out of focus" and
lasted seconds. He then stood up and felt nauseous, did not
vomit. Also, had a dizzy sensation, sort of like the room was
spinning, more on the left side of him. Felt like his balance
was off, was falling more to the left. This sensation lasted
several minutes, and then he returned to baseline. He is not
sure if closing his eyes improved the dizziness as he did not
try it. Did not have any dysarthria, word finding difficulties,
focal weakness or numbness with this. As Mr. ___ was back
to baseline, he proceeded with his plans to go out for dinner
with his girlfriend. At dinner, he had several more episodes of
dizziness, imbalance but not as severe as the initial episode.
He did not have nausea, vision changes with these. He is not
sure how many episodes he had. Mr. ___ then decided to go
the to ED.
Today, he was at home with air conditioner in the heat and was
hydrating well (drank ___ cups of fluids). He denies any recent
URI, fevers. Did have a mild frontal headache briefly which
resolved. Of note, in the past, patient has had vertigo. This
was ___ years ago in the setting of ?otitis media. However,
then, the symptoms were much more severe.
On neuro ROS, the pt denies headache, diplopia, dysarthria,
dysphagia, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention.
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 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:
-Aortic stenosis s/p Aortic valve replacement, 23 mm ___
___ ___ (Porcine valve)
-Coronary artery disease, s/p RCA drug eluting stent in ___
-Type II Diabetes mellitus
-Dyslipidemia
-Obesity
-Sleep Apnea
-GERD
-Hearing Loss L ear
-osteoarthritis left knee
-left rotator cuff repair 3 months ago
Social History:
___
Family History:
father with CAD, died at ___
mother with breast cancer
Physical Exam:
Admission Physical Exam:
Vitals: T 98.1 HR 63 BP 165/51 RR 18 O2 97% 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. No left/right
confusion. 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. Pronation of left upper
extremity.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4* ___ ___ 5 5 5 5 5 5-
R 5 ___ ___ 5 5 5 5 5 5-
*pain limited, rotator cuff repair surgery 3 months ago
-Sensory: No deficits to light touch, cold sensation,
proprioception throughout. Mildly decreased sensation to pin
prick in lower extremity to mid shin on left. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally. Mildy slow on finger tapping on the left, mild
dysmetria on heel to shin on the left.
- ___: negative, unable to reproduce symptoms
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem with difficulty. Romberg present,
falls to the left.
Discharge physical exam: on further examination, it appears that
the pronator drift on the L arm is not enough to be significant,
and the patient does have some slight decreased ability to
finger tap on the L side, but it seems to be related to a recent
L shoulder injury. exam otherwise unchanged
Pertinent Results:
ADMISSION LABS
___ 07:55AM GLUCOSE-106* UREA N-18 CREAT-0.9 SODIUM-141
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-28 ANION GAP-15
___ 07:55AM ALT(SGPT)-23 AST(SGOT)-27 ALK PHOS-40
___ 07:55AM CALCIUM-9.4 PHOSPHATE-4.0 MAGNESIUM-2.0
CHOLEST-142
___ 07:55AM %HbA1c-6.4* eAG-137*
___ 07:55AM TRIGLYCER-152* HDL CHOL-43 CHOL/HDL-3.3
LDL(CALC)-69
___ 07:55AM WBC-7.3 RBC-4.92 HGB-14.7 HCT-42.2 MCV-86
MCH-29.9 MCHC-34.9 RDW-13.7
___ 07:55AM PLT COUNT-214
___ 11:50PM URINE HOURS-RANDOM
___ 11:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 11:50PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 10:15PM GLUCOSE-79 NA+-141 K+-3.8 CL--95* TCO2-32*
___ 10:14PM CREAT-1.2
___ 10:14PM estGFR-Using this
___ 10:10PM UREA N-21*
___ 10:10PM WBC-10.4 RBC-5.19 HGB-15.6# HCT-44.9 MCV-87
MCH-30.1 MCHC-34.7 RDW-13.8
___ 10:10PM PLT COUNT-255
___ 10:10PM ___ PTT-33.5 ___
CTA head ___
No acute infarct or vessel cut off identified. Mild plaque at
the carotid bifurcations without hemodynamically significant
stenosis bilaterally.
CXR ___
No acute cardiopulmonary process.
MRI head ___
read pending at time of discharge. My read: no stroke
Echo ___
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). There is no ventricular septal defect. Right ventricular
chamber size and free wall motion are normal. A bioprosthetic
aortic valve prosthesis is present. The aortic valve prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular gradients. No masses or vegetations are seen on
the aortic valve, but cannot be fully excluded due to suboptimal
image quality. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: No cardiac source of embolism seen. Cannot exclude
thrombus on AVR. Normal global and regional biventricular
systolic function. Negative bubble study.
Brief Hospital Course:
Mr. ___ is a ___ year old right handed man with history of
HTN, HLD, DM II, aortic stenosis s/p porcine valve, CAD s/p DES
who presents as a code stroke for an episode of vertigo and
abnormal vision. Patient had an episode of sudden onset "out of
focus" vision and room spinning sensation and nausea. He also
felt like he was falling to the left. This resolved after
several minutes but then he had several less severe episodes
over the evening. Initially, a code stroke was called, but
symptoms had occured 5.5 hours ago so not in the tPA time
window. Also, symptoms were resolved. On exam, he had some L
sided slower finger tapping, which could be due to rotator cuff
injury. No nystagmus. However, given large amount of stroke risk
factors and age, got MRI to rule out cerebellar stroke.
MRI showed no stroke on my read (final read pending at time of
DC). A1C was well controlled at 6.4, and LDL was well controlled
at 69. Aspirin was initially increased to 325, but when MRI
showed no stroke, it was decreased back to home dose of 162.
Metoprolol was continued in house, but lisinopril and
amplodipine were initially held in case of stroke. Since there
was no stroke, these were continued at time of DC. Orthostatic
vital signs were checked while the patient was in house, and
were negative. However, since he was not taking his full BP
regimin at the time, we recommend rechecking orthostatics as an
outpatient.
The patient also complained of some leg cramping with walking
concerning for possible claudication, so we recommend outpatient
vascular studies / ankle brachial index testing to assess for
peripheral artery disease.
No events were seen on tele in house. However, if symptoms
recur, we recommend considering a heart monitor (Holter) as an
outpatient.
The patient was asymptomatic at time of DC, without recurrent
dizziness.
Code Status: full
TRANSITIONAL ISSUES
- final MRI read pending at time of DC
- follow up with PCP and ___
- recommend vascular studies of legs as outpatient to assess for
claudication
- recommend repeating orthostatic VS as outpatient when on full
BP regimin
- if symptoms recur as outpatient, consider Holter monitor
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 162 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO BID
4. Amlodipine 10 mg PO DAILY
hold for SBP < 100
5. Famotidine 20 mg PO BID
6. Lisinopril 10 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Rosuvastatin Calcium 40 mg PO DAILY
9. GlipiZIDE 10 mg PO BID
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Nitroglycerin SL 0.4 mg SL PRN angina
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 162 mg PO DAILY
3. Famotidine 20 mg PO BID
4. Fish Oil (Omega 3) 1000 mg PO BID
5. GlipiZIDE 10 mg PO BID
6. Lisinopril 10 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Rosuvastatin Calcium 40 mg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Nitroglycerin SL 0.4 mg SL PRN angina
11. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
1. dizziness
Secondary diagnosis
1. hypertension
2. coronary artery disease status post stent placement
3. history of aortic stenosis with porcine heart valve in place
4. type 2 diabetes
5. hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted for dizziness to rule out a
stroke. MRI of your brain did not show a stroke. Echo of your
heart was normal.
It is important that you keep all follow up appointments, and
take all medications as prescribed.
Followup Instructions:
___
|
10271044-DS-12 | 10,271,044 | 25,590,216 | DS | 12 | 2126-09-26 00:00:00 | 2126-09-26 14:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
morphine
Attending: ___
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
___ lumbar puncture
Mechanical intubation
History of Present Illness:
Mr. ___ is a ___ right-handed man with history
notable for HTN, HLD, NIDDM, OSA (on CPAP), hypothyroidism, and
osteoarthritis s/p bilateral TKR presenting with several
episodes of confusion and speech disturbance.
Mr. ___ family reports first noticing increasing
lethargy over the past week, which has progressed gradually
without clear exacerbations, and has been associated with
decreased oral intake. Subsequently, while on a drive to ___
with his son yesterday, Mr. ___ was noted to have a
thirty-minute period of somnolence and speech disturbance. His
son notes that Mr. ___ was "coming in and out" of
wakefulness and had "garbled" speech, largely due to changes in
pronunciation rather than using new or incomprehensible words;
no
adventitious movements or urinary incontinence were noted,
though he was noted to favor leaning to his left. Following this
episode, Mr. ___ reportedly returned rapidly to his
recent baseline, without worsened lethargy than prior to the
episode. On returning home in the evening, Mr. ___ was
again felt to be at his baseline with normal speech. Mr.
___ himself has
some recollection of this episode, recalling that he "came in
and out" of wakefulness while in the car.
This morning, Mr. ___ wife woke up to find him
downstairs, dressed as usual with normal speech; however, Mr.
___ reported a sense of malaise, prompting his wife to
take him to urgent care. There, at about 11:00, he was noted to
become abruptly confused, and had an episode of (loose) fecal
and
urinary incontinence while being helped to the restroom; he was
noted to be abnormally unperturbed by this development. Mr.
___ recalls this episode, noting that he felt the urge to
void, but was ultimately unable to continue to control it.
During this period, he was also noted to be rapidly picking away
at unseen objects on his person, and at times was again leaning
to
his left. Overall, Mr. ___ wife notes that he would
have periods of ___ seconds of unresponsiveness followed by up
to 10 minutes of confusion and speech disturbance during this
period, similar to timing described by his son from the day
prior.
As Mr. ___ was previously noted to have an episode of
confusion and lethargy with lithium toxicity, he was thus
referred to the ___, where he had a lithium level of
1.04 with otherwise unremarkable laboratory testing (aside from
positive urine toxicology for opioids, which he is prescribed).
He also underwent NCHCT and CXR which were unremarkable. Mr.
___ family noted that he returned to his baseline
mental status around 15:30, but again felt that he became more
confused around 17:00, again picking at unseen objects. As a
result, Mr. ___ was transferred to ___ for further
evaluation. Of note, in the ___ ED, he was noted to have a
FSBG of 59, for
which he received 25 g dextrose; he was not found to be
hypoglycemic at ___.
Mr. ___ himself partially recalls the above episodes,
noting periods of decreased alertness as well as a sensation of
worsening of his chronic bilateral upper extremity tremors. He
denies a sensation of déjà ___, jamais ___, dysgeusia, dysosmia,
or sense of derealization. He denies similar episodes in the
past.
On review of systems, aside from the above, Mr. ___
denies recent dizziness, vertigo, vision change, diplopia,
hearing change, dysarthria, dysphagia, focal weakness,
paresthesiae, gait disturbance, fevers, nausea, vomiting, chest
discomfort, abdominal pain, or changes in bowel or bladder
habits. He did note chills with possible subjective fevers ___
nights ago.
Past Medical History:
HTN
HLD
NIDDM
OSA (on CPAP)
Hypothyroidism
Osteoarthritis s/p bilateral TKR
Social History:
___
Family History:
No family history of seizures or neurologic disorders.
Physical Exam:
ADMISSION EXAM:
===============
Vitals: T: 98.7 P: 71 R: 18 BP: 166/88 SpO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple
Pulmonary: No tachypnea or increased WOB
Cardiac: Warm, well-perfused
Abdomen: Soft, distended.
Extremities: BLE venous stasis dermatitis, edema.
Neurologic:
-Mental Status: Alert, oriented to place though reported date as
___ Somewhat inattentive, naming DOWB with some
difficulty (___), and unable to name ___.
Language is otherwise fluent with intact naming and
comprehension
though with noticeable labial dysarthria. Able to follow both
midline and appendicular commands. No apparent hemineglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2 mm ___. EOMI without nystagmus.
VFF
to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: No pronator drift bilaterally. Symmetric, BUE postural
tremor with outstretched hands.
Delt Bic Tri WrE FFl FE IP Quad Ham* TA
L 5 5 4+* ___ 5 5 4+ 5
R 5 5 5 ___ 5 5 4+ 5
*Pain-limited.
-Sensory: No deficits to light touch or cold sensation
throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
-Coordination: Action tremor without dysmetria on FNF
bilaterally.
-Gait: Deferred.
DISCHARGE EXAM:
===============
Temp: 97.8 (Tm 98.4), BP: 149/90 (131-153/80-90), HR: 78
(66-91), RR: 18 (___), O2 sat: 98% (98-100), O2 delivery: RA
Exam
General: Obese man supine in bed, NAD
HEENT: NC/AT
Pulmonary: comfortable on RA
Cardiac: RRR, no m/r/g
Abdomen: soft, obese, non-tender
Extremities: WWP, no C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-MS: awake, alert. Oriented to self, ___, hospital, date.
Able
to give some history. Speech is fluent with moderate dysarthria.
-CN: PERRL, 3>2 b/l. EOMI, no nystagmus. No facial droop. Tongue
midline. Unable to see palate. Dysarthria stable.
-Motor: Normal bulk and tone. No pronator drift. No tremor or
asterixis. Moves all four limbs antigravity, deferred focal
motor
testing.
-Sensory: Deferred
-Reflexes: Deferred
-Coordination: mild dysmetria on FNF, L>R
-Gait: deferred
Pertinent Results:
ADMISSION LABS:
===============
___ 06:05PM LACTATE-1.4
___ 05:45PM GLUCOSE-105* UREA N-8 CREAT-1.2 SODIUM-151*
POTASSIUM-4.3 CHLORIDE-120* TOTAL CO2-21* ANION GAP-10
___ 05:45PM CALCIUM-8.7 PHOSPHATE-1.6* MAGNESIUM-1.8
___ 05:45PM WBC-9.1 RBC-3.67* HGB-11.0* HCT-34.7* MCV-95
MCH-30.0 MCHC-31.7* RDW-14.3 RDWSD-49.1*
___ 05:45PM NEUTS-89.3* LYMPHS-5.0* MONOS-4.6* EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-8.14* AbsLymp-0.46* AbsMono-0.42
AbsEos-0.00* AbsBaso-0.01
___ 05:45PM PLT COUNT-104*
___ 05:45AM URINE HOURS-RANDOM
___ 05:45AM URINE UHOLD-HOLD
___ 05:45AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:52AM AMMONIA-<10
___ 08:10PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 07:24PM %HbA1c-5.1 eAG-100
___ 07:17PM URINE HOURS-RANDOM
___ 07:17PM URINE HOURS-RANDOM
___ 07:17PM URINE HOURS-RANDOM
___ 07:17PM URINE UHOLD-HOLD
___ 07:17PM URINE GR HOLD-HOLD
___ 07:17PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 07:00PM GLUCOSE-74 UREA N-7 CREAT-1.1 SODIUM-145
POTASSIUM-4.5 CHLORIDE-113* TOTAL CO2-21* ANION GAP-11
___ 07:00PM estGFR-Using this
___ 07:00PM ALT(SGPT)-11 AST(SGOT)-14 CK(CPK)-40* ALK
PHOS-123 TOT BILI-0.4
___ 07:00PM cTropnT-<0.01
___ 07:00PM ALBUMIN-3.8 CALCIUM-8.8 PHOSPHATE-2.6*
MAGNESIUM-2.2
___ 07:00PM TSH-0.41
___ 07:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 07:00PM WBC-7.1 RBC-4.02* HGB-12.0* HCT-39.3* MCV-98
MCH-29.9 MCHC-30.5* RDW-13.9 RDWSD-49.7*
___ 07:00PM NEUTS-79.4* LYMPHS-12.4* MONOS-6.6 EOS-1.1
BASOS-0.1 IM ___ AbsNeut-5.62 AbsLymp-0.88* AbsMono-0.47
AbsEos-0.08 AbsBaso-0.01
___ 07:00PM PLT COUNT-121*
___ 07:00PM ___ PTT-21.3* ___
INTERVAL LABS:
==============
___ 10:31AM BLOOD ALT-26 AST-29 AlkPhos-120 TotBili-0.3
___ 10:31AM BLOOD calTIBC-228* Ferritn-233 TRF-175*
___ 07:24PM BLOOD %HbA1c-5.1 eAG-100
___ 07:51AM BLOOD TSH-1.8
___ 04:58AM BLOOD Free T4-1.4
___ 07:51AM BLOOD Cortsol-8.2
___ 06:05AM BLOOD Lithium-0.3*
___ 07:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 03:06AM BLOOD Lactate-0.7
DISCHARGE LABS:
===============
___ 05:47AM BLOOD WBC-8.4 RBC-3.70* Hgb-11.1* Hct-34.6*
MCV-94 MCH-30.0 MCHC-32.1 RDW-14.1 RDWSD-47.5* Plt ___
___ 05:47AM BLOOD Glucose-130* UreaN-18 Creat-1.4* Na-143
K-4.5 Cl-106 HCO3-22 AnGap-15
___ 05:47AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2
IMAGING:
========
Abdominal ultrasound ___:
1. Cirrhotic liver morphology with mild splenomegaly measuring
up to 14.0 cm.
2. Patent hepatic vasculature.
3. Cholelithiasis without evidence of cholecystitis.
CTA head and neck ___:
1. No acute intracranial abnormality.
2. No evidence of high-grade stenosis, occlusion, aneurysm, or
dissection.
CXR ___:
Initial radiograph demonstrates right mainstem bronchus
intubation. The
subsequent radiograph performed at 12:21 p.m. demonstrates
interval retraction of the ET tube, which now terminates
approximately 5.4 cm above the carina. There is improved
aeration of the lung volumes between the 2 exams. Mild
bibasilar atelectasis is persistent. No evidence of
pneumothorax.
IMPRESSION:
Second radiograph of the series demonstrates appropriate
termination of the ETT approximately 5.4 cm above the carina.
MRI head with and without contrast ___:
1. Left parietal region artifact and motion limits examination.
2. Within limits of study, no acute intracranial abnormalities.
3. Within limits of study, no definite evidence of intracranial
enhancing mass or abnormal enhancement.
4. Probable artifact overlying pituitary as described. If
concern for
pituitary mass, consider dedicated pituitary MRI for further
evaluation.
5. Chronic left external capsule hemorrhagic infarct.
6. Paranasal sinus disease with findings concerning for acute
sinusitis, and nonspecific mastoid fluid, as described.
CXR ___:
Comparison to ___. The course of the feeding tube is
unremarkable. The tip projects over the proximal parts of the
stomach. To be securely positioned, the tube could be advanced
by 5 cm. No complications. Stable mild bilateral areas of
atelectasis. Stable moderate cardiomegaly. No pleural
effusions.
CXR ___:
Comparison to ___. Lung volumes have decreased. There
are new
parenchymal opacities at both the left and the right lung bases,
potentially consistent with aspiration or aspiration pneumonia.
No pulmonary edema. No pleural effusions. No pneumothorax.
EEG ___:
=========
CONTINUOUS EEG: In the awake state, the posterior dominant at
best reaches a low amplitude, moderately formed, poorly
sustained 7 Hz activity. Briefly 9 Hz activity is achieved.
There is no asymmetry. There is a well formed anterior posterior
gradient.
The background consists of mild alpha, moderate theta, and
moderate delta,
with scant beta.
SLEEP: Drowsiness was noted by the presence of vertex waves.
Rudiments of
spindles and K complexes were noted, representing stage N2
sleep. High
amplitude generalized delta slowing was also noted indicating
deep sleep.
PUSHBUTTON ACTIVATIONS: There are no pushbutton activations.
SPIKE DETECTION PROGRAMS: There are several automated spike
detections,
predominantly for electrode and movement artifact. There are no
epileptiform discharges.
SEIZURE DETECTION PROGRAMS: There are no automated seizure
detections,
predominantly for electrode and movement artifact. There were no
electrographic seizures.
QUANTITATIVE EEG: Trend analysis is performed with Persyst Magic
Marker
software. Panels include automated seizure detection, rhythmic
run detection and display, color spectral density array,
absolute and relative asymmetry indices, asymmetry spectrogram,
amplitude integrated EEG, burst suppression ratio, envelope
trend, and alpha delta ratios. Segments showing abnormal trends
are reviewed.
CARDIAC MONITOR: Shows a generally regular rhythm with an
average rate of
80-110 bpm.
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of:
1. Generalized background slowing suggestive of a mild
encephalopathy, non-
specific in etiology. There were no push button events. There
were no seizures or epileptiform discharges.
Brief Hospital Course:
PATIENT SUMMARY:
================
Mr. ___ is a ___ year old man with prior history of EtOH
cirrhosis, multiple vascular risk factors, and bipolar disorder
on multiple psychotropic medications who initially presented
with fever, rigidity, and somnolence concerning for encephalitis
vs. medication related-toxidrome (such as neuroleptic malignant
syndrome). His hospital course was c/b central DI as
hypernatremia improved with DDAVP. As patient's condition
improved, he was able to maintain normal sodium off DDAVP.
ACUTE ISSUES:
=============
# Encephalopathy
# Medication Toxidrome
Extensive workup including MRI, LP, and broad toxic-metabolic
screen was unrevealing other than protein of 92 (3->5 WBCs).
Enterovirus, HSV PCRs both negative in the CSF. Unable to send
paraneoplastic/autoantibody panel due to lack of sufficient CSF
for additional testing. The patient's mental status improved
significantly with adjustment of his psychotropic medications
and all anti-microbials were subsequently discontinued. Latuda,
nortriptyline, oxycodone, lithium, buproprion were weaned off.
Later buproprion was restarted at 75 mg BID per psychiatry
recommendations. Patient continued on home lamotrigine and
seroquel started for sleep. Suspect encephalopathy was likely
multifactorial, due primarily to medication induced effects
(possibly NMS given fever, rigidity on admission) and fluid
shifts in the setting of diabetes insipidus. Mental status
improved dramatically over the course of his hospitalization.
# Acute renal insufficiency
Patient developed ___ with serum Cre 1.6 up from 1.1 on
admission. Urine Na < 20 consistent with hypovolemic
hyponatremia. Improved to 1.4 with IVF.
# Dysphagia
Patient seen and evaluated by speech and swallow team while in
house. FEES revealed mild oral and moderate pharyngeal dysphagia
most notable for reduced bolus control with posterior loss and
reduced pharyngeal clearance resulting in residue for thin
liquids that spills into the airway and is deeply penetrated and
suspected to be aspirated. As such, it was recommended that
patient's diet be regular solids with nectar pre-thickened
liquids. The patient was counseled on the importance of
maintaining this diet as well as the risk of aspiration and
possible infection associated with ingestion of thin liquids.
The patient understood the risks and would like to proceed with
thin liquids despite the risk of aspiration, infection, and even
death.
TRANSITIONAL ISSUES:
====================
# Bipolar Disorder: Needs to follow with a psychiatrist to
manage mood disorders and medications. Provided phone number
___ for ___ for him to call and
schedule new appointment.
# Patient should be re-evaluated by speech and swallow team at
rehab and again counseled on the importance of mitigating risk
of aspiration events with nectar pre-thickened liquids. He
currently understands the risk of thin liquids and would
nevertheless like to proceed with ingestion of thins.
# Patient's Cre 1.4 on day of discharge. Improved from 1.6
follow IVF as noted above. Recommend maintaining euvolemia and
would consider rechecking creatinine as well as complete
chemistry panel in 5 days to confirm continued improvement in
renal function.
# Patient noted to have cirrhotic appearing liver on abdominal
ultrasound. Please consider referral to hepatologist for further
evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lithium Carbonate 300 mg PO BID
2. dutasteride 0.5 mg oral DAILY
3. Cialis (tadalafil) 5 mg oral DAILY BPH
4. famciclovir 250 mg oral BID
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Metoprolol Tartrate 25 mg PO BID
7. BuPROPion (Sustained Release) 450 mg PO QAM
8. Nortriptyline 75 mg PO QHS neuropathy
9. HYDROmorphone (Dilaudid) 8 mg PO Q8H:PRN Pain - Severe
10. Latuda (lurasidone) 120 mg oral QHS
11. Tamsulosin 0.4 mg PO QHS
12. LamoTRIgine 150 mg PO BID
13. Lisinopril 5 mg PO DAILY
14. Ferrous Sulfate 325 mg PO BID
15. Lidocaine 5% Patch 1 PTCH TD QAM
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. QUEtiapine Fumarate 25 mg PO QHS
3. Thiamine 100 mg PO DAILY
4. BuPROPion 75 mg PO BID
5. Cialis (tadalafil) 5 mg oral DAILY BPH
6. dutasteride 0.5 mg oral DAILY
7. famciclovir 250 mg oral BID
8. Ferrous Sulfate 325 mg PO BID
9. LamoTRIgine 150 mg PO BID
10. Levothyroxine Sodium 25 mcg PO DAILY
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. Lisinopril 5 mg PO DAILY
13. Metoprolol Tartrate 25 mg PO BID
14. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
========
Encephalopathy due to NMS vs. Polypharmacy
Central diabetes insipidus
Acute kidney injury
SECONDARY:
==========
Oropharyngeal dysphagia
Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
You were in the hospital because you were confused. Your family
was concerned about your speech as well.
While in the hospital, you had a number of tests to make sure
that you had no infection in your nervous system. Fortunately,
all of these tests were normal. You had an MRI which was also
normal. We suspect that your confusion was related to some of
the medications you were taking since your confusion improved
after we changed your medicines.
While in the hospital, you were also found to have a high sodium
level. The endocrinology team saw you and thought that you had a
condition called diabetes insipidus. This improved after
receiving a medication called ddAVP. Now this medication is
stopped as your body is recovering and you're sodium levels have
normalized.
You were also found to have an injury to kidneys. This was
likely related to dehydration and improved with some fluids.
After leaving the hospital, you should follow up with your
primary care doctor and ___ psychiatrist as well as the
neurologist as scheduled below.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
10272054-DS-19 | 10,272,054 | 24,094,251 | DS | 19 | 2153-08-23 00:00:00 | 2153-08-23 17:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending: ___.
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year old female with history of type 1 DM, c/b gastroperesis,
and diabetic retinopathy that presents from clinic today with
DKA. Patient has suffered from DM1 since age ___ and has
previously had DKA ___ years ago for dietary indiscretion,
however, currently maintains a very strict diet. Patient
re-sited her insulin pump ___ days ago. Since then, she has
consistently had readings ~250-500 despite bolusing with the
usual 8U regular insulin that typically corrects hyperglycemia.
Since re-siting her pump, she describes nausea, lethargy, and
fatigue. Last night she reports onset of polydipsia, and
polyuria. This morning she was feeling "fine" but noted her BS
to be in the 500's. She arrived to her regularly scheduled PCP
appointment today, and noted to have a BS of 672. At the time,
she described unsteadiness on her feet, cloudy headedness, and a
single episode of non-bloody, non-bilious emesis. She also
noticed burning substernal chest pain and epigastric pain today.
Pain is similar to her previous GERD and gastroperesis pain, but
not identical. Denies radiation. Not exacerbated by movement or
effort. Patient has not had any food since symptoms began. She
was sent to the ED for further management of hyperglycemia.
In the ED, initial vs were: 6 98.0 110 163/74 20. Labs notable
for glucose 638, Na 127, K 7.3 (hemolyzed), Cl 87, HCO3 18, BUN
31, and Cr 1.1 with AG 29. UA (+) for 1000+ Glu, and ketones.
Acetone (-). Trop (-) x1 and EKG unchanged from prior. Evaluated
by ___ downstairs with recommendation to temporarily d/c
pump, as they were concerned that a kinked needle in the pump
may be underlying cause of hyperglycemia. She was bolused with
8U humalog and started on insulin gtt @ 8U/hr. Received 2L NS in
ED, and started on ___ L prior to transfer to MICU. ___ L given
with 40meq KCl. Venous pH 7.13 and repeat K 5.0, Na 135, and Cl
85.
On the floor, patient reports lethargy and fatigue but is
conversive. Denies persistent nausea, vomiting, or SOB.
Epigastric burning improved from earlier today
Past Medical History:
1. Type 1 Diabetes Mellitus complicated by neuropathy,
retinopathy, gastric paresis. Diagnosed at age ___, currently on
insulin pump. Last HgbA1c was 7.8%, 2 weeks ago. Followed by
Dr. ___ at ___.
2. Hypothyroidism -- diagnosed ___ years ago, symptoms controlled
with synthroid.
3. Hyperlipidemia -- treated with simvastatin. ___ TC 146, HDL
80, trig 49
4. Panic Attacks/GAD -- symptoms for ___ years, episodes often
correspond with stress in her life. Panic attacks have
decreased since starting Abilify 1 mo ago.
5. Gastroparesis -- occasional constipation, takes Senna
6. Ankle Fracture s/p ORIF in ___ -- injured after slipping
and falling on clothing on stairwell.
7. Hypertension -- controlled on lisinopril
Social History:
___
Family History:
Father passed away at age ___ from CAD and stroke. Mother had
T1DM and passed away at age ___ from ___. No siblings.
Physical Exam:
Admission Exam:
General: Lethargic, oriented x3. Appears stated age
HEENT: Sclera anicteric, Dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
ejection murmur heard best at RUSB.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge Exam:
General: Oriented x3. Appears stated age
HEENT: Sclera anicteric, Dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, NMRG
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
___ 09:25AM BLOOD WBC-13.8*# RBC-4.04* Hgb-13.0 Hct-40.8
MCV-101* MCH-32.1* MCHC-31.8 RDW-13.3 Plt ___
___ 09:25AM BLOOD UreaN-30* Creat-1.3* Na-130* K-5.0 Cl-86*
HCO3-19* AnGap-30*
___ 03:04PM BLOOD Glucose-401* Na-135 K-5.0 Cl-101
calHCO3-15*
___ 03:04PM BLOOD ___ pH-7.16* Comment-GREEN TOP
.
Discharge Labs:
___ 01:52AM BLOOD WBC-18.8* RBC-3.52* Hgb-11.3* Hct-34.4*
MCV-98 MCH-32.0 MCHC-32.8 RDW-13.7 Plt ___
___ 01:52AM BLOOD Glucose-126* UreaN-23* Creat-0.9 Na-138
K-4.5 Cl-108 HCO3-21* AnGap-14
___ 01:52AM BLOOD Calcium-8.5 Phos-1.6* Mg-2.0
.
Pertinent Labs:
___ 09:25AM BLOOD HIV Ab-NEGATIVE
___ 09:25AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
___ 09:25AM BLOOD Acetone-NEGATIVE
___ 11:45AM BLOOD cTropnT-<0.01
___ 08:43PM BLOOD cTropnT-<0.01
___ 11:45AM BLOOD Lipase-16
___ 11:45AM BLOOD Glucose-638* UreaN-31* Creat-1.1 Na-127*
K-7.3* Cl-87* HCO3-18* AnGap-29*
___ 04:18PM BLOOD Glucose-342* UreaN-31* Creat-1.1 Na-134
K-4.8 Cl-100 HCO3-18* AnGap-21*
___ 08:43PM BLOOD Glucose-165* UreaN-26* Creat-0.9 Na-137
K-5.2* Cl-107 HCO3-22 AnGap-13
___ 01:52AM BLOOD Glucose-126* UreaN-23* Creat-0.9 Na-138
K-4.5 Cl-108 HCO3-21* AnGap-14
___ 11:56AM URINE RBC-1 WBC-3 Bacteri-NONE Yeast-NONE Epi-3
___ 11:56AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose->1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
.
Imaging:
Normal chest findings as can be identified on portable AP single
view examination.
Brief Hospital Course:
___ F with PMH significant for DM1 c/b gastroparesis and diabetic
retinopathy that presented in DKA ___ insulin pump dysfunction
admitted to MICU, DKA resolved and insulin pump restarted and
discharged on HD#1 home.
#DKA: Patient presented with hyperglycemia in 600s, AG acidosis
with pH ~7.2 and AG 25, and urinary ketones consistent with DKA.
Acetone in serum negative, however, b-hydroxybutyrate was not
tested. Most likely etiology believed to be pump failure, as her
hyperglycemia started after re-siting, and pump noted to be
kinked in ED. Volume resuscitated with NS until corrected Na WNL
and Glu <200, then switched to ___. Supplemented with KCl
when serum K <5.3 and >3.3. AG closed overnight. She was
evaluated by ___ in the AM after admission. Given 12U lantus
and insulin drip continued after pump repaired and restarted,
FSG afterwards checked and were 100-200s. Patient started on
regular diet. She was given compazine with relief.
#Reflux/Gastroparesis: Patient has chronic GERD and
gastroparesis, takes compazine at home. In ED complaining of
chest discomfort/heartburn similar to prior reflux. Troponins
negative x 2. EKG no signs of ST changes. She was given PPI
and compazine for heartburn and nausea with relief of symptoms.
#Depression: Continued cymbalta and wellbutrin on HD#1 after DKA
resolved.
#HLD: Continued simvastatin on HD#1 after DKA resolved.
#Diabetic retinopathy: Recent cataract surgery. Patient
continued home eye drops while admitted.
#Leukocytosis: Likely reactive ___ DKA. Afebrile, and no
evidence of infection. Cultures with no grwoth.
TRANSITIONAL ISSUES
# Needs follow-up with ___ within several days as had pump
malfunction and should be closely monitored
# Will follow-up with PCP ___ 1 week
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 1 mg PO HS:PRN insomnia/anxiety
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Omeprazole 40 mg PO QHS
4. Duloxetine 120 mg PO QAM
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Rifaximin 200 mg PO BID
8. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral daily
9. Multivitamins 1 TAB PO DAILY
10. ciclopirox *NF* 0.77 % Topical daily
11. clindamycin phosphate *NF* 1 % Topical daily
12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID
13. Vigamox *NF* (moxifloxacin) 0.5 % ___ TID
14. Neomycin-Polymyxin-Dexameth Ophth. Oint 1 Appl BOTH EYES QHS
15. Simvastatin 40 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Duloxetine 120 mg PO QAM
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Lorazepam 1 mg PO HS:PRN insomnia/anxiety
6. Neomycin-Polymyxin-Dexameth Ophth. Oint 1 Appl BOTH EYES QHS
7. Omeprazole 40 mg PO QHS
8. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID
9. Rifaximin 200 mg PO BID
10. Simvastatin 40 mg PO DAILY
11. Vigamox *NF* (moxifloxacin) 0.5 % ___ TID
12. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral daily
13. ciclopirox *NF* 0.77 % Topical daily
14. clindamycin phosphate *NF* 1 % Topical daily
15. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diabetic ketoacidosis
Malfunctioning insulin pump
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 admitted to the medical ICU for very high blood sugar
due to your insulin pump not working correctly. ___ were given
insulin and your sugars improved. Your providers from the
___ repaired and restarted your insulin pump. ___
will need to follow-up with your providers from the ___
___ and your PCP within the next 1 week to make sure your
sugars are well controlled.
It was a pleasure treating ___ at ___ we wish ___ a safe and
speedy recovery.
Followup Instructions:
___
|
10272120-DS-19 | 10,272,120 | 25,887,706 | DS | 19 | 2149-04-01 00:00:00 | 2149-04-01 14:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right hip pain
Major Surgical or Invasive Procedure:
___: Treatment of right subtrochanteric hip fracture with
intramedullary nail.
History of Present Illness:
PCP: PCP: ___. ___
CC: hip pain
HPI:
Ms ___ is a ___ female with history of HTN, NIDDM,
pulmonary fibrosis presenting after unwitnessed mechanical fall
onto right hip with radiologic evidence of hip fracture,
admitted to medicine for pre-operative risk stratification.
Per patient was in USOH when while walking with her walker, got
caught on rug/floor and fell onto right hip. She denies head
trauma/LOC, neck/back pain. Was on ground appx. 1 hour before
son found her, was unable to stand or move right leg. Denies
precipitating CP/SOB, lightheadeness. EMS arrival with leg
shortened and ext. rotated.
In the ED, initial vitals: 99 87 158/86 16 98%. Exam: +right hip
with TTP over proximal femur, ext. rotated, shortened. 2+ ___
pulses b/l. Labs notable for leukocytosis to 18, HCT 30.4
creatinine 1.0, UA negative. EKG NSR LAD, NI no acute st-t
changes. Trauma imaging: FAST negative, CT head, cspine no acute
process. CXR with LLL pneumonia, starting on IV
azithro/ceftiraxone
Femur pelvis hip: +neck fx of R femur and orthopedics was
consulted who felt unstable Right hip fracture required urgent
operative fixation.
Prior to transfer, foley was placed and pre-operative coags were
ordered. Patient received 2mg IV morphine for pain and was
admitted to medicine.
VS prior to transfer 92 140/89 20 99%
Currently, patient is comfortable, oriented x1. Lives
independently, and at baseline is alert and oriented. Able to
complete most tasks.
Of note, patient was hospitalized in ___ for complaints of
chest pain. During that admission no ischemic EKG changes were
appreciated and cardiac markers were negative. Telemetry showed
frequent PVCs, and patient confirmed palpitations, so metoprolol
12.5mg BID was started, with resultant decrease in ectopy. Since
that time no documentation of repeat episode of chest pain.
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, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
1. Hypertension.
2. Diabetes.
3. Osteoporosis.
4. History of vertigo.
5. Decreased hearing.
6. Varicose veins.
7. Idiopathic pulmonary fibrosis.
8. Hyperlipidemia.
9. Remote h/o syncope ___ "heart pause" per son.
10. Glaucoma.
11. Macular degenration.
PAST SURGICAL HISTORY: Significant for cholecystectomy and
appendectomy as well as bilateral cataract removal.
Social History:
___
Family History:
Parents died in ___. No h/o CAD, DM, HTN.
Physical Exam:
VS - Temp 98.8F, 120/76BP , 82HR , 18R , 98O2-sat % RA
GENERAL - NAD, comfortable, sleepy but arousable, oriented to
person, palce (___) not oriented to time
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, ___ SEM heard thru-out
precordium with radiation to carotids, nl S1-S2
LUNGS - anterior fields CTAB,, scant crackles at the bilateral
bases, good air movement, resp unlabored, no accessory muscle
use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 2+ peripheral pulses (radials, DPs), right
leg externally rotated; right hip/proximal thigh indurated on
palpation
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, non-focal neuro exam, sensation grossly
intact throughout
On Discharge:
VS - Temp 98.3F, 112-140/72-83BP , 78-85 HR , 20 R , 98 O2-sat %
RA
GENERAL - NAD, awake, speaking in ___, eating her breakfast
calmly
HEENT - NC/AT, sclerae anicteric, dry MM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, ___ SEM heard throughout
precordium with radiation to carotids, nl S1-S2
LUNGS - anterior fields CTAB, good air movement, resp unlabored,
no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 2+ peripheral pulses (radials, DPs), right
leg in sitting position, she is easily moving it at the knee.
Bandage on right hip is c/d/i. The patietn has resolving
ecchymoses which extends from her left hip into her groin.
SKIN - no rashes or lesions
NEURO - awake, Alert and appropriate, moving all four
extremities
Pertinent Results:
___ 10:40PM BLOOD WBC-18.7*# RBC-3.21* Hgb-10.2* Hct-30.4*
MCV-95 MCH-31.8 MCHC-33.6 RDW-13.2 Plt ___
___ 03:45PM BLOOD WBC-14.6* RBC-2.73* Hgb-8.7* Hct-25.8*
MCV-94 MCH-31.7 MCHC-33.6 RDW-13.8 Plt ___
___ 05:15AM BLOOD WBC-10.3 RBC-2.42* Hgb-7.4* Hct-23.0*
MCV-95 MCH-30.6 MCHC-32.2 RDW-14.1 Plt ___
___ 05:00PM BLOOD WBC-13.6* RBC-2.97* Hgb-9.3*# Hct-27.6*
MCV-93 MCH-31.4 MCHC-33.8 RDW-14.5 Plt ___
___ 05:35AM BLOOD WBC-16.4* RBC-3.16* Hgb-9.7* Hct-29.3*
MCV-93 MCH-30.7 MCHC-33.1 RDW-14.9 Plt ___
___ 06:55AM BLOOD WBC-15.5* RBC-3.13* Hgb-9.7* Hct-28.9*
MCV-92 MCH-30.8 MCHC-33.4 RDW-14.8 Plt ___
___ 06:45AM BLOOD WBC-10.8 RBC-2.62* Hgb-8.0* Hct-24.6*
MCV-94 MCH-30.5 MCHC-32.5 RDW-14.8 Plt ___
___ 06:35AM BLOOD WBC-8.4 RBC-2.52* Hgb-7.8* Hct-23.9*
MCV-95 MCH-30.8 MCHC-32.6 RDW-14.5 Plt ___
___ 06:20AM BLOOD WBC-12.9*# RBC-3.61*# Hgb-11.0*#
Hct-34.3*# MCV-95 MCH-30.5 MCHC-32.1 RDW-14.5 Plt ___
___ 01:30PM BLOOD WBC-13.9* RBC-3.34* Hgb-10.4* Hct-31.2*
MCV-94 MCH-31.2 MCHC-33.3 RDW-14.7 Plt ___
___ 05:35AM BLOOD ___ PTT-32.8 ___
___ 10:40PM BLOOD Glucose-200* UreaN-26* Creat-1.0 Na-132*
K-3.9 Cl-94* HCO3-27 AnGap-15
___ 06:20AM BLOOD Glucose-172* UreaN-27* Creat-0.7 Na-136
K-4.7 Cl-97 HCO3-29 AnGap-15
___ 06:20AM BLOOD ALT-18 AST-27 LD(LDH)-368* AlkPhos-92
TotBili-1.6*
___ 06:20AM BLOOD Hapto-296*
Micro:
Urine culture: negative
Blood culture: negative x2
Imaging:
Femur Films: ___
AP view of the pelvis, AP and lateral views of the right femur
proximally anddistally.
There is an acute displaced intertrochanteric right femoral
fracture. There
is an slight valgus deformity . Distally the femur is intact
but diffusely
osteopenic. No other fractures identified. Femoral head is
well seated in
the acetabulum. Atherosclerotic calcifications are noted.
IMPRESSION:
Acute right femoral neck fracture.
CXR: ___
FINDINGS: As compared to the previous radiograph, the known
bilateral
pulmonary fibrosis, predominating in the subpleural lung areas,
is unchanged
in severity and distribution. No new parenchymal opacities,
suggesting
overlaying pulmonary edema or acute exacerbation, are visible.
There are no
pleural effusions and no pneumothoraces. Borderline size of the
cardiac
silhouette. Moderate tortuosity of the thoracic aorta. There
is severe
spinal scoliosis as well as the clips after cholecystectomy are
constant
CXR: ___
FINDINGS: In comparison with the study of ___, there is
little overall
change in the diffuse prominence of interstitial markings
consistent with
severe bilateral pulmonary fibrosis. No definite new
parenchymal opacities to
suggest pulmonary edema or pneumonia, though these would be
difficult to
assess on anything but clinical grounds, given the diffuse
pulmonary changes
DISCHARGE LABS
___ 07:20AM BLOOD WBC-9.4 RBC-3.14* Hgb-9.9* Hct-31.2*
MCV-100* MCH-31.4 MCHC-31.6 RDW-14.8 Plt ___
___ 07:20AM BLOOD Glucose-149* UreaN-27* Creat-0.8 Na-134
K-4.7 Cl-98 HCO3-27 AnGap-14
___ 07:20AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.7
___ 11:47AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 11:47AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-1
Brief Hospital Course:
Ms ___ is a ___ female with history of HTN, DM, pulmonary
fibrosis presenting after unwitnessed mechanical fall who
underwent treatment of right subtrochanteric hip fracture with
intramedullary nail on ___ with post-operative course
complicated by delirium.
.
# RIght Subtrochanteric Hip Fracture. Incurred after a
mechanical fall. Cardiac work-up negative. Patient was deemed
low risk for an intermediate risk procedure and she underwent
uncomplicated procedure (intramedullary nail placement) on
___. Post-operatively, she was placed on DVT ppx with
Lovenox 30mg SC. She required 2u of pRBCs for anemia though
secondary to mild bleeding at surgerical site. Pain was
controlled with standing tylenol. She was quickly made weight
bearing as tolerated and worked with physical therapy with plan
to discharge to rehab for optimization of strength and utility.
OUTPATIENT ISSUES:
[] Ortho follow-up
[] Continue anticoagulation for 1month post-operatively
___ - ___
[] Discharge to rehab
# Acute reversible encephalopathy (Delirium). Patient
intermittently delirious in house. Likely secondary to age,
underlying mild cognitive impairment as well as fracture itself,
pain and pain medications. Attempts were made to minimize
narcotics in treatment of pain and she remained comfortable on
tylenol. Re-orientation was difficult as patient was ___
speaking. Work-up for additional trigger ie infection was
unrevealing: UA, UCx, BloodCx: negative. CXR with baseline
pulmonary fibrosis otherwise no focal consolidation. Patient
was managed with prn benzos as needed (required total of 2 doses
in house)
OUTPATIENT ISSUES:
[] Continue pain control with Tylenol ___ mg TID
[] prn Zydis 2.5mg prn once daily x3 days and then STOP
# Anemia. HCT drifted down post-operatively and received 1u of
pRBCs on POD2. Additionally HCT noted to downtrend on ___.
Guaiac negative. Hemolysis labs largely negative. Exam with
superficial hematoma over the right hip which was the suspected
source of anemia. Patient transfused one additional unit prior
to discharge with stable HCT at time of discharge.
# Hyponatremia. Patient with baseline hyponatremia with Na range
127-135. As an outpatient she is maintained on a fluid
restriction of <2L. In house she was continued on the fluid
restriction with stable Na,
OUTPATIENT ISSUES:
[] continue 2L fluid restriction
# Diabetes. On metformin at home; transitioned to insulin
sliding scale in house. Resumed outpatient metformin at time of
discharge.
# HTN. Largely normotensive in house. Home amlopidine and
lisinopril were restarted prior to discharge.
# CONTACT
Son ___
Home# ___
Cell # ___
# Confirmed Full Code
# No studies pending at time of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
hold for sbp<100
2. Amlodipine 2.5 mg PO DAILY
hold for sbp<100, hr<50
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. Ocuvite *NF* (vit C-vit E-lutein-min-om-3) 150-30-6-150
mg-unit-mg-mg Oral once daily
2 capsules by mouth. once daily
5. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -400 unit
Oral BID
6. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 400-250 mcg
Oral daily
7. Acetaminophen 1000 mg PO Q8H:PRN pain
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. MetFORMIN (Glucophage) 500 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Amlodipine 2.5 mg PO DAILY
hold for sbp<100, hr<50
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. Lisinopril 10 mg PO DAILY
hold for sbp<100
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Senna 2 TAB PO HS
7. Docusate Sodium 100 mg PO BID
8. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -400 unit
Oral BID
9. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 400-250 mcg
Oral daily
10. MetFORMIN (Glucophage) 500 mg PO DAILY
11. Ocuvite *NF* (vit C-vit E-lutein-min-om-3) 150-30-6-150
mg-unit-mg-mg Oral once daily
2 capsules by mouth. once daily
12. Dorzolamide 2%/Timolol 0.5% Ophth. ___ DROP BOTH EYES BID
13. Enoxaparin Sodium 30 mg SC DAILY
end date: ___
14. OLANZapine (Disintegrating Tablet) 2.5 mg PO Q2H:PRN
agitation Duration: 3 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
-- Right subtrochanteric fracture
-- 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:
Dear Ms ___ it was a pleasure taking care of you.
You wer admitted after a fall and were found to have a hip
fracture. You were evaluated by the orthopedic surgeons who
decided to operate on ___. You underwent an uncomplicated
intervention. Post-operatively you were started on an
anticoagulant, known as Lovenox, which you will need to use for
one month. Additionally your pain was managed with standing
Tylenol. You worked with physical therapy and ultimately
discharged to rehab to optimize your strength and mobility.
Please see a list of your attached medications
Followup Instructions:
___
|
10272140-DS-18 | 10,272,140 | 22,497,750 | DS | 18 | 2164-03-06 00:00:00 | 2164-03-06 22:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Lidocaine / Xylocaine / Keflex / Percocet / Niacin /
Adhesive / novocaine
Attending: ___.
Chief Complaint:
Right middle and lower lobe collapse
Major Surgical or Invasive Procedure:
Bronchoscopy ___
History of Present Illness:
___ with a history of asthma and atrial fibrillation who
presents
with a four day history of cough and new SOB on exertion
yesterday. Of note, patient underwent bronchoscopy with EBUS
TBNA
and BAL on ___ which showed mucus plugging of her RML that was
successfully opened with suctioning. Patient well post procedure
with the exception of some mild right sided chest pain and back
pain which eased the following day, and the development of a
dry,
non-productive cough. She spent the ___ at her daughter's
house
where she felt generally well with the exception of persistent
cough. Over the course of the week, the cough became
progressively more frequent but remained non-productive. A
single
temperature of 100.2 was recorded.
Patient returned to work on ___ but was aware of SOB on
exertion when walking to work. Initially this only occurred when
climbing stairs, requiring having to stop before reaching top of
stairs. However, this progressed and began occurring when
walking
on the flat and the patient was subsequently sent home.
Of note, patient has experienced two episodes of pneumonia and
an
episode of influenza since ___. She feels her symptoms on
this occasion are very similar to previous LRTIs.
Patient attended her PCP ___ (___) where she was noted to
have
a SaO2 of 87%. CXR demonstrated findings consistent with right
lower lobe collapse and possible right middle lobe collapse. She
was encouraged to attend ED post this.
On further questioning the patient denies fevers, sweats,
rigors,
wheeze, chest pain, palpitations and hemoptysis.
In the ED, initial VS were: 98.3 98 137/116 22 91% RA
EKG - no acute ischemic changes, RBBB and T wave inversion as
previously seen
Bloods:
WCC 11.4 Hgb 14.3 Plt 279 BUN 15 Creat 0.8 Electrolytes
normal Troponin <0.01 Lactate 1.7 Glucose 104
Blood and urine cultures pending
Received levofloxacin 750mg IV STAT, albuterol neb and
guaifenesin in ED
Interventional pulmonary were consulted, felt right middle/lower
lobe collapse likely secondary to mucus plugging, unlikely to be
a blood clot. Despite hypoxia, no urgent indication for
bronchoscopy. They recommended continuing Abx, albuterol neb and
anti-mucolytic. Also recommended chest physio, incentive
spirometer and flutter valve. They will continue to monitor.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient felt much improved from earlier
in the day. Cough was much less frequent and severe. SOB was not
an issue as patient remained in bed, but certainly feels it is
much easier to breath. No complaints, eager to have her dinner.
Later in evening, episode of desaturation on ward to 81% on 2L
nasal cannula. On questioning, patient had fallen asleep before
CPAP was applied. Desaturation likely secondary to OSA. Repeat
EKG showed no changes from previous. Examination no change from
previous. Portable CXR stable, no new effusion/consolidation, no
evidence of pneumothorax. SaO2 increased to 93-94% on 5L.
Past Medical History:
1. Sweet's Syndrome
- reportedly inactive for at least one year
- followed with Dr. ___
2. Asthma
3. h/o Atypical Chest pain
4. Vertigo
5. Paroxysmal Atrial Fibrillation
- not on coumadin, reports no A Fib for ___ years
6. Benign Hypertension
7. Hyperlipidemia
8. h/o Cdiff
9. Common Variable Immune Deficiency (IgG and IgM deficient)
10. Hx recurrent sinus infections s/p sinus surgery at ___ Eye
and Ear ___
Social History:
___
Family History:
Mother - ___ Cancer
Father - Lung Cancer
Sister - COPD
Physical ___:
ADMISSION PHYSICAL EXAM:
VS: 98.4 150/84 92 18 90% 2L
GENERAL: NAD, patient comfortable in bed.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Reduced air entry in right lower zone, otherwise good air
entry, no wheezes, rales, rhonchi, breathing comfortably without
use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact, strength ___ in all extremities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VITALS: 98.3 PO 115 / 71 95 18 91 Ra
General: appears comfortable lying in bed
HEENT: EOMI, no conjunctival pallor, MMM
Neck: Supple, non-tender, no LAD
CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops appreciated
Lungs: clear to auscultation bilaterally, breathing comfortably
withoutusing accessory muscles of respiration.
Abdomen: soft, non-tender, no distention
Ext: No cyanosis/pitting edema
Neuro: A&Ox3, grossly intact
Skin: warm and well perfused, no bruises or rashes noted
Pertinent Results:
ADMISSION LABS:
==============
___ 02:20PM BLOOD WBC-11.4* RBC-5.14 Hgb-14.3 Hct-44.1
MCV-86 MCH-27.8 MCHC-32.4 RDW-13.7 RDWSD-42.5 Plt ___
___ 02:20PM BLOOD Neuts-62.9 Lymphs-17.9* Monos-6.8
Eos-11.4* Baso-0.6 Im ___ AbsNeut-7.16* AbsLymp-2.04
AbsMono-0.77 AbsEos-1.30* AbsBaso-0.07
___ 02:20PM BLOOD ___ PTT-28.7 ___
___ 02:20PM BLOOD Glucose-104* UreaN-15 Creat-0.8 Na-139
K-4.2 Cl-102 HCO3-24 AnGap-17
___ 02:28PM BLOOD Lactate-1.7
PERTINENT LABS:
==============
___ 06:40AM BLOOD Glucose-113* UreaN-16 Creat-0.8 Na-141
K-4.2 Cl-103 HCO3-24 AnGap-18
___ 07:10AM BLOOD ___ PTT-26.0 ___
___ 06:40AM BLOOD WBC-8.0 RBC-4.88 Hgb-13.2 Hct-42.5 MCV-87
MCH-27.0 MCHC-31.1* RDW-13.7 RDWSD-43.5 Plt ___
DISCHARGE LABS:
==============
___ 07:10AM BLOOD WBC-8.4 RBC-4.49 Hgb-12.5 Hct-40.0 MCV-89
MCH-27.8 MCHC-31.3* RDW-13.9 RDWSD-45.1 Plt ___
___ 07:10AM BLOOD Glucose-122* UreaN-13 Creat-0.7 Na-141
K-4.4 Cl-103 HCO3-19* AnGap-23*
___ 07:10AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.2
Brief Hospital Course:
Ms ___ is a ___ year old woman with a history of asthma and
atrial fibrillation who presented with a four day history of
cough and new shortness of breath on exertion. Of note, patient
underwent bronchoscopy with EBUS TBNA and BAL on ___, 4 days
prior to admission, which showed mucus plugging of her RML that
was successfully opened with suctioning. Chest X Ray on ___ at
an outpatient appointment showed collapse of right lower lobe
and possible collapse of right middle lobe.
ACUTE ISSUES:
===================================
#Right middle/lower lobe collapse
#Hypoxia
Initially suspected to be pneumonia vs mucus plug. Patient had
been afebrile without leukocytosis, but was treated empirically
with levofloxacin. After 3 days of minimal improvement in
symptoms, and chest X rays on ___ showing no improvement
in right lower lobe collapse, a bronchoscopy was performed.
Bronchoscopy performed ___ revealed blood clot suspected to
be from recent EBUS. There was successful aspiration and
re-inflation of the collapsed lung as seen by chest X ray.
Levofloxacin was given for a 5 day course. She was weaned off
oxygen and had an ambulatory O2 of 94-96% on room air.
- follow up with Dr. ___ pulmonology on ___
#Eosinophilia
On CBCs ordered to monitor patient's WBC, absolute eosinophil
count was notably elevated during admission at 1.30 (peak). It
was previously within normal limits on ___ at 0.14, and
remained slightly elevated during admission. The etiology is not
quite clear but given patient's complicated immunologic history,
this may be related.
- at next visit please check CBC with diff to monitor
eosinophilia
#Gram negative rods in urine
Patient's urine culture from ___ was positive for E coli,
resistant to bactrim and ciprofloxacin. Patient was asymptomatic
during hospitalization. She denied urinary frequency, urgency,
dysuria and foul-smelling urine. We ordered a repeat urine
culture given the resistances seen in this organism and our
patient's lack of history of UTIs and symptoms.
- follow up repeat UA/Urine culture ___. If patient develops
symptoms she may require treatment.
#Common Variable Immune Deficiency
Patient has history of IgG deficiency complicated by multiple
lung infections. Is chronically on augmentin as outpatient.
Followed by ___, MD of ___.
CHRONIC/STABLE ISSUES:
===================================
#Obstructive Sleep Apnea. During this hospitalization, patient
had one night where she desaturated into the ___. It was found
that she had fallen asleep without her CPAP. When CPAP was
placed correctly, her saturations returned to the mid ___.
Patient uses CPAP at home; settings 6cm/H2O.
#HTN
- continued home lisinopril, diltiazem, and verapamil
#HLD
- continued atorvastatin 80mg
#Paroxysmal atrial fibrillation. CHADSVASC 3.
- continuing on verapamil SR 360mg and diltiazem ER 120mg
- no anticoagulation necessary as per cardiology ___
TRANSITIONAL ISSUES:
===================================
[ ] follow up with specialists as needed (Dr. ___ allergy for
CVID or Dr. ___ Pulmonology)
[ ] follow up CT trachea (___) per pulm recs
[ ] resume augmentin prophylaxis on ___
[ ] repeat CBC w/ diff at next visit to evaluate for persistent
eosinophilia
[ ] follow up repeat urine culture (___), treat as
outpatient if necessary
[ ] follow up pending blood and urine cultures
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amoxicillin-Clavulanic Acid ___ mg PO Q24H
2. Fluticasone Propionate NASAL 1 SPRY NU QHS
3. Lisinopril 10 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Albuterol 0.083% Neb Soln 1 NEB IH Q8H:PRN Asthma
6. Albuterol Inhaler 2 PUFF IH Q4-6H:PRN Asthma
7. Guaifenesin-CODEINE Phosphate ___ mL PO QPM:PRN Cough
8. Diltiazem Extended-Release 120 mg PO DAILY
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. Montelukast 10 mg PO DAILY
11. PARoxetine 30 mg PO QPM
12. Verapamil SR 360 mg PO Q24H
13. Aspirin 325 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q8H:PRN Asthma
2. Albuterol Inhaler 2 PUFF IH Q4-6H:PRN Asthma
3. Amoxicillin-Clavulanic Acid ___ mg PO Q24H
4. Aspirin 325 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
7. Diltiazem Extended-Release 120 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU QHS
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. Guaifenesin-CODEINE Phosphate ___ mL PO QPM:PRN Cough
11. Lisinopril 10 mg PO DAILY
12. Montelukast 10 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. PARoxetine 30 mg PO QPM
15. Verapamil SR 360 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
================
Collapsed Right Lower Lobe
SECONDARY DIAGNOSIS
================
Obstructive Sleep Apnea
Hypertension
Paroxysmal atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ was a pleasure taking care of you at ___
___.
Why was I hospitalized?
- you came in with shortness of breath
- your shortness of breath was caused by a collapsed portion of
your lung
What happened while I was in the hospital?
- you were treated with antibiotics just for possible pneumonia
causing your collapsed lung
- you had a procedure done by the lung doctors, where they
looked into your lung and sucked out mucus and some blood that
was causing a blockage
- you received medications to help your breathing and break up
mucus
What should I do when I go home?
- you should follow up with your PCP, ___ in ___ weeks
- you should resume your home medications
- Please continue to use your incentive spirometer and acapella
valve
- Please resume your augmentin starting ___.
It was a pleasure taking care of you. We wish you all the best,
Your ___ Team
Followup Instructions:
___
|
10272398-DS-16 | 10,272,398 | 21,696,828 | DS | 16 | 2131-04-22 00:00:00 | 2131-04-26 22:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left leg swelling, pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ medical ___ with history of 1
prior DVT ___ years ago) of RLE in the setting of multiple long
plane rides to ___, no longer anticoagulated, who presents
after an outpatient DVT ultrasound showed an extensive DVT of
the
left lower extremity.
He noted 5 days of significant swelling in the left lower
extremity. He first noted the swelling on ___ and started
using his old compression stockings. He noted mild upper thigh
stiffness. He has had a few weeks of non-productive cough
without
hemoptysis. He does report recent URI symptoms a few weeks ago
that have subsequently improved. He has had no chest pain,
shortness of breath, or dyspnea.
In terms of hx of DVT, patient states that he was on warfarin
for
6 months which was discontinued.
Denies chest pain, shortness of breath, dizziness or
lightheadedness. He saw his doctor today, who performed a DVT
ultrasound that shows an extensive lot. They are also concerned
that he had new EKG changes, and was mildly tachycardic. He
received Lovenox prior to arrival at ___ ED and per patient
report at approximately noon.
On arrival to ___ ED, patient borderline tachycardic, but
appears well, breathing comfortably on room air.
Past Medical History:
History of radiation therapy
Thyroid nodule
Hypercholesterolemia
Obesity
Thrombophlebitis
Post-phlebitic syndrome
History of actinic keratoses
Impaired glucose tolerance
Abdominal umbilial hernia
Vasectomy
Social History:
___
Family History:
Retinal detachment (brother), Mother with hx of multiple
"mini-strokes."
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITALS: ___ 2132 Temp: 98.5 PO BP: 135/78 L Lying HR: 98
RR: 16 O2 sat: 93% O2 delivery: Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi.
Abdomen: Normoactive bowel sounds. Soft, non-tender,
non-distended, bowel sounds present, no organomegaly, no rebound
or guarding, R abdominal with reducible mass.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, there is 2+ edema of b/l
___.
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: ___ 1525 Temp: 98.3 PO BP: 138/85 R Sitting HR: 108
RR: 20 O2 sat: 96% O2 delivery: RA
General: NAD.
Lungs: CTAB.
CV: RRR, no MRG.
GI: Soft, nontender, nondistended.
Ext: non-pitting edema of L leg compared to R, extending from
thigh down to foot. No obvious ecchymosis or palpable cords.
Mild
TTP of L posterior thigh. DPs 2+.
Neuro: PERRL, EOMI.
Pertinent Results:
ADMISSION LABS
===================
___ 03:07PM WBC-11.3* RBC-4.97 HGB-14.7 HCT-46.9 MCV-94
MCH-29.6 MCHC-31.3* RDW-12.9 RDWSD-44.9
___ 03:07PM NEUTS-65.8 ___ MONOS-7.8 EOS-2.7
BASOS-0.5 IM ___ AbsNeut-7.41* AbsLymp-2.55 AbsMono-0.88*
AbsEos-0.31 AbsBaso-0.06
___ 03:07PM ___ PTT-36.3 ___
___ 03:07PM proBNP-78
___ 03:07PM cTropnT-<0.01
___ 03:07PM GLUCOSE-91 UREA N-12 CREAT-0.7 SODIUM-141
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-25 ANION GAP-14
DISCHARGE LABS
==================
___ 06:45AM BLOOD WBC-9.3 RBC-4.65 Hgb-13.8 Hct-43.8 MCV-94
MCH-29.7 MCHC-31.5* RDW-12.9 RDWSD-44.4 Plt ___
___ 06:45AM BLOOD Glucose-103* UreaN-10 Creat-0.8 Na-141
K-4.6 Cl-102 HCO3-29 AnGap-10
___ 06:45AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1
IMAGING
===============
CTA CHEST ___ IMPRESSION:
1. Extensive pulmonary emboli involving both the right and left
main pulmonary arteries as well as segmental and subsegmental
branches of multiple pulmonary lobes as described above. No
evidence of right heart strain or pulmonary infarct at this
time.
2. No acute aortic abnormality.
3. Cholelithiasis without evidence of acute cholecystitis.
4. 6 mm thyroid nodule. No follow-up is recommended per ACR
criteria outlined below.
ECHO REPORT ___
CONCLUSION: The left atrial volume index is normal. There is
normal left ventricular wall thickness with a normal cavity
size. There is normal regional and global left ventricular
systolic function. The visually estimated left ventricular
ejection fraction is 65%. There is no resting left ventricular
outflow tract gradient. Mildly dilated right ventricular cavity
with low normal free wall motion. Tricuspid annular plane
systolic excursion (TAPSE) is normal. The aortic sinus is mildly
dilated with normal ascending aorta diameter for gender. The
aortic arch diameter is normal. The aortic valve leaflets (3)
appear structurally normal. There is no aortic valve stenosis.
There is trace aortic regurgitation. The mitral valve leaflets
appear structurally normal with no mitral valve prolapse. There
is trivial mitral regurgitation. The pulmonic valve leaflets are
normal. The tricuspid valve leaflets appear structurally normal.
There is physiologic tricuspid regurgitation. The pulmonary
artery systolic pressure could not be estimated. There is no
pericardial effusion.
Brief Hospital Course:
Brief Hospital Course
=================================
___ w/ hx of provoked ___ DVT, not on anticoagulation,
presented with OSH US revealing extensive clots in the LLE,
found to have bilateral PEs on CTA, admitted for anticoagulation
and stabilization.
#LLE DVT
#Bilateral PE: Patient noticed generalized L leg swelling 5 days
prior to admission and presented to his PCP who obtained an US
demonstrating large clot burden/DVT in his LLE, from the common
femoral to the posterior tibial veins. No clear provoking events
for VTE. Patient was referred to the ED where CTA chest
deomonstrated large burden of bilateral pulmonary emboli.
Patient was noted to have tachycardia up to the 120s and a RBBB
on ECG, not seen on prior, which suggested potential right heart
strain. He was started on heparin gtt and admitted to the
medicine ward. While admitted, BNP was negative, and there was
no evidence of right heart strain on CTA chest. Thus we obtained
a TTE which revealed only mild RV dilation with low normal free
wall motion. On the medical floor, the patient was maintaining
O2 sats on room air and was no longer tachycardic. He did not
have chest pain, SOB, leg pain, hemoptysis, back pain. Patient
was transitioned to apixaban with plan for indefinite
anticoagulation, given that this is his second DVT. Of note, he
has a past history of provoked RLE DVT in the setting of long
plane rides. Recommend outpatient hematology work up to evaluate
potential hypercoagulable state given this is his second episode
of VTE.
Transitional Issues
============================================
[ ] Discharged on apixaban for anticoagulation of unprovoked DVT
and PE. Would recommend indefinite anticoagulation given this is
his second DVT and DVT/PE appear unprovoked.
[ ] Apixaban management: Discharged on 10mg BID for 14-day
course (through ___. Starting ___, patient is instructed
to reduce his dose to 5mg BID on-going.
[ ] Recommend age-appropriate cancer screening given unprovoked
DVT/PE and concern for hypercoagulable state.
Medications on Admission:
No Pre-Admission Medications
Discharge Medications:
1. Apixaban ___ mg PO BID
RX *apixaban [Eliquis] 5 mg (74 tabs) ___ tablets(s) by mouth
twice daily as directed Disp #*1 Dose Pack Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral Pulmonary Emboli
Left Lower Extremity DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were seen in the hospital for clots in your legs and
lungs.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were evaluated for clots in your lungs and in your left
leg. You were started on a blood thinner called apixaban to
treat the clots. This medicine will prevent your clots from
getting bigger.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- You are being discharged with a medicine called apixaban.
Please follow the instructions on your apixaban medication
packs. Please take 10mg twice daily through ___. On ___
___, please lower your dose to 5mg twice daily.
- Please follow up with your primary care doctor within the next
week.
- We recommend you see a blood doctor to evaluate if you are at
a higher risk to develop these blood clots in the future.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10273064-DS-7 | 10,273,064 | 23,850,781 | DS | 7 | 2151-06-12 00:00:00 | 2151-06-12 17:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lamictal
Attending: ___.
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Ms. ___ is a ___ woman with past history of
hypothyroidism, depression, ?bipolar disorder, recently admitted
at ___ 3 days prior to admission for malaise and
neutropenia thought to be due to lamictal which was
discontinued(lamictal had been started 1 month prior, adderal
also discontinued); who presented again with continued weakness,
joit pain, myalgias, malaise, headache, and anorexia; found to
be persistently neutropenic (ANC 220) of unclear etiology.
She reports fatigue started over a year ago when she was
diagnosed with hypothyroidism which improved somewhat but she
says never really improved. Her appetite has been poor for about
6 months and she reports an unintentional weight loss of about
30 lbs during that time.
On the ___ 1 week prior to admission, she noticed the onset
of flu like symptoms of chills, myalgias, and malaise. She
became progressively more weak to the point where her boyfriend
had to wash her becasuse she didn't have the strength. She also
noticed the onset of bilateral hip, feet , knee (states both
"kneecaps"), and neck pain also started during this time. She
had been started on lamictal 1 month prior. denied any history
of ever having low blood counts previously.
She states symptoms have been ongoing for approximately one
week. She has associated low-grade fevers at home. She was
hospitalized at ___ for 3 days after she presented
there and so to be leukopenic with white count 1.4. She had
extensive workup including CMV, EBV, Lyme titers, blood cultures
which were all unrevealing. Her Lamictal and Adderall were
stopped as they were thought to be contributing to her
leukopenic, despite this she has had persistent myalgias, neck
pain headache poor p.o. intake. She endorses 30 pound weight
loss unintentional over the past 6 months as well. No recent
travel no unusual rashes, no sick contacts.
She was transferred to our ___ from ___ to our ___ for
further evaluation.
She was recently admitted to ___ 3 days prior to
admission for similar complaints and also noted to have
neutropenia at that time. At the time of this writing I have no
records from ___ and I have faxed a release of information
form for them to be faxed. per ___ reporrts, there the CRP was
normal and her ___ antigen "suggested and acute
subacute infection" and her cytopenias were though to be due to
lamictal. She was seen by the ID consultant there who did not
believe this was bacterial infection and lactic acid and
procalcitonin were both normal. Her symptoms improved and she
was sent home.
Since then, she continued to feel profoundly weak and slightly
short of break. She mentioned that she was apparently diagnosed
with EBC last year (unclear circumstances). She apparently also
had a negative RA and SLE studies earlier this week as well.
She presented again to ___ ___ with vague symptoms of
overall fatigue, intermittent fevers (although none documented),
chills, and a 30 lb unintentional weight loss over several
weeks/possibly months. She was transferred to the ___ ___ for
further management.
In the ___, she had one ___ of 87/47 which improved with
fluids 2l NS. LP was done and she was admitted for further
management.
ROS:
(+)30 lb weight loss over 6 months, recent menstrual bleeding
heavier than usual. "soaking" night sweats x 3 days, insomnia,
anorexia, did report a few loose BMs recently but not overt
diarrhea
(-)denied CP, SOB, SI/HI
Remainder of comprehensive 10 point ROS it otherwise negative.
Past Medical History:
as above including hypothyroidism, depression and anxiety and
"they think I may have bipolar disorder"
Past Surgical History:
-s/p cholecystectomy in ___
-various "knee surgeries"
Social History:
___
Family History:
no family history of hematologic disorders
mother has hypothyroidism
Physical Exam:
Admission Exam:
Vitals: reportedly tempt at ___ was 102, T currently
97 P61 113/64 RR18 98% on RA
Consitutional: tired appearing, awakens to voice but
occasionally nods off.
Eyes: pale, EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
MSK: I cannot find e/o inflammatory arthritis. No palpable
synovitis.
Skin: Tattoos. somewhat dry skin. No visible rash. No jaundice.
LYMPH: shoddy cervical LAD, no dominant nodes.
Neuro: Her neck is somewhat stiff but moveable. She has some
moderate difficulty touching her chin to her chest. AAOx3. CNs
II-XII intact. MAEE.
Psych: Full range of affect
Discharge Exam:
VS: 98.4 ___ 18 96% RA
Consitutional: NAD, AAOx3, engages in normal conversation,
comfortable appearing.
Eyes: pale, EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
MSK: no joint erythema, effusions or e/o arthritis
Skin: No apparent rashes
LYMPH: no palpable ___ in neck, axillae, inguinal areas
Neuro: Moving all extremities, AAOx3, no focal deficits grossly
Psych: Full range of affect
Pertinent Results:
ADMISSION LABS
___ 08:46AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-750*
POLYS-0 ___ ___ 08:46AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-162*
POLYS-0 ___ ___ 08:46AM CEREBROSPINAL FLUID (CSF) PROTEIN-39
GLUCOSE-59
___ 03:35AM LACTATE-0.9
___ 03:30AM URINE HOURS-RANDOM
___ 03:30AM URINE HOURS-RANDOM
___ 03:30AM URINE UCG-NEGATIVE
___ 03:30AM URINE GR HOLD-HOLD
___ 03:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-POS* mthdone-NEG
___ 03:30AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 03:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
___ 03:30AM URINE RBC-7* WBC-9* BACTERIA-FEW YEAST-NONE
EPI-4 TRANS EPI-<1
___ 03:30AM URINE MUCOUS-OCC
___ 03:10AM GLUCOSE-103* UREA N-16 CREAT-0.8 SODIUM-137
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-26 ANION GAP-14
___ 03:10AM estGFR-Using this
___ 03:10AM ALT(SGPT)-61* AST(SGOT)-76* ALK PHOS-61 TOT
BILI-0.1
___ 03:10AM LIPASE-127*
___ 03:10AM ALBUMIN-3.9 CALCIUM-8.5 PHOSPHATE-3.3
MAGNESIUM-1.7
___ 03:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:10AM WBC-1.4* RBC-3.90 HGB-10.5* HCT-32.9* MCV-84
MCH-26.9 MCHC-31.9* RDW-16.6* RDWSD-51.3*
___ 03:10AM NEUTS-15* BANDS-1 LYMPHS-77* MONOS-3* EOS-0
BASOS-0 ATYPS-4* ___ MYELOS-0 AbsNeut-0.22* AbsLymp-1.13*
AbsMono-0.04* AbsEos-0.00* AbsBaso-0.00*
___ 03:10AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-1+
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
___ 03:10AM PLT SMR-LOW PLT COUNT-104*
___ 03:10AM ___ PTT-33.0 ___
___: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with severe headache // bleed?
TECHNIQUE: Contiguous axial images of the brain were obtained
without
contrast. Coronal and sagittal reformations as well as bone
algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.7 mGy
(Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
No evidence of infarction, hemorrhage, edema, or mass effect.
The ventricles
and sulci are normal in size and configuration.
No evidence of fracture. Other than minimal partial
opacification in the left
ethmoidal air cell, the visualized portion of the paranasal
sinuses, mastoid
air cells, and middle ear cavities are essentially clear. The
visualized
portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial abnormality including no hemorrhage.
___: Chest PA and lateral
COMPARISON: None.
FINDINGS:
The lungs are clear. No focal consolidation, effusion, edema, or
pneumothorax. The heart is top-normal in size. The mediastinum
is not
widened. No acute osseous abnormality.
IMPRESSION:
No focal pneumonia.
DISCHARGE LABS
___ 06:55AM BLOOD WBC-1.9* RBC-3.74* Hgb-10.1* Hct-31.7*
MCV-85 MCH-27.0 MCHC-31.9* RDW-16.6* RDWSD-51.5* Plt ___
___ 06:55AM BLOOD ALT-102* AST-97* LD(LDH)-266* AlkPhos-76
TotBili-0.2
___ 07:23AM BLOOD VitB12-743 Folate-18.8
___ 01:05PM BLOOD calTIBC-321 Ferritn-75 TRF-247
___ 01:05PM BLOOD TSH-4.1
___ 07:23AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative
___ 07:23AM BLOOD PEP-NO SPECIFI
___ 01:05PM BLOOD HIV Ab-UNABLE TO HIV1-NEGATIVE
HIV2-NEGATIVE
___ 07:25AM BLOOD HCV Ab-Negative
___ 03:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:25AM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM-PND
___ 10:25AM BLOOD EHRLICHIA CHAFFEENSIS (HUMAN MONOCYTIC
EHRLICHIOSIS) IGG AND IGM-PND
___ 01:05PM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-Test
___ 07:20PM URINE RBC->182* WBC-132* Bacteri-FEW Yeast-NONE
Epi-2 TransE-1
___ 08:46AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-750*
Polys-0 ___ ___ 08:46AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-162*
Polys-0 ___ ___ 08:46AM CEREBROSPINAL FLUID (CSF) TotProt-39 Glucose-59
___ 7:48 am SEROLOGY/BLOOD CHEM 36___ ___.
**FINAL REPORT ___
LYME SEROLOGY (Final ___:
NO ANTIBODY TO B. BURG___ DETECTED BY EIA.
Blood (EBV)
**FINAL REPORT ___
___ VIRUS VCA-IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop ___ weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
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.
___ 7:20 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
OUTSIDE HOSPITAL LABS
___ CRP 0.5
___ ___ neg
EBV Nuc antigen POS, VCA IgG POS, Early Ag NEG, VCA IgM NEG
Brief Hospital Course:
Ms. ___ is a ___ woman with past history of
hypothyroidism, depression, ?bipolar disorder, recently admitted
at ___ 3 days prior to admission for malaise and
neutropenia thought to be due to lamictal which was
discontinued(lamictal had been started 1 month prior, adderal
also discontinued); who presented again with continued weakness,
joint pain, myalgias, malaise, headache, fever (T 102 reportedly
at ___, and anorexia; found to be pancytopenic.
#Pancytopenia: Differential viral cause vs. parasitic vs.
rheumatologic cause vs. medication effect (Lamictal, ?Adderall,
?Prozac) vs. primary hematologic cause, eg leukemia/lymphoma.
Heme/onc was consulted.
Lamictal had been stopped approximately 1 week prior to
admission.
A broad range of testing showed: ___ and RF negative, normal
CRP, EBV serology shows e/o prior infection. Hep B and Hep C
neg. CMV VL undetectable. Lyme ab neg. SPEP no abnormality.
Initial screening HIV antibody showed a low level positive but
confirmatory testing for HIV Ab 1 and HIV Ab 2 multispot was
negative. This was discussed with patient. (The result
returned a few minutes prior to discharge and this WILL NEED TO
BE REPEATED with HIV VIRAL LOAD as an outpatient.)
Suspicion for rheumatologic causes was lower given the negative
antibodies above and her joint pains resolved so she really had
no other e/o autoimmune disease.
There was suspicion for possible parasitic disease eg
anaplasma/ehrlichia due to constellation of symptoms and lab
findings; she comes from ___ so she has risk for both
HME and HGA. She improved completely from a symptom standpoint
and she was afebrile through the hospitalization.
Counts were improving and patient was asymptomatic for 2 days
prior to discharge. She was offered bone marrow biopsy but
refused and this was reasonable given counts were improving and
thought very most likely to be due to an infectious cause. She
was set up with hematology/oncology in 2 weeks to follow up and
directed to get CBC checked in the meantime and faxed to
heme/onc. If counts are not normal or dramatically improved by
that point, then she will require bone marrow biopsy.
#Fever/myalgias/malaise: No fevers during admission and symptoms
completely resolved. Did have enterococcus UTI by urine culture
(although she was asymptomatic from dysuria standpoint) and was
treated with ceftriaxone x 3 days then stopped. Otherwise
differential was as above, given the pancytopenia: parasitic vs.
viral vs possibly bacterial from UTI but seems less likely given
the more systemic syndrome. LP negative and CXR neg. Added
doxycycline starting ___ for ?anaplasma empirically, to
complete 14 day course. This would also cover for Lyme just in
case antibody testing happened to early to catch the disease.
#Anemia: She has known prior iron deficiency anemia (previously
on iron but not currently) normocytic MCV 84. Iron studies
unremarkable (Fe 75, ferritin 75). Retic count very low which is
consistent with poor marrow response. B12 and folate normal.
#PSYCH/Depression/bipolar: Held lamictal and should be held
indefinitely d/t pancytopenia. Continued Prozac/hydroxyzine for
now; if counts remain low as an outpatient will need to stop
Prozac as this can cause cytopenias as well and will need psych
consult to talk about consolidating meds in view of Bipolar
disorder.
TRANSITIONAL ISSUES
#Blood cx pending not final resulted yet (No growth to date)
#Initial screening HIV antibody showed a low level positive but
confirmatory testing for HIV Ab 1 and HIV Ab 2 multispot was
negative. This was discussed with patient. (The result
returned a few minutes prior to discharge and this WILL NEED TO
BE REPEATED with HIV VIRAL LOAD as an outpatient.)
#CBC to be checked at ___ follow up appointment and results also
faxed to Heme/Onc fellow Dr. ___ will contact patient if
heme/onc appointment can be cancelled (eg, if counts have fully
recovered). Otherwise, ___ clinic will be calling patient
with an appointment in benign heme.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nicotine Patch 21 mg TD DAILY
2. QUEtiapine Fumarate 25 mg PO BID
3. Levothyroxine Sodium 88 mcg PO DAILY
4. FLUoxetine 60 mg PO DAILY
5. HydrOXYzine 100 mg PO QHS
(note that lamictal and adderal were recently stopped during
hospitalization 3 days prior at ___)
Discharge Medications:
1. FLUoxetine 60 mg PO DAILY
RX *fluoxetine 60 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
2. HydrOXYzine 100 mg PO QHS
3. Levothyroxine Sodium 88 mcg PO DAILY
RX *levothyroxine 88 mcg 1 tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
4. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour Apply 1 patch daily Disp #*14 Patch
Refills:*0
5. QUEtiapine Fumarate 25 mg PO BID
RX *quetiapine 25 mg 1 tablet(s) by mouth twice a day Disp #*28
Tablet Refills:*0
6. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*26 Tablet Refills:*0
7. Outpatient Lab Work
ICD: ___.81
Please check CBC with differential on ___ and fax to Dr. ___
___.
Discharge Disposition:
Home
Discharge Diagnosis:
Pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for a low white blood cell count and a
possible urinary tract infection. You had a chest xray and a
lumbar puncture which were both negative for infection. You
were treated with antibiotics and the hematology team came to
see you. It is possible that one of the drugs you were taking,
the lamictal, may have been the culprit. This has already been
stopped. Also possible, was a viral infection or parasitic
infection (like from a tick bite). Your fevers resolved and
your symptoms also resolved. We sent many lab tests to check
and see if you have an infection and some of those are still
pending. Your blood counts were rising and since you felt well,
we decided to let you go home with close follow up. We moved up
your PCP appointment and you should get your bloodwork checked
at that appointment and then faxed to the hematology/oncology
doctor here at ___, Dr. ___. This is printed on the
prescription for the lab draw, which we have provided for you.
The hematology/oncology office will call you with an
appointment; if the bloodwork looks normal by the time you get
labs drawn, then Dr. ___ will call you and you may not have to
come in.
We also started you on an antibiotic called doxycycline just in
case of a parasitic infection, which you should take for 13 more
days. (A total of 2 weeks.)
Followup Instructions:
___
|
10273267-DS-11 | 10,273,267 | 25,014,291 | DS | 11 | 2168-10-23 00:00:00 | 2168-10-23 17:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Niaspan Extended-Release / simvastatin
Attending: ___
Chief Complaint:
___ with sigmoid stricture causing a partial large bowel
obstruction
Major Surgical or Invasive Procedure:
Laparoscopic converted to open sigmoid resection
History of Present Illness:
___ with history of sigmoid diverticulitis and stricture
confirmed on ___ on sigmoidoscopy, no malignancy in biopsies,
who presents with recurrent symptoms of constipation, abdominal
distention and abdominal pain. She vomited a couple of times
without relief. She took milk of magnesia this morning given her
constipation and had a bowel movement, however, abdominal
distention did not improve. She does not recall the last time
she
passed flatus.
She was recently admitted to ___ with similar symptoms and
discharged on a low residue diet with plans for robotic
laparoscopic sigmoid colectomy with primary end-to-end
colorectal
anastomosis in ___ after screening colonoscopy.
Past Medical History:
Past Obstetrical History: G0.
Past Gynecologic History: Age of menarche 10, regular periods
every 28 days lasting five to seven days until the age of ___.
No further bleeding until very recently with cyclical light
bleeding, no pain with full bladder or bowel movement. She is
virginal. She has never had a Pap smear. She has had normal
mammograms. No history of infection. No contraception.
Past Medical History: obesity, hypertension,
hypercholesterolemia, hypothyroidism
Past Surgical History: laparoscopic cholecystectomy, umbilical
hernia repair (unsure if mesh)
Social History:
___
Family History:
Both her parents died from heart disease in their ___. Her
father's mother was diagnosed with breast cancer at age ___.
Patient reports that her paternal grandmother died from an
anesthesia complication, ? pseudocholinesterase
deficiency, however she had her cholecystectomy without
difficulty.
Physical Exam:
Physical exam:
General: AxOx3. Appears well
HEENT: Eyes anicteric. PEERLA. EOMI. Mucus membranes appear
moist
Chest: Symmetric. CTAB. No crackles. No DTP
Cards: RRR.
Abdomen: Slightly distended, incisional tenderness, appropriate,
no R/G. JP drain with serosanguineous output. Midline lower
umbilical wound avc in place with no issues
Neuro: Moving all extremities equally. Sensation grossly intact.
___ strength UE and ___.
Pertinent Results:
___ 12:55PM BLOOD WBC-11.1* RBC-4.19 Hgb-12.6 Hct-40.3
MCV-96 MCH-30.1 MCHC-31.3* RDW-14.5 RDWSD-50.8* Plt ___
___ 07:17AM BLOOD ___ PTT-26.3 ___
___ 06:52AM BLOOD Glucose-113* UreaN-8 Creat-0.6 Na-142
K-3.4* Cl-103 HCO3-28 AnGap-11
___ 06:52AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.9
Brief Hospital Course:
___ presented to ___ on ___ with symptoms of bowel
obstruction. She was taken to the or for a laparoscopic Sigmoid
colectomy, the case needed to be converted to open. She
tolerated the procedure well without complications (Please see
operative note for further details). After a brief and
uneventful stay in the PACU, the patient was transferred to the
floor for further post-operative management.
Neuro: Pain was well controlled on Iv medications then
transitioned to oral pain medications. at the time of discharge
she was tolerating her pain well on a multimodal analgesia plan
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulm: The patient remained stable from a pulmonary standpoint;
oxygen saturation was routinely monitored. Had good pulmonary
toileting, as early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI: The patient was initially kept NPO after the procedure. The
patient was later advanced to and tolerated a regular diet at
time of discharge. the patient had return of bowel function
which was complicated by high output diarrhea, which resolved
with time. Patient's intake and output were closely monitored
GU: The patient had a Foley catheter that was removed prior to
discharge. Urine output was monitored as indicated. At time of
discharge, the patient was voiding without difficulty.
ID: The patient was closely monitored for signs and symptoms of
infection and fever.
Heme: The patient had blood levels checked daily during their
hospital course to monitor for signs of bleeding. The patient
received subcutaneous heparin and ___ dyne boots were used
during this stay, she was encouraged to get up and ambulate as
early as possible. The patient is being discharged on a
prophylactic dose of Lovenox.
On Post operative day 4, the patient was discharged to home with
services. At discharge, she was tolerating a regular diet,
passing flatus, voiding, and ambulating independently. She will
follow-up in the clinic in ___ weeks. This information was
communicated to the patient directly prior to discharge.
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] 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 rehab hospital disposition.
[ ] Lack of insurance coverage for ___/ Rehab services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
dispo
[x] No social factors contributing in delay of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg IV DAILY
2. Lactulose 30 mL PO TID
3. Magnesium Citrate 300 mL PO ONCE
4. Hydrochlorothiazide 25 mg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Vitamin D 6000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*50 Tablet Refills:*0
2. Enoxaparin Sodium 60 mg SC Q12H
RX *enoxaparin 60 mg/0.6 mL 1 syringe SC twice a day Disp #*60
Syringe Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
4. Potassium Chloride 60 mEq PO DAILY
RX *potassium chloride [Klor-Con 10] 10 mEq 1 tablet(s) by mouth
once a day Disp #*5 Tablet Refills:*0
5. Hydrochlorothiazide 25 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Vitamin D 6000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
___ with sigmoid stricture causing a partial large bowel
obstruction, now status post laparoscopic converted to open
sigmoid resection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after an open Colectomy for
surgical management of your large bowel obstruction. You have
recovered from this procedure well and you are now ready to
return home to continue your recovery. Samples of tissue were
taken and has been sent to the pathology department. You will
receive these pathology results at your follow-up appointment.
If there is an urgent need for the surgeon to contact you
regarding these results they will contact you before this time.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to discharge which is
acceptable; however it is important that you have a bowel
movement in the next ___ days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but you should not have prolonged constipation. Some loose stool
and passing of small amounts of dark, old appearing blood are
expected. However, if you notice that you are passing bright red
blood with bowel movements or having large amounts of loose
stool without improvement please call the office or go to the
emergency room. While taking narcotic pain medications you are
at risk for constipation, please take an over the counter stool
softener such as Colace.
If you have any of the following symptoms please call the office
at ___:
fever greater than 101.5
increasing abdominal distension
increasing abdominal pain
nausea/vomiting
inability to tolerate food or liquids
prolonged loose stool
extended constipation
inability to urinate
Incisions:
You have a long vertical surgical incisions on your abdomen. It
is important that you monitor these areas for signs and symptoms
of infection including: increasing redness of the incision
lines, white/green/yellow/malodorous drainage, increased pain at
the incision, increased warmth of the skin at the incision, or
swelling of the area.
You may shower; pat the incisions dry with a towel, do not rub.
If you have steri-strips (the small white strips), they will
fall off over time, please do not remove them. Please do not
take a bath or swim until cleared by the surgical team.
Pain
It is expected that you will have pain after surgery, this will
gradually improve over the first week or so you are home. You
should continue to take 2 Extra Strength Tylenol (___) for
pain every 8 hours around the clock. Please do not take more
than 3000mg of Tylenol in 24 hours or any other medications that
contain Tylenol such as cold medication. Do not drink alcohol
while taking Tylenol. You may also take Advil (Ibuprofen) 600mg
every 8 hours for 7 days, please take Advil with food. If these
medications are not controlling your pain to a point where you
can ambulate and perform minor tasks, you should take a dose of
the narcotic pain medication. Please do not take sedating
medications or drink alcohol while taking the narcotic pain
medication. Do not drive while taking narcotic medications.
Activity
You may feel weak or "washed out" for up to 6 weeks after
surgery. Do not lift greater than a gallon of milk for 3 weeks.
At your post op appointment, your surgical team will clear you
for heavier exercise. In the meantime, you may climb stairs,
and go outside and walk. Please avoid traveling long distances
until you speak with your surgical team at your post-op visit.
Thank you for allowing us to participate in your care, we wish
you all the best!
You will be discharged home on Lovenox injections to prevent
blood clots after surgery. You will take this for 30 days after
your surgery date, please finish the entire prescription. Please
follow all nursing teaching instruction given by the nursing
staff. Please monitor for any signs of bleeding: fast heart
rate, bloody bowel movements, abdominal pain, bruising, feeling
faint or weak. If you have any of these symptoms please call our
office or seek medical attention. Avoid any contact activity
while taking Lovenox. Please take extra caution to avoid
falling.
Followup Instructions:
___
|
10274145-DS-12 | 10,274,145 | 26,170,962 | DS | 12 | 2180-08-06 00:00:00 | 2180-08-06 20:30:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
fevers, flu and right posterior leg pain
Major Surgical or Invasive Procedure:
I&D
History of Present Illness:
___ y/o M with PMHX of DM type I complicated by retinopathy,
neuropathy, nephropathy with baseline CKD stage 3, CAD s/p CAGB
and PVD s/p bilateral BKAs who was seen at urgent care on ___
for fevers, myalgias and cough. Pt was found to have influenza
and was started on Tamiflu. He returns to the ED with worsening
fevers, pain/swelling in right posterior leg and general
malaise.
Pt was notably febrile, tachycardic and hypotensive on arrival
to
the ED with lactate of 6, hyperglycemia, ___ and elevated AG
acidosis. Exam was notable for abscess over right posterior
thigh. Pt was given resuscitation with ___ of IVF, Vanc/Zosyn
and underwent bedside I/D of abscess over posterior right leg.
Pt was seen by ___ due to concern for potential DKA and had
adjustments made to insulin pump for concurrent sepsis.
Past Medical History:
Type 1 DM, on an insulin pump
HTN
Hyperlipidemia
CAD s/p CABG
History of ischemic cardiomyopathy, with recovery of LVEF
PAD
History of MRSA osteomyelitis
s/p bilateral BKA
CKD stage III
proliferative retinopathy of both eyes
Social History:
___
Family History:
Two brothers died of CV disease in ___. Sister died of colon
CA at age ___. Two siblings with factor V Leiden.
Physical Exam:
VITALS: last 24-hour vitals were reviewed; afebrile.
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: MMM
CV: RRR no apprec m/r/g
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: s/p bilateral BKAs
SKIN: mild residual erythema and soft tissue induration near to
I/D site. Draining purulent exudate; wich in place.
NEURO: Alert, oriented, face symmetric, moving all four
extremities without difficulty
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS
___ 09:31AM BLOOD WBC-6.1 RBC-3.08* Hgb-9.8* Hct-30.2*
MCV-98 MCH-31.8 MCHC-32.5 RDW-13.0 RDWSD-46.2 Plt ___
___ 09:31AM BLOOD Neuts-91* Bands-1 Lymphs-6* Monos-2*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-5.61 AbsLymp-0.37*
AbsMono-0.12* AbsEos-0.00* AbsBaso-0.00*
___ 09:31AM BLOOD Glucose-305* UreaN-47* Creat-2.1* Na-135
K-4.6 Cl-96 HCO3-13* AnGap-26*
___ 09:44AM BLOOD Lactate-6.3* -> 1.1
DISCHARGE LABS
___ 06:54AM BLOOD WBC-6.1 RBC-2.66* Hgb-8.5* Hct-25.7*
MCV-97 MCH-32.0 MCHC-33.1 RDW-13.7 RDWSD-48.8* Plt ___
___ 06:54AM BLOOD Glucose-161* UreaN-22* Creat-1.1 Na-141
K-4.6 Cl-105 HCO3-24 AnGap-12
MICROBIOLOGY
Blood cultures x2 ___: no growth four days
Wound culture from I&D of R leg abscess ___:
BETA STREPTOCOCCUS GROUP B. HEAVY GROWTH.
ANAEROBIC GRAM POSITIVE COCCUS(I). MODERATE GROWTH.
Soft tissue ultrasound (day prior to discharge)
No evidence of fluid collection in the area of new marked site
of
clinical cellulitis and prior incision and drainage site.
Brief Hospital Course:
___ w/ DM1 (on a pump), CKD III, retinopathy, bilateral BKAs
(ambulatory with prostheses), recent diagnosis of influenza, who
was admitted with sepsis ___ RLE cellulitis.
#CELLULITIS OF RLE
#SEPSIS
Patient was septic on arrival, but underwent I&D for source
control and received aggressive IV fluids with resolution of
septic physiology.
Treated with vanc/zosyn in the ED then vanc/CTX on the floor,
and then switched to vanc/CTX/Flagyl on advice of ID. Cultures
finally grew only GBS, so he is discharged on a prolonged
two-week course of Augmentin.
He was instructed to pack the I&D site with a wick and cover it
with gauze while it finishes healing. Given wound care supplies.
He found packing the wound painful in house, so he was given a
few oxycodone pills he can take prior to planned dressing
changes.
Patient will see his PCP in ___ week to ensure that the cellulitis
is mostly resolved.
Worked with ___ to figure out strategies for mobility while
temporarily unable to use his R leg prosthesis and was provided
with a rolling walker.
#INFLUENZA
Completed Tamiflu in house. He complained of terrible cough and
required near-maximal doses of cough medicine. Discharged with
benzonatate and codeine Rx.
#DM
Followed by ___ in house. They increased his insulin dose in
the setting of acute infection, and felt that by the time of
discharge he was still needing higher doses. He will leave of
the following:
BASAL
000___: 0.5
0800-___: ___: 0.55
CORRECTION BOLUSES
Carb correction ratio: 1u for every 10g carbs
Correction factor: 1:40
The patient is asked to contact his diabetician when this
becomes too much for him to help him down-titrate the dose.
OUTSTANDING ISSUES:
1) Ensure resolution of cellulitis/abscess
2) He was frequently hypertensive with systolic in the 170s in
house, even after all his home meds were resumed. However, he
was also orthostatic so meds were not increased.
3) Note that his baseline creatinine is 1.1, not 1.9 as recently
suspected. If it drifts back up, consider that he may be
chronically hypovolemic and reconsider use of torsemide.
4) Insulin dose increased by about 25% across the board; this
will likely go back to his prior dose as infection resolves.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU QHS
4. subcutaneous insulin pump subcutaneous continuous
5. Ranitidine 150 mg PO QHS
6. Simvastatin 80 mg PO QPM
7. Torsemide 10 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO BID
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*28 Tablet Refills:*0
2. Benzonatate 200 mg PO TID
RX *benzonatate 200 mg 1 capsule(s) by mouth three times a day
Disp #*18 Capsule Refills:*0
3. Codeine Sulfate 15 mg PO Q4H:PRN cough
RX *codeine sulfate 15 mg 1 tablet(s) by mouth every four (4)
hours Disp #*16 Tablet Refills:*0
4. Dextromethorphan Polistirex ___ mg PO Q12H
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH
PAIN
RX *oxycodone 5 mg 1 capsule(s) by mouth daily before dressing
change Disp #*5 Capsule Refills:*0
6. Aspirin 81 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU QHS
8. Losartan Potassium 100 mg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO BID
12. Ranitidine 150 mg PO QHS
13. Simvastatin 80 mg PO QPM
14. subcutaneous insulin pump (see hospital course for doses)
15. Torsemide 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis of right lower extremity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please take AUGMENTIN (amoxicillin-clavulinate) twice daily for
two weeks.
Change the dressing on your wound every other day.
1) Rinse the whole area with clean water (can use soap on the
surrounding area, but not in the open part)
2) Pack it firmly with gauze ribbon as a wick to draw the pus
out. As it closes up, you will be able to get less and less
ribbon in.
3) Cover with gauze pads and secure with tape.
I think you will only need to do this a few times before the
hole is pretty much closed up and pus is no longer draining.
You will see your PCP in ___ week to check on the infection, and
to recheck your blood pressure and ajust your blood pressure
meds if needed.
******************
For your insulin pump, the ___ Diabetes doctor felt you still
need the higher pump settings:
BASAL
12am 0.5
05am 0.5
08am 0.575
07pm 0.55
09pm 0.55
CORRECTION BOLUSES
Carb correction ratio: 1u for every 10g carbs
Correction if blood sugar is high: 1u for every 40 the sugar is
high.
Followup Instructions:
___
|
10274145-DS-9 | 10,274,145 | 24,521,778 | DS | 9 | 2174-06-12 00:00:00 | 2174-06-12 12:56:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
Foot infection and fever
Major Surgical or Invasive Procedure:
___ Right guillotine below-knee amputation.
___ Revision and closure of right below-knee amputation.
History of Present Illness:
Mr ___ is a ___ y/o M with hx of T1DM and chronic R foot ulcer
(followed by Dr ___ in podiatry, undergoing evaluation for
amputation), here with worsening right foot pain and swelling,
as well as fevers to 101.4 since yesterday.
.
He was last seen by his podiatrist on ___, when he underwent
debridement and continued on oral antibiotics. There was
discussion about undergoing BKA in coming weeks-months.
.
In the ED, initial VS: 104.4, HR 124, 136/43, RR 18, O2 100%.
Exam was notable for a 4x8 cm right inferior foot ulcer and
smaller ulcer on lateral malleolus, without purulent drainage.
___ pulses were dopplerable. Left foot also had small ulcer on
medial malleolus. Labs revealed leukocytosis with mild bandemia,
hgb/hct 7.7/23.7 (baseline ___, BUN/creat ___ (baseline
creat 1.2). Lactate 2.4. Plain films revealed charcot foot and
subcutaneous air in right foot/ankle. He was given vancomycin,
ciprofloxacin, metronidazole, acetaminophen, and hydromorphone.
Podiatry recommended IV antibiotics and admission to medicine,
with vascular consult on floor. ACS felt exam not c/w
necrotizing fasciitis. VS prior to transfer were 99.3, 96, 18,
103/49, 96% RA.
Past Medical History:
- T1 DM c/b retinopathy, nephropathy, neuropathy
- CAD s/p multiple NSTEMIs -> CABG ___
- CHF, with normalization of ventricular function following CABG
- Htn
- CKD
- chronic ulcers b/l feet
- HL
- H/o MRSA BSI ___
- H/o MRSA osteomyelitis ___ s/p vancomycin x 8 weeks-->
doxycycline suppression
- H/o MSSA BSI ___ s/p 11 weeks of therapy with vancomycin
(___) followed by 2 weeks of Linezolid with transition to
Levofloxacin/Doxycycline suppressive therapy stopped on ___
Social History:
___
Family History:
Two brothers died of CV disease in ___. Sister died of colon
CA at age ___. Two siblings with factor V Leiden.
Physical Exam:
ON ADMISSION:
VS - Temp 99.4F, BP 106/49, HR 108, R 20, O2-sat 95% RA
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVP 5 cm H20 at 30 degrees; +HJR,
no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - tachycardic, regular, +systolic murmur throughout
precordium, most prominent at LUSB. No rub
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - B ___ with tight dressing over feet/ankles. 3+ RLE
edema (stable/chronic per pt), no cyanosis or clubbing
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, gait assessment deferred
ON DISCHARGE:
VS: Afebrile, VSS
Resp: CTAB, no wheezes/crackles/rhonchi
CV: RRR, normal S1/S2, no S3/S4/m/g/r
Abd: Soft, NT/ND
Wound: staples open to air, no hematoma, no eccymosis
Ext:
Fem Pop DP ___
Right palp palp
Left palp palp palp palp
Pertinent Results:
ADMISSION LABS:
___ 07:25PM WBC-15.8*# RBC-2.69* HGB-7.7* HCT-23.7*
MCV-88 MCH-28.5 MCHC-32.4 RDW-13.8
___ 07:25PM NEUTS-84* BANDS-4 LYMPHS-7* MONOS-5 EOS-0
BASOS-0 ___ MYELOS-0
___ 07:25PM HYPOCHROM-3+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
___ 07:25PM PLT COUNT-544*
___ 07:25PM GLUCOSE-164* UREA N-29* CREAT-1.6* SODIUM-136
POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-27 ANION GAP-19
___ 07:33PM LACTATE-2.4*
MICRO:
___ SWAB GRAM STAIN-PENDING; WOUND CULTURE-PENDING;
ANAEROBIC CULTURE-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ SWAB GRAM STAIN-FINAL; WOUND CULTURE-PRELIMINARY;
ANAEROBIC CULTURE-PRELIMINARY
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
STUDIES:
___ R ANKLE FILM: Again demonstrated are locules of gas seen
around the ankle. No gas extends proximally up into the leg,
which makes necrotizing fascitis unlikely. The findings are more
compatible with local infection. Known extensive secondary
changes following neuropathic osteoarthropathy with massive
generalized reformations. Documentation is provided in four
images.
___ R FOOT AP/LAT: Charcot arthropathy with plantar soft
tissue ulceration. Limited evaluation for underlying
osteomyelitis given extensive osseous deformity/fragmentation.
Presence of soft tissue gas in the tissues surrounding the
distal tibia and fibula/hindfoot raise possibility of soft
tissue infection. Necrotizing fasciitis impossible to exclude.
Please correlate clinically and with more proximal views of the
right tibia/fibula as clinically warranted.
___ CXR: No acute intrathoracic process.
Brief Hospital Course:
The patient was admitted for a septic right foot. He was started
on broad spectrum antibiotics. The patient underwent a
guillotine Right BKA on ___. The patient tolerated the
procedure well. Post-operatively, the patient did well, had
great pain control with his block. He recieved two units of
blood. He remained on bedrest for the appropriate time period.
His wound cultures grew MSSA, and his blood cultures from ___
also grew MSSA. He was continued on IV antibiotics and seen by
infectious disease to help tailor his regimen. He went beack to
the OR on ___ for a completion and closure Right BKA, which
he tolerated well. Postoperatively, the patient did well, had
adequate pain control. He received 3 units of blood. Physical
Therapy worked with him to help with transfers and upper body
strengthening. He was also followed by ___ for uncontrolled
sugars, which have been improving. The patient was discharged to
a rehab facility in stable condition. He will go wth a PICC and
IV nafcillin for 4 weeks and levaquin for 10 days. The patient
is afebrile and has minimal pain and his white count has
improved. He will follow up in ___ clinic and with
podiatry.
Medications on Admission:
- acetic acid - 0.25 % Solution - use on wound once a day
- CYCLOBENZAPRINE - 10mg Q8 PRN neck pain
- FLUTICASONE - 50 mcg Spray 2 sprays each nostril daily
- FUROSEMIDE - 120 mg BID
- GLUCAGON PRN
- INSULIN ASPART [NOVOLOG PENFILL] - PUMP
- METOPROLOL SUCCINATE - 200 mg Tablet daily
- OMEPRAZOLE - 20 mg BID
- RANITIDINE HCL - 300 mg QHS
- SILVER SULFADIAZINE - 1 % Cream - apply to area left foot once
a day
- SIMVASTATIN - 80 mg daily
- TADALAFIL [CIALIS] - 20 mg PRN
- VALSARTAN [DIOVAN] - 80 mg daily
- ASPIRIN - 81 mg daily
- FERROUS SULFATE - 324 mg (65 mg Iron) daily
- MULTIVITAMIN - one Tablet daily
Discharge Medications:
1. Insulin Pump IR1250 Misc Sig: self adminstering
Miscellaneous continuous.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. levofloxacin in D5W 250 mg/50 mL Piggyback Sig: One (1)
Intravenous Q24H (every 24 hours) for 10 days.
9. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
Intravenous Q4H (every 4 hours) for 4 weeks.
10. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. Lasix 40 mg Tablet Sig: Three (3) Tablet PO once a day.
12. Diovan 80 mg Tablet Sig: One (1) Tablet PO once a day.
13. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
14. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
15. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours).
16. fluticasone 50 mcg/Actuation Disk with Device Sig: Two (2)
Inhalation once a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Septic right foot.
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 FOLLOWING BELOW KNEE AMPUTATION
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
.
ACTIVITY:
There are restrictions on activity. On the side of your
amputation you are non weight bearing until cleared by your
Surgeon. You should keep this amputation site elevated when ever
possible.
.
You may use the other leg to assist in transferring and pivots.
But try not to exert to much pressure on the amputation site
when transferring and or pivoting. Please keep knee immobilizer
on at all times to help keep the amputation site straight.
.
No driving until cleared by your Surgeon.
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s) .
.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
.
Exercise:
.
Limit strenuous activity for 6 weeks.
.
Do not drive a car unless cleared by your Surgeon.
.
Try to keep leg elevated when able.
.
BATHING/SHOWERING:
.
You may shower immediately upon coming home. No bathing. A
dressing may cover youre amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
.
WOUND CARE:
.
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
.
MEDICATIONS:
.
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
You have a PICC line through which you will receive IV
antibiotics (nafcillin) for a total of 2 weeks.
.
CAUTIONS:
.
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
.
Avoid pressure to your amputation site.
.
No strenuous activity for 6 weeks after surgery.
.
DIET :
.
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
.
FOLLOW-UP APPOINTMENT:
.
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
.
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10274368-DS-2 | 10,274,368 | 22,376,342 | DS | 2 | 2176-10-04 00:00:00 | 2176-10-04 12:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall with LOC
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yea old male on Pradaxa for atrial fibrillation had a
mechanical fall while climbing stairs into his home. The patient
was balancing leftover dishes when he lost his balance and fell
backwards onto his sister who was behind him. He endorses a loss
of consciousness with his next memory after the fall being
awakened at ___.
Past Medical History:
DM II
HTN
HLD
Gout
Pancreatitis
Atrial fibrillation
Actinic Keratosis
Basal Cell Skin cancer
Social History:
___
Family History:
non-contributory
Physical Exam:
ON ADMISSION:
O: T:99.5 BP: 162/80 HR:65 R:18 O2Sats: 95% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ EOMs
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
ON DISHCARGE:
___: Alert and oriented x3. PERRL. EOMs intact. Face
symmetrical. Tongue midline. No pronator drift. Full strength
___ on bilateral upper and lower extremities. Denies headache,
nausea, dizziness. Ambulating with cane (baseline)
Pertinent Results:
___ Non-contrast head CT
IMPRESSION:
1. Compared to ___, no new or enlarging hemorrhage.
2. No significant change in a small right parietal subdural
hemorrhage or
subdural hematoma along the falx.
3. Unchanged large right parietal subgaleal hematoma without
underlying or
other fracture.
4. No midline shift. No definite sulcal effacement.
5. No evidence of infarction, edema or mass.
6. Involutional changes and likely chronic microvascular
ischemic changes.
Brief Hospital Course:
Mr. ___ is an ___ yo M with history of afib on Pradaxa who was
transferred from ___ after a mechanical fall
sustained at his home when he lost his balance carrying dishes.
A non-contrast head CT was concerning for a small right subdural
hematoma and he was transferred to ___ ED. He was given
praxadine and was admitted to the neuro floor for further
evaluation. A repeat NCHCT was stable and he remained
neurologically stable. He was started on Keppra prophylactically
for 7 days. He began ambulating with nursing with a cane from
home and physical therapy was consulted. ___ determined the
patient was cleared to go home with 24 hour supervision that
could be provided by the patient's sister. He is also being
discharged with outpatient physical therapy.
On discharge he remained neurologically intact and denies
headaches, nausea, and dizziness. He is to continue Keppra for 7
days unless he has a seizure in which case he will need to
continue the medication. He may resume his Pradaxa after 7 days.
There is no need to follow-up with neurosurgery however should
follow-up with his PCP after discharge.
Medications on Admission:
Allopurinol ___ daily
Amlodipine 5mg daily
Dabigatran etexilate 150mg BID
Furosemide 40mg daily
Hydrocholorothiazide 25mg daily
Regular insulin
Lisinopril 20mg BID
Motoprolol succinate 25mg daily
Mirtazapine 15mg daily
Simvastatin 20mg QHS
Zolpidem 10mg daily prn
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
Do not exceed 4GM acetaminophen in 24 hours.
2. Docusate Sodium 100 mg PO BID
3. LevETIRAcetam 500 mg PO Q12H Duration: 7 Days
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
4. Senna 17.2 mg PO HS
5. Insulin SC
Sliding Scale - to resume home dose and frequency
Fingerstick QACHS, QPC2H, HS, QAM
Insulin SC Sliding Scale using REG Insulin - to resume home dose
and frequency
6. Allopurinol ___ mg PO DAILY
7. amLODIPine 5 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Hydrochlorothiazide 25 mg PO DAILY
10. Lisinopril 20 mg PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Mirtazapine 15 mg PO QHS
13. Simvastatin 20 mg PO QPM
14.Outpatient Physical Therapy
Diagnosis: Right subdural hematoma
Indication: Balance training and endurance training.
Frequency/Duration: ___ for 1 week
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Right SDH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (cane).
Discharge Instructions:
Discharge Instructions
Brain Hemorrhage without Surgery
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may resume your Pradaxa in 7 days.
You have been discharged on Keppra (Levetiracetam) for 7 days.
This medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instructions. It is
important that you take this medication consistently and on
time. If you have a seizure you will need to continue this
medication and should inform your PCP.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10274526-DS-9 | 10,274,526 | 21,117,739 | DS | 9 | 2180-04-17 00:00:00 | 2180-04-25 06:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pain in the right axilla
Major Surgical or Invasive Procedure:
Excisional biopsy of the right axillary lymph node.
History of Present Illness:
Briefly, Mr. ___ is a ___ y/o male with a history of substance
abuse who presented with pain under his axilla. He notes that he
first noticed some discomfort about 1 and half weeks ago. At
that time he had dull abdominal pain and vomiting 5x of watery
content, he is constipated. Pain and vomiting resolved in 2
days. After the pain in abdomen he started havin burning
sensation during urination, had to urinate ___ times during the
day and ___ during the night. After ___ days urinary symptoms
went away. However, pain in his axilla persisted. He thought it
was something that would pass however the discofort got worse
and he noted that there was swelling so he presented to ___. He
notes that they did X-rays and told him to take tylenol and
ibuprofen and that it would resolve. They recommended that he
get plugged in with a PCP. The pain continued to get worse and
felt that a golf ball sized mass was begining to develop. He
represented to ___ which sent him home again. Due to his
continued concern he presented to BI for evaluation. The pain is
only located under his right axilla and denied any radiation. He
rated the pain ___ but gets up to a ___ with manipulation.
Lying on his side makes the pain worse and keeping his arm
elevated makes the pain better. He notes that he has been having
fevers for the past week upb to 101 and that his friends have
told him that he has lost weight, about ___ Ibs in the last 3
mo. He says he is sweating during the night. He had no sexual
contacts (denies STDs), no travels or contacts with animals for
the long time. He was scheduled to see his new PCP ___ 2 days.
.
In the ED, initial VS: 98.2 95 131/76 16 100%. He had an
ultrasound of his right axilla which showed a 5.3 x 3.5 x 4.9 cm
heterogeneous mass with internal hypoechogenicity, likely
necrosis, and vascularity. Findings concerning for necrotic
lymph node/malignancy and biopsy/FNA recommended. He was given 2
tabs of percocet and admitted for further evaluation.
.
On the floor, he states that he continues to be in pain. He
notes that the percocet helped but did not last very long.
Past Medical History:
Substance Abuse (oxycodone crushed, heated and injected iv)
Knee Injury (torn ACL/MCL)
L4 and L5 compressed
Social History:
___
Family History:
His grandmother had a significant MI at the age of ___. He denied
any family history of malignancy. He notes having an aunt with
lupus.
Physical Exam:
PE at the admission:
VS - Temp F 99.3, BP 114/66, HR 74, 98 O2-sat % RA
GENERAL - well-appearing in NAD, wet from sweating,
uncomfortable but appropriate
HEENT - EOMI, sclerae anicteric, MMM
NECK - supple, no thyromegaly, no JVD,
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, 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)
No track marks noted on right arm
LYMPH - large lymph node palpated in right axilla which was
tender, soft and freely mobile, no other lymph nodes can be
palpated.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout,
.
PE at the discharge:
VS - Temp F 97.8, BP 98/58, HR 73, 97 O2-sat % RA
GENERAL - well-appearing in NAD, wet from sweating,
uncomfortable but appropriate
HEENT - EOMI, sclerae anicteric, MMM
NECK - supple, no thyromegaly, no JVD,
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, 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)
No track marks noted on right arm
LYMPH - large lymph node palpated in right axilla which was
tender, soft and freely mobile, no other lymph nodes can be
palpated.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout.
Pertinent Results:
Labs at the admission:
___ 08:20PM BLOOD WBC-9.2 RBC-4.57* Hgb-12.6* Hct-37.8*
MCV-83 MCH-27.5 MCHC-33.2 RDW-12.7 Plt ___
___ 08:20PM BLOOD Neuts-67.7 ___ Monos-4.1 Eos-1.6
Baso-0.6
___ 08:20PM BLOOD Glucose-94 UreaN-10 Creat-1.0 Na-137
K-4.2 Cl-100 HCO3-26 AnGap-15
___ 05:40AM BLOOD ALT-25 AST-23 AlkPhos-79 TotBili-0.2
___ 05:40AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.0
.
Labs at the discharge:
___ 05:18AM BLOOD WBC-7.2 RBC-4.36* Hgb-12.5* Hct-36.3*
MCV-83 MCH-28.6 MCHC-34.3 RDW-12.8 Plt ___
___ 05:18AM BLOOD Neuts-66.4 ___ Monos-4.6 Eos-3.2
Baso-0.6
___ 05:18AM BLOOD Plt ___
___ 05:18AM BLOOD Glucose-101* UreaN-13 Creat-0.9 Na-136
K-4.2 Cl-101 HCO3-27 AnGap-12
___ 05:18AM BLOOD ALT-25 AST-17 LD(LDH)-145 AlkPhos-72
TotBili-0.2
.
CT scan of the chest:
1. No hilar or mediastinal adenopathy. Mediastinal contour
displaced by fat
accounts for the appearance on conventional radiographs.
2. Large right axillary mass, less likely organized hematoma.
3. Mild bronchiolar inflammation, most commonly seen in smokers,
or patients
with severe allergies or asthma.
.
CXR:
There is moderate enlargement of both hila, left greater than
right as well as
lobulation to mediastinal contours lateral to the pulmonary
outflow tract and
extending into the aortopulmonic window consistent with central
adenopathy.
It could be tiny granulomatous calcifications in the lungs or
these might be
vessels on end. There are no nodules large enough to raise
concern for
malignancy. Heart size is normal and there is no pleural
effusion.
Differential diagnosis includes sarcoidosis as well as other
causes of
adenopathy, dependent upon clinical circumstances, which could
include
lymphoma or disseminated malignancy.
.
US of the right axilla: 5.3 x 3.5 x 4.9 cm axillary mass with
internal vascularity, which
may represent a necrotic or malignant lymph node. Further
evaluation with
FNA/biopsy is recommended.
Brief Hospital Course:
___ a history of substance abuse presented with pain under
his axilla noted to have a concerning lymph node on ultrasound.
We have performed the excisional biopsy of the lymph node and
have sent the tissuse for the analysis - for Bartonella (cat
scratch disease), TB, culture, PHD (question of malignancy and
autoimmune diseases), serology for Bartonella. HIV and RPR
already came negative. CT chest was also performed but this
showed small lymphnode with calcifications, but not
significantly enlarged. We will let him know the results of the
biopsy at the phone No at his mother's place: ___.
Results of biopsy arrived one week after discharge. See results
section. Biopsy was highly suspcious for a Bartonella
infection, this in addition to Igg and IgM positive Bartonella
titers, and patient hisotry of cat scratch were suggestive of
Bartonella being the cause of enlarged lymph node. Patient was
informed of this diagnosis.
Pt. will come tomorrow ___ for the PPD reading.
He will f/u with the homeless center at the ___ in a week.
Documents will be sent to Dr. ___, ___, ___
___, who will see him on ___.
Medications on Admission:
ibuprofen for pain
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours)
as needed for pain for 3 days.
Disp:*24 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Rigth axillary lymphadenopathy
Substance Abuse
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. You came because of the
pain and nodule in your right armpit. The nodule was a lymph
node that was removed for analysis, the results will return in
one week. We will call you with the results of a lymph node
biopsy at the phone number you gave us. Please follow up with
the PCP for the homeless in a week time for wound check.
Please follow up tomorrow to our ward, ___
___ floor, ___ for the reading of PPD test.
We gave you a prescpription for the pain medication - oxycodone,
for the next few days. In addition to that you can take Tylenol
up to 3 g a day for pain. Additional pain medications will need
to be prescribed by your primary care.
Followup Instructions:
___
|
10274866-DS-25 | 10,274,866 | 21,280,906 | DS | 25 | 2167-09-01 00:00:00 | 2167-09-07 13:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / acetaminophen
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___ w/ HTN, DM, Asthma, CAD who presents with
dyspnea and productive cough for 5 days. He states his breathing
has been worse for the last several years, but that over the
last 5 days he developed a productive cough of yellow sputum. He
endorses some subjective chills but no fever. (+) Orthopnea,
denies PND, leg swelling, weight gain, Nausea/vomiting. He
denies any sick contacts or recent travel. He recently got a flu
shot at his PCP
In the ___, initial vitals: 99.4 83 135/81 20 100% RA
- Exam notable for: diffuse wheezes
- Labs notable for: WBC 8.3, hgb 12.6, Cr 1.1, Flu negative,
Trop negative x2, lactate 1.4. H
- Imaging notable for: bibasilar fibrotic changes without acute
cardiopulmonary process.
- Pt given: Azithromycin 500mg PO, Prednisone 60mg daily,
Zofran, morpine, oxycodone, insulin and multiple nebulizers of
albuterol and ipratoprium.
- Vitals prior to transfer: 98.1 90 109/65 18 99% RA
On arrival to the floor, pt reports his breathing feels fine and
improved from prior.
Past Medical History:
DM
Anemia
Asthma/COPD
CAD
angioedema
subdural hematoma
schizoaffective disorder
exertional dyspnea
Social History:
___
Family History:
No history of hereditary angioedema, daughter with diabetes.
Otherwise non-contributory.
Denies family psychiatric history.
Physical Exam:
ADMISSION EXAM:
Vitals- 97.1 121/67 90 18 96% RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- poor air movement, end expiratory wheezes
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present,
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro-alert and conversational, able to move all extremities
DISCHARGE EXAM:
Vitals- 97.4 119/79 (107-122) 74 18 97%RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- good air movement,diffuse rhonchi, transmitted upper
airway sounds
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present,
GU- no foley
Ext- warm, well perfused, no clubbing, cyanosis or edema
Neuro-alert and conversational, able to move all extremities
Pertinent Results:
ADMISSION LABS:
___ 04:10PM ___ PTT-28.5 ___
___ 04:10PM PLT COUNT-194
___ 04:10PM NEUTS-65.5 ___ MONOS-11.0 EOS-2.9
BASOS-0.7 IM ___ AbsNeut-5.45 AbsLymp-1.62 AbsMono-0.92*
AbsEos-0.24 AbsBaso-0.06
___ 04:10PM WBC-8.3 RBC-4.30* HGB-12.6* HCT-38.6* MCV-90
MCH-29.3 MCHC-32.6 RDW-12.5 RDWSD-40.6
___ 04:10PM CALCIUM-9.6 PHOSPHATE-1.9* MAGNESIUM-1.4*
___ 04:10PM cTropnT-<0.01
___ 04:10PM GLUCOSE-221* UREA N-20 CREAT-1.1 SODIUM-137
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-26 ANION GAP-14
___ 04:24PM LACTATE-1.4
___ 05:15PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 10:15PM cTropnT-<0.01
___ 08:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
DISCHARGE LABS:
___ 06:47AM BLOOD WBC-11.2* RBC-4.02* Hgb-12.1* Hct-35.8*
MCV-89 MCH-30.1 MCHC-33.8 RDW-12.4 RDWSD-40.0 Plt ___
___ 04:10PM BLOOD Neuts-76.7* Lymphs-12.2* Monos-10.0
Eos-0.1* Baso-0.3 Im ___ AbsNeut-10.33*# AbsLymp-1.64
AbsMono-1.35* AbsEos-0.01* AbsBaso-0.04
___ 06:47AM BLOOD ___ PTT-26.3 ___
___ 06:47AM BLOOD Glucose-133* UreaN-24* Creat-1.0 Na-139
K-3.5 Cl-101 HCO3-24 AnGap-18
PERTINENT IMAGING:
CXR
Bibasilar fibrotic changes are noted, better seen on patient's
prior CT chest examination. The lungs are well expanded without
focal consolidation, pleural effusion, pneumothorax, or
pulmonary edema. The cardiomediastinal silhouette is within
normal limits.
IMPRESSION:
Chronic bibasilar fibrotic changes without acute cardiopulmonary
process.
Brief Hospital Course:
___ w/ HTN, DM, Asthma, CAD presents with dyspnea for 1 day. He
describes the cough as productive with subjective chills but no
fever. He denies any lower leg swelling
# COPD Exacerbation: Patient with dyspnea on exertion with
diffuse wheezing and no improvement in ___ with azithromycin and
prednisone. Patient found to have a viral bronchitis and
presumed COPD exacerbation. He was started on prednisone and
azithromycin and improved. He was discharged to complete a 5 day
course of both (stop ___. He should follow up with pulmonary
as an outpatient to get PFTs.
# DM -held oral agents, continued home regimen
#HTN- continued home BP meds
#CAD- continued BB, statin, ASA
# Mental Health- continued home meds
TRANSITIONAL ISSUES:
-started Spiriva
-finish 5 day course of Prednisone 40mg (Stop ___
-finish 5 day course of azithromycin (Stop ___
-outpatient PFTs
-Smoking cessation
# CODE STATUS: Full (confirmed ___
# CONTACT: ___ (Daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. GlipiZIDE 5 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Ibuprofen 600 mg PO Q8H:PRN pain
5. levemir 15 Units Breakfast
levemir 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Lactulose 15 mL PO DAILY constipation
7. Losartan Potassium 100 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Perphenazine 16 mg PO Frequency is Unknown QHS
10. Viagra (sildenafil) 100 mg oral DAILY:PRN need
11. Simvastatin 40 mg PO QPM
12. TraZODone 100 mg PO QHS
13. Aspirin 81 mg PO DAILY
14. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
BID
15. Multivitamins 1 TAB PO DAILY
16. Naphazoline-Pheniramine Ophth. Solution 1 DROP BOTH EYES TID
17. Omeprazole 20 mg PO DAILY
18. peg 400-propylene glycol 0.4-0.3 % ophthalmic TID
19. Terbinafine 1% Cream 1 Appl TP DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Ibuprofen 600 mg PO Q8H:PRN pain
4. levemir 15 Units Breakfast
levemir 50 Units Bedtime
5. Losartan Potassium 100 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Simvastatin 40 mg PO QPM
10. TraZODone 100 mg PO QHS
11. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
12. Azithromycin 250 mg PO Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
13. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 2 IH INH
daily Disp #*1 Capsule Refills:*0
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap
inh daily Disp #*1 Capsule Refills:*0
14. Viagra (sildenafil) 100 mg oral DAILY:PRN need
15. Terbinafine 1% Cream 1 Appl TP DAILY
16. Perphenazine 16 mg PO QHS QHS
17. peg 400-propylene glycol 0.4-0.3 % ophthalmic TID
18. Naphazoline-Pheniramine Ophth. Solution 1 DROP BOTH EYES TID
19. Lactulose 15 mL PO DAILY constipation
20. GlipiZIDE 5 mg PO DAILY
21. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
BID
22. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
COPD Exacerbation
Bronchitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you at ___
___. You came to the hospital because you had a cough
and trouble breathing. You were found to have a bronchitis and a
worsening of your underlying lung disease. We gave you
antibiotics and steroids to help with your breathing. Please
finish your prescriptions. We are also starting you on a new
inhaler.
Please follow up at your appointments below.
~Your ___ Team
Followup Instructions:
___
|
10275325-DS-3 | 10,275,325 | 29,093,969 | DS | 3 | 2135-09-20 00:00:00 | 2135-09-20 10:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L humerus fracture
Major Surgical or Invasive Procedure:
ORIF L medial condyle elbow
History of Present Illness:
___ healthy male with no past medical history presents
with left arm pain and the feeling of a pop after a workout
injury. On exam the patient is closed and neurovascularly
intact, patient was splinted and wrapped. X-rays demonstrate a
displaced left medial epicondyle fracture. This is a surgical
injury, the patient prefers to be admitted to the hospital
knowing that he may not have surgery tomorrow given the OR
schedule and the variability of what comes in overnight.
Past Medical History:
Healthy
Social History:
___
Family History:
NC
Physical Exam:
ACE c/d/I
Fires AIN/PIN/ulnar
SILT on digits
Digits WWP distally
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 humerus fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF of his L distal humerus
fracture, 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 ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the left upper extremity, and will be
discharged on ASA 325mg daily for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
Pantoprazole
MultiV
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*50 Tablet Refills:*0
2. Aspirin 325 mg PO DAILY Duration: 28 Days
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*28
Tablet Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed Disp #*20 Tablet Refills:*0
4. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Left medial condyle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please
follow your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non-weightbearing left upper extremity. Okay for coffee-cup
but NO more weight than that.
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is an
over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean off
this medication in 1 week or sooner. This is an example on how
to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and continue following
the bowel regimen as stated on your medication prescription
list. These meds (senna, colace, miralax) are over the counter
and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your physicians
at discharge.
8) Continue all home medications unless specifically instructed
to stop by your surgeon.
ANTICOAGULATION:
- Please take aspirin 325mg once daily for 4 weeks. This is to
prevent blood clots. You will not need to take this medication
forever.
WOUND CARE:
- You may shower after 3 days. 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.
- You may take down the ACE wrap after 3 days. After this,
incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
Please call his office to confirm this appointment at the time
of your discharge. His office number is ___.
Followup Instructions:
___
|
10275408-DS-5 | 10,275,408 | 20,562,387 | DS | 5 | 2157-02-20 00:00:00 | 2157-02-19 09:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bike accident
Major Surgical or Invasive Procedure:
C67 ACDF
History of Present Illness:
Reason for Consult: c-spine fractures
HPI: ___ s/p bicycle accident, bicycle versus car. He had loss
of
consciousness, and has no recollection of the accident. He was
wearing a helmet, which sustained significant damage. He is
currently fully oriented, and complains only of pain in his
right
arm, from the elbow through the hand.
In the ED, CT head showed small subarachnoid hemorrhage and
intraparenchymal hemorrhage. CT C-spine showed minimally
distracted fractures through the articular pillars of C4, C6 and
C7.
PMH: Inguinal hernia as child
MED: None
ALL: NKDA
SH: Rare alcohol, no tobacco or drugs
PE:
Vitals:
General: NAD
Mental Status: AAOx3
No c-spine tenderness
Cranial nerves II-XII grossly intact
Sensory:
States diminished sensation to light touch throughout the
entirety of the hand, fingers, and forearm distal to the elbow
bilaterally, not specific to any dermatome or nerve distribution
T2-L1 (Trunk) intact
___ L2 L3 L4 L5S1S2
(Groin)() (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
Rintactintactintactintact intactintact
Lintact intactintactintact intactintact
Motor:
UEDlt(C5)Bic(C6)WE(C6)Tri(C7)WF(C7)FF(C8)FinAbd(T1)
R 5 5 0 5 0 0 0
L 5 5 3 5 ___
___ Flex(L1)Add(L2)
___
R ___ 5 5 5 5
L 5 5 5 5 5 5 5
Reflexes
Bic(C4-5)BR(C5-6)Tri(C6-7)Pat(L3-4)Ach(L5-S1)
R 1 1 1 2 1
L 1 1 1 2 1
Rectal tone: WNL per ED/ACS
Estimated Reliability of Exam: fair, limited by pain throughout
b/l UE
LABS: 3.7 > 43.5 < 149
___ 10.8 PTT 27.8 INR 1.0
IMAGING: CT c-spine wet read (not final): Minimally distracted
fractures through the articular pillars of C4, C6 and C7.
Alignment is maintained.
IMPRESSION & RECOMMENDATIONS: ___ s/p bicycle accident, now
with
cervical spine fractures seen on CT and possible weakness in the
right hand, but poor reliability of exam. Inability to obtain a
normal neurologic exam, recommend emergent MRI of the cervical
spine for cord injury. ___ J. collar at all times. We will
followup on the MRI results.
Past Medical History:
see HPI
Social History:
___
Family History:
see HPI
Physical Exam:
At time of discharge
Sensory: decreased in both UE, non dermtomal.
Motor:
UEDlt(C5)Bic(C6)WE(C6)Tri(C7)WF(C7)FF(C8)FinAbd(T1)
R 2 2 1 3 1 0 0
L 2 3 2 3 ___
___ Flex(L1)Add(L2)
___
R ___ 5 5 5 5
L 5 5 5 5 5 5 5
DTR normal in ___. UE decreased.
Pertinent Results:
___ 10:20AM PH-7.32* INTUBATED-NOT INTUBA VENT-SPONTANEOU
COMMENTS-GREEN TOP
___ 10:20AM HGB-14.5 calcHCT-44 O2 SAT-86 CARBOXYHB-2 MET
HGB-0
___ 10:20AM freeCa-1.12
___ 10:19AM LIPASE-29
___ 10:19AM WBC-3.7* RBC-5.07 HGB-14.2 HCT-43.5 MCV-86
MCH-28.0 MCHC-32.7 RDW-12.9
___ 10:19AM ___ PTT-27.8 ___
___ 10:19AM ___
MRI cervical spine
1. Increased cord signal at C4-C5 level concerning for cord
edema or cord
contusion.
2. Disc herniation at C6-C7 level narrowing the spinal canal and
remodeling
the cervical spinal cord as described above.
3. Acute compression fractures of C7, T1, T2, and T3 vertebral
bodies as
described above. Increased signal intensity at the
anteroinferior part of C2
concerning for bone contusion.
4. Increased Signal intensity seen in the posterior elements of
C3, C4, C6,
and C7 on the left. The fractures at these sites were much
better evaluated
on the recent CT cervical spine study.
Elbow hand wrist Xray
Slight obliquity limits the lateral view of the elbow, but there
is no
evidence for fracture, dislocation, bone destruction or joint
effusion.
The ulnar styloid is attenuated with a small smooth corticated
ossicle where
the styloid would usually be expected suggesting either a normal
variant or
perhaps sequela of remote prior trauma. The scapholunate joint
appears
minimally irregular, also probably a chronic finding if it were
to be
confirmed, although bony detail is not optimally assessed with
because of
overlying dressing material. However, there is no evidence for a
recent
fracture, dislocation or bone destruction.
CT head
1. Small subarachnoid hemorrhage in the bilateral frontal lobes,
punctate
intraparenchymal hemorrhage in the right corpus callosum, and
equivocal focus
of hemorrhage in the right cerebellar hemisphere. Attention to
the latter
site is recommended in follow-up to help determine whether a
true lesion is
present at the site since the posterior fossa is difficult to
assess due to
streak artifact. The focus of hemorrhage in the corpus callosum
raises concern
for diffuse axonal injury.
2. No significant mass effect or cerebral edema.
3. No evidence of fracture
___ 10:20AM PH-7.32* INTUBATED-NOT INTUBA VENT-SPONTANEOU
COMMENTS-GREEN TOP
Brief Hospital Course:
Patient was admitted to the ACS service and transferred to ___
Spine Surgery Service and taken to the Operating Room for the
above procedure. Refer to the dictated operative note for
further details. The surgery was without complication and the
patient was transferred to the PACU in a stable condition.
TEDs/pnemoboots were used for postoperative DVT prophylaxis.
Intravenous antibiotics were continued for 24hrs postop per
standard protocol. Initial postop pain was controlled with a
PCA. Diet was advanced as tolerated. The patient was
transitioned to oral pain medication when tolerating PO diet.
Foley was removed on POD#2.
Right wrist and elbow injury was investigated in the ED using
radiographs. No fractures were noted.
For head injury, Neurosurgery recommended:
1. Antiseizure Prophylaxsis is not required
2. Follow- up appointment with Dr ___ in 4 weeks, with
a Non-contrast CT scan of the head.
OT were consulted for arms/hand splints.
___: Patient developed stage 2 pressure sore over the medial
epicondyle of right elbow.
Physical therapy was consulted for mobilization OOB to ambulate.
Occupational therapist were consulted. Hand splints were given
to prevent joint contractures. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
Medications on Admission:
None
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
2. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain fever.
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation. Tablet(s)
6. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Central cord syndrome and C67 disc protrusion and right sided C4
C6 C7 facet fractures.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You have undergone the following operation: Anterior Cervical
Decompression and Fusion
Immediately after the operation:
- Activity:You should not lift anything greater than 10 lbs
for 2 weeks. You will be more comfortable if you do not sit in a
car or chair for more than ~45 minutes without getting up and
walking around.
- ___/ Physical Therapy:
o ___ times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can
tolerate.
o Isometric Extension Exercise in the collar: 2x/day x ___xercises as instructed.
- Swallowing: Difficulty swallowing is not uncommon after
this type of surgery. This should resolve over time. Please
take small bites and eat slowly. Removing the collar while
eating can be helpful however, please limit your movement of
your neck if you remove your collar while eating.
- Cervical Collar / Neck Brace: You need to wear the brace
at all times until your follow-up appointment which should be in
2 weeks.
- Wound Care:Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to
control your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take
baseline x rays and answer any questions.
o We will then see you at 6 weeks from the day of the
operation. At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Physical Therapy:
see discharge instructions
Treatments Frequency:
see discharge instructions
Followup Instructions:
___
|
10275529-DS-27 | 10,275,529 | 28,720,493 | DS | 27 | 2125-06-03 00:00:00 | 2125-06-05 21:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
reglan with prozac / Motrin
Attending: ___.
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with history of NASH cirrhosis complicated by
ascites, varices, and encephalopathy, hepatocellular carcinoma
status post TACE and RFA without recurrence, portal vein
thrombosis currently on Lovenox, on transplant list with MELD
28, diabetes, and gastroparesis presenting with anemia. She has
refractory ascites requiring q2week paracentesis and presented
today for a paracentesis. She had 5.1 L of fluid removed (and
received 37.5 grams of 25% albumin) and was sent to the ED
post-procedure for a drop in Hct. Recent H./H. from ___ was
___ and today is 7.0/22.8.
Patient feels well. Denies any new weakness, headache, fevers.
She denies any chest pain or shortness of breath. She denies any
melena or hematochezia. She denies any back pain or abdominal
pain. She denies any hematuria.
In the ED, initial VS were 97.6 52 92/38 18 99% RA. UA was
negative. WBC 2.5, H/H 7.0/22.8, plt 82. Peritoneal fluid with
30 WBCs. INR 1.0. Cr 1.5 (at baseline), ALT 39, AST 50,
Tbili0.6, albumin 3.9. She had guaiac positive brown stools.
Patient was ordered for 1unit pRBCs.
Past Medical History:
- NASH cirrhosis complicated by varices, ascites, encephalopathy
- Hepatocellular carcinoma
- Diabetes mellitus
- Gastroparesis
- Hypertension
- Hyperlipidemia
- History of MRSA bacteremia (___)
- Serotonin syndrome in the setting of metoclopramide?
- Transverse colonic adenoma (on CLN in ___ with history of
prior colonic polyps - repeat due in ___
ONCOLOGIC HISTORY:
- Liver MRI on ___ showed a 3-4 cm segment VI lesion with
arterial enhancement and washout consistent with HCC;
recommendation for TACE-RFA made at liver tumor conference
- ___ - TACE to segment VI lesion
- ___ - CT-guided thermal ablation of segment VI
hepatocellular carcinoma
- ___ - Right-sided thoracentesis - likely post-TACE
exudative effusion, cytology and cultures negative
- ___ - MR imaging without recurrence; interval progression
of a non-occlusive thrombus now involving the proximal vein and
superior
mesenteric vein (now with nearly occlusive thrombus), close to
the confluence
PAST SURGICAL HISTORY:
- open cholecystectomy (___)
- total abdominal hysterectomy (___)
Social History:
___
Family History:
She has a positive family history of CAD. Her brother died with
heart attack at age of ___. Her father died with unknown primary
cancer with metastasis to the brain and her mother died with
bladder cancer at the age of ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.6 52 92/38 18 99% RA
General: well appearing female, NAD
HEENT: dry MM, anicteric sclerae, pink conjunctiva
Neck: Supple
CV: RRR (+)S1/S2 no m/r/g
Lungs: Generally CTA b/l
Abdomen: Soft, non-distended, non-tender, ecchymoses at
enoxaparin sites
GU: Deferred
Ext: Warm, well-perfused, no ___ edema
Neuro: AOx3, no asterixis
Skin: Warm, dry
DSICHARGE PHYSICAL EXAM:
VS: 98.1 (Tmax 98.7) 104/44 (97-104) 59 (59-60) 20 100RA
General: well appearing female, NAD
HEENT: dry MM, anicteric sclerae, pink conjunctiva
Neck: Supple
CV: RRR (+)S1/S2 no m/r/g
Lungs: Generally CTA b/l
Abdomen: Soft, non-distended, non-tender, ecchymoses at
enoxaparin sites
GU: Deferred
Ext: Warm, well-perfused, no ___ edema
Neuro: AOx3, no asterixis
Skin: Warm, dry
Pertinent Results:
ADMISSION LABS:
___ 08:19AM BLOOD WBC-4.0 RBC-2.87* Hgb-8.0* Hct-24.6*
MCV-86 MCH-27.9 MCHC-32.5 RDW-16.6* Plt Ct-92*
___ 02:25PM BLOOD Neuts-73.6* Lymphs-12.8* Monos-9.3
Eos-3.0 Baso-1.3
___ 08:24AM BLOOD ___
___ 08:19AM BLOOD Glucose-83 UreaN-36* Creat-1.5* Na-138
K-4.6 Cl-103 HCO3-25 AnGap-15
___ 08:19AM BLOOD ALT-39 AST-50* TotBili-0.6
___ 08:19AM BLOOD Albumin-3.9 Calcium-9.0 Phos-3.0 Mg-2.8*
___ 03:16PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:16PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 03:16PM URINE RBC-5* WBC-1 Bacteri-FEW Yeast-NONE Epi-1
___ 03:16PM URINE CastHy-20*
___ 03:16PM URINE Hours-RANDOM UreaN-1062 Creat-115 Na-LESS
THAN K-57 Cl-LESS THAN
MICRO:
PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 3:16 pm URINE SOURCE: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
IMAGING:
PARACENTESIS ___:
IMPRESSION:
Successful diagnostic and therapeutic paracentesis with removal
of 5.1 L of clear, straw-colored ascitic fluid.
CXR ___:
IMPRESSION:
No acute cardiopulmonary process.
DISCHARGE LABS:
___ 06:10AM BLOOD WBC-2.8* RBC-3.02* Hgb-8.2* Hct-26.2*
MCV-87 MCH-27.3 MCHC-31.5 RDW-17.0* Plt Ct-82*
___ 06:10AM BLOOD ___ PTT-33.0 ___
___ 06:10AM BLOOD Glucose-163* UreaN-30* Creat-1.3* Na-136
K-4.7 Cl-103 HCO3-23 AnGap-15
___ 06:10AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.7*
Brief Hospital Course:
___ with h/o NASH cirrhosis (with prior decompensation including
varices undergoing serial banding, ascites and encephalopathy),
prior hepatocellular carcinoma (s/p TACE in ___ and RFA in
___ without recurrence of disease) active on the transplant
list with a MELD of 28, PVT on anticoagulation, DM complicated
by gastroparesis, hypertension, hyperlipidemia admitted after a
paracentesis with drop in Hct to 22.
##Anemia: Patient found to have 5-7% HCT drop (to 22%) from
prior baseline. Prior to albumin resuscitation, HCT was 25% from
recent baseline of 30%. No obvious bleeding, though found to
have guaiac positive brown stool in ED. Patient denies any
symptoms consistent with symptomatic anemia. Patient has history
of varices s/p banding and GAVE which might be contributing to
subacute blood loss. Further downtrend in HCT after paracentesis
likely dilutional in setting of albumin resuscitation. Patient
received 1 unit PRBCs in ED with appropriate bump in Hct. Her
Hct remained stable around ___. Her daily enoxaparin for
portal vein thrombosis was initially held in setting of possible
bleed but restarted on discharge.
##Acute kidney injury: Patient with uptrending creatinine from
baseline, 1.5 from previous 1.4 in ___ be secondary to
pre-renal etiology in setting of diuretics use vs. HRS type II.
Patient's Cr down to 1.3 on ___.
##Ascites: Patiently currently undergoing biweekly paracentesis
for diuretic-refractory ascites. Patient had 5L fluid removed on
___ and received 37.5g albumin prior to admission. Ascitic
fluid without evidence of infection. Patient was continued on
home furosemide 40mg daily and spironolactone 50mg daily.
##Cirrhosis: Secondary to ___, currently awaiting liver
transplant. MELD 11 at admission. Total bilirubin at baseline.
Patient has an appointment at ___ for transplant
evaluation.
##Diabetes: Patient was continued on home regimen of insulin.
##Depression: Continued fluoxetine.
TRANSITIONAL ISSUES:
-Monitor CBC within ___ weeks of discharge to ensure
Hemoglobin/hematocrit are stable (H/H were 8.2/26.2 on
discharge)
-Monitor electrolytes and Cr
-Follow-up urine culture from ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 150 mg SC DAILY
Start: ___, First Dose: First Routine Administration Time
2. Ezetimibe 10 mg PO DAILY
3. Fluoxetine 20 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Lactulose 30 mL PO TID
7. Lorazepam 0.5 mg PO PRN anxiety
8. Nadolol 30 mg PO DAILY
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. Pantoprazole 40 mg PO Q12H
11. Rifaximin 550 mg PO BID
12. Spironolactone 50 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. calcium carb-mag oxide-vit D3 Dose is Unknown oral daily
15. Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 15 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Ezetimibe 10 mg PO DAILY
2. Fluoxetine 20 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 15 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Lactulose 30 mL PO TID
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Nadolol 30 mg PO DAILY
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Pantoprazole 40 mg PO Q12H
10. Rifaximin 550 mg PO BID
11. Spironolactone 50 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. calcium carb-mag oxide-vit D3 1 tablet ORAL DAILY
14. Enoxaparin Sodium 150 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
15. Lorazepam 0.5 mg PO PRN anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: anemia
SECONDARY DIAGNOSES: non-alcoholic steatohepatitis cirrhosis,
hepatocellular carcinoma s/p TACE and RFA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ was a pleasure taking care of you at ___. You were admitted
after a paracentesis for a drop in your blood count. You
received one unit of blood and your blood count came up.
Please keep your follow-up appointments as below. Please reutn
to the emergency room if you experience fevers, chills, chest
pain, shortness of breath, nausea, vomiting, blood in your
stool, dark black stool or any other new or concerning symptoms.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10275529-DS-29 | 10,275,529 | 22,792,434 | DS | 29 | 2128-01-01 00:00:00 | 2128-01-05 23:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
reglan with prozac / Motrin
Attending: ___
Chief Complaint:
Gastroenteritis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of NASH Cirrhosis and HCC, s/p liver transplant (on
tacrolimus) ___ at ___ c/b heart failure and
stroke, DM c/b intermittent gastroparesis presenting with acute
nausea and diarrhea.
Patient states that she has been on a diet with her husband, but
decided to "celebrate" and eat fried clams on ___ after
seeing Dr. ___ in clinic with no complaints. However on
___, she noted abrupt onset of massive watery,
non-bloody diarrhea associated with crampy abdominal pain. The
pain subsided in the afternoon, however recurred ___
afternoon with ongoing epigastric abdominal/crampy pain. She
states that the abdominal pain was not relieved with defecation
or food associated with a mild fever at 100.1F. She endorses
mild dyspnea, otherwise no orthopnea, PND, swelling of CP. She
denies any hemoptysis, hematochezia, or melena. Given these
symptoms, she called Dr. ___ who referred her to
___ ED for further evaluation.
IN THE ED:
Initial vitals were:
98.0 67 124/102 18 100% RA
Labs of note were:
7.5 > 11.6/35.5 < 175
138 | 100 | 32
--------------< 216
5.1 | 20 | 1.5 (baseline 1.5)
ALT: 59 AP: 107 Tbili: 0.4 Alb: 4.3
AST: 39 Lip: 13
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
___: 13.3 PTT: 30.9 INR: 1.2
Studies done were:
___
06:42 Liver Or Gallbladder Us (Single Organ)
1. Patent hepatic vasculature.
2. Echogenic liver, compatible with hepatic steatosis.
___
Chest (Pa & Lat)
Stable cardiomegaly without evidence of acute intrathoracic
process.
Hepatology was consulted who recommended admission to
___.
Patient was given:
___ 06:57 IV Lorazepam 1 mg
___ 07:51 IVF NS 1000 mL
___ 08:55 IV Morphine Sulfate 4 mg
___ 08:55 IV Ondansetron 4 mg
___ 11:54 PO/NG Aspirin 81 mg
___ 11:54 PO/NG FLUoxetine 20 mg
___ 11:54 PO/NG amLODIPine 10 mg
___ 11:54 PO/NG Furosemide 40 mg
___ 11:54 PO Tacrolimus 1.5 mg
___ 12:58 PO/NG Levothyroxine Sodium 88 mcg
___ 14:05 PO/NG Apixaban 5 mg
Transfer vitals were:
98.3 65 146/73 18 100% RA
On arrival patient notes mild improvement in abdominal pain. She
continues to endorse mild nausea. Otherwise, no other
complaints.
ROS otherwise negative.
Past Medical History:
- NASH cirrhosis s/p Liver Transplant at ___ in ___
- H/O Hepatocellular carcinoma
- GAVE
- Diabetes mellitus
- ___ Advisa pacemaker (___) for tachy-brady
- Gastroparesis
- Hypertension
- Hyperlipidemia
- History of MRSA bacteremia (___)
- Serotonin syndrome in the setting of metoclopramide?
- Transverse colonic adenoma (on CLN in ___ with history of
prior colonic polyps - repeat due in ___
Social History:
___
Family History:
She has a positive family history of CAD. Her brother died with
heart attack at age of ___. Her father died with unknown primary
cancer with metastasis to the brain and her mother died with
bladder cancer at the age of ___.
Physical Exam:
ADMISSION EXAM:
==============================
VS: T 98.2 BP 113/77 HR 63 RR 16 O2 96% on RA
GENERAL: WDWN Caucasian female. A&O x 3 in NAD, lying in bed
comfortably
HEENT: EOMs in tact. anicteric sclera. dry MM
NECK: Supple, no LAD, JVP flat.
HEART: RRR, normal S1/S2, no murmurs rubs or gallops.
LUNGS: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: soft, mild ttp in epigastrium, no guarding/rebound. RUQ
surgical scar c/d/I.
EXTREMITIES: wwp, 2+ pulses throughout, no edema
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
DISCHARGE EXAM:
==============================
VS: 98.7PO 120 / 60 65 18 96 RA
I/Os: ___ (24 hr), 150/uncharted (8 hr)
Weight: ___: 119.2kg
GENERAL: WDWN Caucasian female. A&O x 3 in NAD, lying in bed
comfortably
HEENT: EOMs intact. anicteric sclera.
NECK: Supple, no LAD, JVP flat.
HEART: RRR, normal S1/S2, no murmurs rubs or gallops.
LUNGS: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: soft, +BS, mild ttp in LLQ, no guarding/rebound. RUQ
surgical scar.
EXTREMITIES: wwp, 2+ pulses throughout, trace edema
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Pertinent Results:
ADMISSION LABS:
==============================
___ 05:15AM WBC-7.5 RBC-4.20 HGB-11.6 HCT-35.5 MCV-85
MCH-27.6 MCHC-32.7 RDW-15.6* RDWSD-47.9*
___ 05:15AM NEUTS-87.4* LYMPHS-5.3* MONOS-5.6 EOS-1.2
BASOS-0.0 IM ___ AbsNeut-6.59* AbsLymp-0.40* AbsMono-0.42
AbsEos-0.09 AbsBaso-0.00*
___ 05:15AM ___ PTT-30.9 ___
___ 05:15AM GLUCOSE-216* UREA N-32* CREAT-1.5* SODIUM-138
POTASSIUM-5.1 CHLORIDE-100 TOTAL CO2-20* ANION GAP-23*
___ 05:15AM ALT(SGPT)-59* AST(SGOT)-39 ALK PHOS-107* TOT
BILI-0.4
___ 05:15AM ALBUMIN-4.3
___ 05:15AM HBsAg-Negative HBs Ab-Positive HBc
Ab-Negative HAV Ab-Negative IgM HAV-Negative
___ 05:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
___ 05:15AM HCV Ab-Negative
MICROBIOLOGY:
==============================
C diff -canceled due to formed stool
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
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.
CMV viral load: not detected
EBV: negative
Hepatitis E: non-reactive
IMAGING/STUDIES:
==============================
CXR ___: Stable cardiomegaly without evidence of acute
intrathoracic process.
RUQ US ___: IMPRESSION:
1. Patent hepatic vasculature.
2. Echogenic liver, compatible with hepatic steatosis.
3. Splenomegaly
DISCHARGE LABS:
==============================
___ 05:09AM BLOOD WBC-3.4* RBC-3.41* Hgb-9.3* Hct-28.9*
MCV-85 MCH-27.3 MCHC-32.2 RDW-15.5 RDWSD-47.3* Plt ___
___ 05:09AM BLOOD Neuts-64.8 Lymphs-17.9* Monos-12.2
Eos-4.2 Baso-0.3 Im ___ AbsNeut-2.18 AbsLymp-0.60*
AbsMono-0.41 AbsEos-0.14 AbsBaso-0.01
___ 05:09AM BLOOD ___
___ 05:09AM BLOOD Plt ___
___ 05:09AM BLOOD Glucose-104* UreaN-22* Creat-1.5* Na-142
K-4.2 Cl-106 HCO3-23 AnGap-17
___ 05:09AM BLOOD ALT-66* AST-40 AlkPhos-95 TotBili-0.3
___ 05:09AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.9
___ 05:15AM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Negative HAV Ab-Negative IgM HAV-Negative
___ 05:09AM BLOOD tacroFK-8.6
___ 05:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
___ with hx of NASH Cirrhosis and HCC, s/p liver transplant (on
tacrolimus) ___ at ___ c/b heart failure and
stroke, DM c/b intermittent gastroparesis presenting with acute
nausea and diarrhea consistent with gastroenteritis.
#GASTROENTERITIS:Patient was admitted for workup of
gastroenteritis given immunocompromised status and was started
empirically on Ciprofloxacin and metronidazole. Ms ___
diarrhea, however, resolved after admission without additional
intervention. Stool cultures, Hep E, CMV, EBV levels were all
negative, also consistent with a self-limited gastroenteritis.
Patient was discharge with ciprofloxacin/metronidazole for a
course of 7 days (___).
#NASH CIRRHOSIS S/P OLT ___: Stable. Tacrolimus level noted to
be elevated on admission so tacrolimus dose was decreased to 1
mg BID. Follow-up level to be drawn on ___.
#chronic dCHF: Per review of Atrius records, with preserved LVEF
with cardiomyopathy likely ___ hypertensive cardiomyopathy.
Appeared euvolemic on exam. Held furosemide while inpatient
because of hypovolemia with gastroenteritis, te be restarted the
day after discharge. No other changes in home meds.
#History of TIA: Followed by Dr. ___ with etiology ___ severe
stenosis of the distal intracranial carotid and proximal middle
cerebral artery. Currently stable. Home ASA, apixaban and
rosuvastatin continued.
#Type II Diabetes Mellitus (insulin-dependent):stable.
#Hypertension: Continued amlodipine 10mg daily and lisinopril
2.5 mg daily
#Chronic Kidney Disease: baseline Cr 1.5. Monitored. Gentle IVF
given on admission given relative hypovolemia
___ Degeneration: received Avastin as outpatient
#Hypothyroidism: Continued Levothyroxine 88mcg daily.
#Depression:Continued fluoxetine 20mg daily.
#GERD: Continue Pantoprazole 40mg daily
#OSA: continued home BiPAP
#Anemia:Continued Iron 325mg daily and multivitamin.
TRANSITIONAL ISSUES:
====================
[] patient should complete 7 day course of ciprofloxacin/flagyl
(last day ___
[] patient to have follow up CBC/Chem 10/Tacrolimus level on
___ as outpatient.
[] patient has number of labs, including stools studies, EBV/CMV
PCR and norovirus PCR pending at discharge. These results will
be followed up by primary team and communicated to Dr. ___.
[] patient to follow up in liver clinic within next ___ weeks.
[] patient discharged on decreased level of tacrolimus. Dose
should be adjusted according to level obtained on ___.
CODE: Full Code
CONTACT:
Proxy name: ___
Relationship: husband Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Amoxicillin ___ mg PO PREOP
4. Apixaban 5 mg PO BID
5. Bevacizumab (Avastin) unknown IV Frequency is Unknown
6. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral BID
7. FLUoxetine 20 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Gabapentin 200 mg PO QHS:PRN pain
10. Levemir 22 Units Bedtime
Insulin SC Sliding Scale using UNK Insulin
11. Levothyroxine Sodium 88 mcg PO DAILY
12. Lisinopril 2.5 mg PO DAILY
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Pantoprazole 40 mg PO Q24H
15. Rosuvastatin Calcium 10 mg PO QPM
16. Tacrolimus 1.5 mg PO Q12H
17. Ferrous Sulfate 325 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. LORazepam 1 mg PO DAILY:PRN anxiety/nausea
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*9 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*13 Tablet Refills:*0
3. Tacrolimus 1 mg PO Q12H
RX *tacrolimus 1 mg 1 capsule(s) by mouth twice a day Disp #*20
Capsule Refills:*0
4. amLODIPine 10 mg PO DAILY
5. Amoxicillin ___ mg PO PREOP
6. Apixaban 5 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Bevacizumab (Avastin) unknown IV INFUSION
9. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral BID
10. Ferrous Sulfate 325 mg PO DAILY
11. FLUoxetine 20 mg PO DAILY
12. Furosemide 40 mg PO DAILY
13. Gabapentin 200 mg PO QHS:PRN pain
14. Levemir 22 Units Bedtime
Insulin SC Sliding Scale using UNK Insulin
15. Levothyroxine Sodium 88 mcg PO DAILY
16. Lisinopril 2.5 mg PO DAILY
17. LORazepam 1 mg PO DAILY:PRN anxiety/nausea
18. Metoprolol Succinate XL 100 mg PO DAILY
19. Multivitamins 1 TAB PO DAILY
20. Pantoprazole 40 mg PO Q24H
21. Rosuvastatin Calcium 10 mg PO QPM
22.Outpatient Lab Work
CBC/CHEM 10/Tacrolimus level on ___.
ICD 10: Z94.4 Results should be faxed to Dr. ___: Fax
___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
===================
Viral Gastroenteritis
Secondary Diagnosis:
====================
Chronic Kidney Disease
Type 2 Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted with nausea, vomiting and
diarrhea, concerning for gastrointestinal infection. You were
treated with IV fluids and antibiotics and your symptoms
improved. You should complete a 7 day course of antibiotics
(last day ___ and follow up with Dr. ___ in liver clinic
(see appointments below).
During admission your tacrolimus level was elevated, so we
decreased your dose to 1mg twice daily. You should continue that
dose until you see Dr. ___ in clinic.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10275529-DS-30 | 10,275,529 | 24,609,806 | DS | 30 | 2128-02-09 00:00:00 | 2128-02-09 14:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
reglan with prozac / Motrin
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of NASH Cirrhosis and HCC, s/p liver transplant (on
tacrolimus) ___ at ___ c/b heart failure and
stroke, DM c/b intermittent gastroparesis who initially
presented to transplant clinic with cough, reported fever to
101, and shortness of breath who was referred to the ED for
further work-up.
A few days ago, she developed nasal congestion that was followed
by a dry cough yesterday evening. She is also sneezing a lot.
This morning, the patient developed a fever to 101 at which
point she called the transplant clinic who recommended she come
in for evaluation. In clinic, the patient was afebrile and
hemodynamically stable, satting well on RA.
She states that she has had orthopnea and dyspnea on exertion
for the past week. She feels trouble breathing when she lies
flat. She also feels diffusely achy. She is not quite herself.
Denies edema.
Denies chest pain, leg swelling, calf pain, or changes in
weight. Of note, her husband was recently treated for pneumonia.
Of note, she had a recent hospital stay for gastroenteritis, but
these symptoms have not recurred.
In the ED
- Initial vitals: 98.0, HR 60, 124/58, 22, 100% RA
- Labs notable for: Flu negative, Cr 1.5 (baseline),
- Imaging notable for: CXR unremarkable
- Pt given: nothing
Past Medical History:
- ___ cirrhosis s/p Liver Transplant at ___ in ___
- H/O Hepatocellular carcinoma
- GAVE
- Diabetes mellitus
- ___ Advisa pacemaker (___) for tachy-brady
- Gastroparesis
- Hypertension
- Hyperlipidemia
- History of MRSA bacteremia (___)
- Serotonin syndrome in the setting of metoclopramide?
- Transverse colonic adenoma (on CLN in ___ with history of
prior colonic polyps - repeat due in ___
- Diastolic CHF
- Stroke
Social History:
___
Family History:
She has a positive family history of CAD. Her brother died with
heart attack at age of ___. Her father died with unknown primary
cancer with metastasis to the brain and her mother died with
bladder cancer at the age of ___.
Physical Exam:
ADMISSION EXAM
==============
Vitals: 98.1, 128 / 77, 59, 18, 95 RA
General: Alert, oriented, pleasant
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, good air movement
CV: RRR, Nl S1, S2, No MRG
Abdomen: obese, soft, NT, ND, +BS, no hepatomegaly, old surgical
scars noted
GU: no foley
Ext: warm, well perfused, obese, no edema
Neuro: CN2-12 intact, no focal deficits
DISCHARGE EXAM
==============
Vitals: 97.8, 133/72, HR 60, RR 18, 95% RA
GENERAL - Alert, pleasant, NAD, lying in bed
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
HEART - RRR, ___ systolic murmur
LUNGS - CTAB with good air movement
ABDOMEN - +BS, obese, NT, ND, no hepatomegaly
EXTREMITIES - warm , no c/c, no edema
NEURO - awake, A&Ox3, no gross focal deficits
Pertinent Results:
ADMISSION LABS
==============
___ 01:40PM BLOOD WBC-5.2 RBC-4.12 Hgb-11.4 Hct-34.9 MCV-85
MCH-27.7 MCHC-32.7 RDW-15.4 RDWSD-46.7* Plt ___
___ 01:40PM BLOOD Neuts-70.0 Lymphs-13.9* Monos-10.7
Eos-4.2 Baso-0.4 Im ___ AbsNeut-3.67# AbsLymp-0.73*
AbsMono-0.56 AbsEos-0.22 AbsBaso-0.02
___ 06:00AM BLOOD ___
___ 01:40PM BLOOD Glucose-138* UreaN-25* Creat-1.5* Na-139
K-4.1 Cl-101 HCO3-22 AnGap-20
___ 01:40PM BLOOD ALT-37 AST-29 AlkPhos-103 TotBili-0.4
___ 01:40PM BLOOD proBNP-499*
___ 01:40PM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.2
___ 01:40PM BLOOD Albumin-4.0
DISCHARGE LABS
==============
___ 06:00AM BLOOD WBC-4.0 RBC-3.89* Hgb-11.0* Hct-33.3*
MCV-86 MCH-28.3 MCHC-33.0 RDW-15.3 RDWSD-47.8* Plt ___
___ 06:00AM BLOOD Neuts-65.7 Lymphs-17.1* Monos-11.6
Eos-4.5 Baso-0.3 Im ___ AbsNeut-2.61 AbsLymp-0.68*
AbsMono-0.46 AbsEos-0.18 AbsBaso-0.01
___ 06:00AM BLOOD Glucose-135* UreaN-22* Creat-1.3* Na-137
K-3.9 Cl-101 HCO3-24 AnGap-16
___ 06:00AM BLOOD ALT-39 AST-32 AlkPhos-98 TotBili-0.5
REPORTS
================
CXR ___
Compared to chest radiographs since ___, most recently ___.
There is no pulmonary edema, pleural effusion, pulmonary
vascular engorgement, or cardiomegaly.Lungs are clear.
Indwelling transvenous right atrial and right ventricular pacer
leads are unchanged in their respective positions, continuous
from the left axillary generator.
MICROBIOLOGY
================
Blood and urine cultures pending
CMV/EBV Viral Loads pending
Influenza negative
Urine Legionella and Strep pneumo pending
Brief Hospital Course:
___ with hx of NASH Cirrhosis and HCC, s/p liver transplant (on
tacrolimus) ___ c/b heart failure and stroke, DM c/b
intermittent gastroparesis, who initially presented to
transplant clinic with cough, reported fever to 101, and
shortness of breath, likely of viral origin.
She was evaluated with labwork, cultures, and a chest x-ray.
None of these were revealing for any acute abnormality. She was
afebrile and hemodynamically stable during her hospital stay,
and was on room air. There was no evidence of volume overload on
exam. It was felt her shortness of breath was likely due to
bronchospasm in the setting of a viral respiratory infection,
and she was thus treated with albuterol inhalers. Antibiotics
were not given due to no evidence of bacterial infection. She
will follow up with her PCP as well as the Transplant ___
clinic. She will keep her cell phone on her, so that we can
contact her if any cultures or microbiologic data come back
positive.
==============
CHRONIC ISSUES
==============
# NASH CIRRHOSIS S/P OLT ___: Performed at ___
with post-op course complicated by CVA and CHF. Recent admission
for gastroenteritis with work-up including CMV, EBV, C. Diff
negative. Had uptrending LFTs and underwent liver biopsy on
___ ___onsistent with toxic metabolic injury such as
nonalcoholic steatohepatitis. RUQ ultrasound showed patent
vasculature. She has been stable on tacrolimus 1mg BID.
# Chronic diastolic CHF: Last TTE in our systemic showed EF 65%
___, thought ___ hypertensive cardiomyopathy. She tells me she
had a more recent TTE at ___ that was stable. Currently
appears euvolemic on exam and breathing on RA. BNP mildly
elevated 499. No evidence of pulm edema on CXR. Slept lying
flat.
- Continued home lasix 40mg daily, Lisinopril, metoprolol
# History of TIA: Followed by Dr. ___ with etiology ___
severe stenosis of the distal intracranial carotid and proximal
middle cerebral. Currently stable.
- Continued ASA 81mg, Apixaban, Rosuvastatin
# Type II Diabetes Mellitus (insulin-dependent): continued home
insulin regimen (though replaced home Detemir with Glargine
while in-house due to formulary restrictions).
# Hypertension: Continue amlodipine 10mg daily and lisinopril
2.5mg daily
# Chronic Kidney Disease: Cr was at her baseline
# Macular edema: has received Avastin as outpatient
# Hypothyroidism: Continue Levothyroxine 88mcg daily.
# Depression: Continue fluoxetine 20mg daily.
# GERD: Continue Pantoprazole 40mg daily
# OSA: continue home BiPAP
# Anemia: Continue Iron 325mg daily and multivitamin.
# Anxiety: continue home ativan
===================
TRANSITIONAL ISSUES
===================
- Started Albuterol inhaler to help with URI-related
bronchospasm
- Pending results on discharge, to be followed by inpatient team
and communicated to outpatient providers if abnormal:
[] tacro level
[] urine Legionella and Strep pneumo
[] CMV and EBV viral loads
[] blood and urine cultures
- To follow-up with PCP and ___ clinic
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Apixaban 5 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. FLUoxetine 20 mg PO DAILY
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Lisinopril 2.5 mg PO DAILY
8. LORazepam 1 mg PO DAILY:PRN anxiety/nausea
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Rosuvastatin Calcium 10 mg PO QPM
13. Tacrolimus 1 mg PO Q12H
14. Furosemide 40 mg PO DAILY
15. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral BID
16. Amoxicillin ___ mg PO PREOP
17. Levemir 30 Units Breakfast
Levemir 36 Units Bedtime
Insulin SC Sliding Scale using Aspart Insulin
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs inhaled
every 4 hours Disp #*1 Inhaler Refills:*1
2. amLODIPine 10 mg PO DAILY
3. Amoxicillin ___ mg PO PREOP
4. Apixaban 5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral BID
7. Ferrous Sulfate 325 mg PO DAILY
8. FLUoxetine 20 mg PO DAILY
9. Furosemide 40 mg PO DAILY
10. Levemir 30 Units Breakfast
Levemir 36 Units Bedtime
Insulin SC Sliding Scale using Aspart Insulin
11. Levothyroxine Sodium 88 mcg PO DAILY
12. Lisinopril 2.5 mg PO DAILY
13. LORazepam 1 mg PO DAILY:PRN anxiety/nausea
14. Metoprolol Succinate XL 100 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Pantoprazole 40 mg PO Q24H
17. Rosuvastatin Calcium 10 mg PO QPM
18. Tacrolimus 1 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Fever
Viral Infection
Secondary:
NASH cirrhosis s/p liver transplant
Chronic diastolic CHF
History of TIA
Type 2 Diabetes
Hypertension
Hypothyroidism
CKD
Depression
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure caring for you at ___. You were admitted
because of a fever. You were evaluated with an x-ray, labwork,
urine testing, and cultures. All of these were normal. There
was no evidence of worsening heart failure. We feel like the
most likely explanation for your symptoms is a viral infection.
We will give you a prescription for an inhaler, as sometimes
these infections can cause spasms in your airway that lead to
shortness of breath.
We will help coordinate follow-up with your Transplant Team.
Please be sure to follow up with your Primary Care Doctor and
other physicians as well.
It was a pleasure,
___ Team
Followup Instructions:
___
|
10275579-DS-7 | 10,275,579 | 29,804,344 | DS | 7 | 2184-11-14 00:00:00 | 2184-11-16 17:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath, unable to get up from fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old male with PMHx of hypertension and
CAD s/p quadruple CABG in ___, brought to ED by ambulance today
after he fell while walking to his car. He remained down for two
hours, unable to get up, but denies head strike or LOC. His
neighbor or son found him and subsequently called EMS. Per
report, the patient has had ongoing weakness and trouble walking
at times over the past year, which he and his son attribute to
his hip pain.
.
Pt has also had progressively worsening exertional dyspnea over
past ___ days. Denies cough or sputum production, but his
breathing is more labored with exertion. He sometimes has
trouble falling asleep secondary to his labored breathing.
Denies chest pain or neck, jaw, shoulder or arm pain. He has not
been hospitalized recently, nor has he had any sick contacts or
clinic appointments since last ___.
.
In the ED, initial VS: 98.9, 95, 164/66, 28, 100% 8L NC. Exam
notable for rigoring, bilateral lower extremity swelling, and
normal mentation, although the pt's son reportedly claimed pt is
at "90% of baseline mental status." Labs revealed leukocytosis
(11K) with left shift, mild hyperglycemia, and INR 1.3. U/a
notable for hematuria and proteinuria. Lactate was 2.4. ECG
showed isolated ___ ST elevation in V2 and CXR revealed wedge
shaped opacity at right costophrenic angle. CT chest was
obtained to further clarify RLL opacity, revealed RLL
consolidation with adjacent effusion. Left hip/pelvis film was
also obtained, which showed no fracture or dislocation. Pt was
given 1L normal saline, ceftriaxone 1gm, azithromycin 500 mg PO,
and acetaminophen 650 mg PO. VS prior to transfer were: 99.6,
141/55, 72, 24, 99 2L NC.
.
On the floor, pt complains of shortness of breath, which is
worse since transferring to the bed from his stretcher. He is
awake and alert, and denies chest pain or palpitations. He
triggered shortly after arrival for tachypnea to RR 32. He was
given nebulizer treatments and acetaminophen. His RR has
subsequently decreased slightly, and he feels that his breathing
has improved somewhat.
.
REVIEW OF SYSTEMS: As per HPI. Also, he has been having regular
nosebleeds over the past ___ weeks, which is unusual for him. He
has occasional foot swelling that resolves with leg elevation.
He denies headache, neck stiffness, congestion, sore throat,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
CAD s/p CABG ___ years ago)
Hypertension
Social History:
___
Family History:
Multiple family members with hypertension. No MI, COPD, or
diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 100.1F, BP 150/62, HR 83, R 30, ___ 96% 2L NC
GENERAL - Alert, interactive, oriented, tachypneic and speaking
in ___ word sentences
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear, face
symmetric
NECK - Supple, no JVD, no carotid bruits
HEART - RRR, nl ___, no MRG
LUNGS - Decreased breath sounds at right base. Mild expiratory
wheeze. No rales or rhonchi, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, trace symmetric edema to ankles bilaterally.
No cyanosis or clubbing. Symmetric 2+ peripheral pulses
NEURO - awake, A&Ox3, muscle strength ___ throughout, sensation
grossly intact throughout, cerebellar exam intact, gait
assessment deferred
Pertinent Results:
LABS:
On admission:
___ 06:10PM BLOOD ___
___ Plt ___
___ 06:10PM BLOOD ___
___
___ 06:10PM BLOOD ___ ___
___ 06:10PM BLOOD ___
___
___ 06:10PM BLOOD CK(CPK)-2199*
___ 06:10PM BLOOD ___ MB ___
___ 06:10PM BLOOD ___
___ 11:25PM BLOOD ___
Cardiac enzymes:
___ 06:10PM BLOOD ___ MB ___
___ 03:54AM BLOOD ___ MB ___
___ 10:55AM BLOOD ___ MB ___
___ 07:55PM BLOOD ___ MB ___
___ 07:05AM BLOOD ___ MB ___
CK trend:
___ 06:10PM BLOOD CK(CPK)-2199*
___ 03:54AM BLOOD ___
___ 10:55AM BLOOD ___ ___
___
___ 07:55PM BLOOD ___
___ 01:19AM BLOOD ___
___ 07:05AM BLOOD ___ ___
___
___ 07:14AM BLOOD ___ ___
___ 09:22PM BLOOD ___
___ 07:29AM BLOOD ___
___ 03:29PM BLOOD ___
___ 07:05AM BLOOD CK(CPK)-6967*
___ 07:20AM BLOOD CK(CPK)-3171*
On discharge:
___ 07:20AM BLOOD ___
___ Plt ___
___ 07:20AM BLOOD ___
___
___ 07:20AM BLOOD CK(CPK)-3171*
___ 07:20AM BLOOD ___
MICRO:
___ URINE ___ negative
___ BLOOD ___ no growth at time of
discharge
___ BLOOD ___ no growth at time of
discharge
___ BLOOD ___ negative
___ BLOOD ___ negative
IMAGING:
___ ECG:
Sinus rhythm. Left atrial abnormality. Diffuse ___
wave
changes. Delayed precordial R wave transition.
___ CXR:
IMPRESSION: ___ opacity at the right costophrenic angle
could be due to consolidation due to infection or pulmonary
infarct, less likely pleural fluid; not well seen on the lateral
view. Chest CT is pending.
___ CT chest:
IMPRESSION: Right lower lobe consolidation with small adjacent
pleural
effusion, concerning for pneumonia.
___ hip xray:
FINDINGS: AP view of the pelvis and AP and lateral views of the
left hip were obtained. No definite acute fracture is seen.
There is no dislocation.
There are mild degenerative changes at the hip joint. The pubic
symphysis and sacroiliac joints are not widened. Contrast is
seen in the distal ureters and within the bladder from recent
___ CT.
___ TTE:
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no pericardial effusion.
___ CXR:
IMPRESSION:
Increased right pleural effusion and increasing right lower lobe
pneumonia.
Brief Hospital Course:
___ y/o M with hx of CAD s/p remote CABG, admitted for
progressive dyspnea on exertion and radiologic evidence of
pneumonia, as well as weakness to the point of being unable to
get up after a fall at home
ACTIVE ISSUES BY PROBLEM:
# Pneumonia: Signs/symptoms and imaging consistent with PNA.
Started on ceftriaxone and azithro for CAP coverage. He made
minimal sputum, so none was sent for culture. Fever curve
trended down, and he was stabilized on room air. His dyspnea
worsened a few days into his course and the infiltrate appeared
worse on repeat chest xray, however this appeared to be due to
fluid overload/CHF rather than worsening infection (see CHF
below). He completed a 5 day course of antibiotics on ___.
Would recommend a follow up xray in a month to ensure resolution
of infiltrate and effusion, however will defer this to his PCP.
# Demand ischemia, CAD: Troponins peaked at 0.20 in the first
day and then came down, suspect troponin leak due to demand
ischemia in the setting of acute illness rather than ACS. No
active chest pain while hospitalized. TTE on ___ did not show
focal wall motion abnormalities, and EF was normal at >55%. He
will need to follow up with his cardiologist and may benefit
from a stress test as an outpatient.
# Rhabdomyolysis: Due to lying on the ground for 2 hours after
this fall. CK elevated from to ___ -> ___ after admission
and UA with large blood but only 11 RBCs, suggestive of
myoglobinuria. AST also elevated to the 500s range. Started on
aggressive IV fluids to prevent ___ nephropathy.
Denied muscle weakness or aches, but seemed significantly
weakened when trying to stand. CK peaked at ___, then slowly
downtrended to 3000s on day of discharge. His renal function
remained normal. His statin was held during his admission and
not restarted on discharge. ___ consider restarting as an
outpatient.
# Acute diastolic CHF: EF >55% by TTE on ___. While receiving
large volumes of fluid for renal protection from his rhabdo, the
patient started becoming more and more dyspneic. His I/O
recordings revealed that he was not staying even and was
accumulating fluid as the days went on. Repeat CXR on ___
showed worsened pleural effusion on the right side as well as
worsening RLL infiltrate. He was offered a thoracentesis for
symptomatic relief as well as a diagnostic aid, however he
decline the procedure. Although volume overload could explain
the effusion, given that the effusion was unilateral and that
Mr. ___ has a strong smoking history, we felt that a
thoracentesis would be appropriate. However, as mentioned
above, Mr. ___ declined the procedure and chooses to be
followed as an outpatient with ___ imaging. He was
aggressively diuresed, and his symptoms improved slowly.
# Weakness: Pt's son gives history of slow functional decline
over past months; increased difficulty with ambulation
attributed to hip, and increasing difficulty falling asleep due
to dyspnea. Now s/p fall and unable to get up for hours. No
fracture seen on hip film. Recent weakness likely exacerbated by
pneumonia, but likely on background of subacute, progressive
weakness. He was seen by physical therapy, who felt that acute
rehab placement would be of benefit to the patient. He was
initially hesistent, but with some urging of his family, he
agreed.
CHRONIC, INACTIVE ISSUES:
# Hypertension: Lisinopril initially held due to possibility of
renal blood flow impairment in setting of rhabdo, however this
was restarted once his rhabdo began resolving. He was continued
on beta blocker (metoprolol rather than lisinopril) and given
lasix rather than HCTZ for improved diuresis. His home regimen
of atenolol, HCTZ, and lisinopril was not changed on discharge.
TRANSITION OF CARE ISSUES:
- Pneumonia: recommend a follow up xray in a month to ensure
resolution of infiltrate and effusion, will defer this to his
PCP
- ___ ischemia: will need to follow up with his cardiologist
and may benefit from a stress test as an outpatient.
- Hyperlipidemia: statin stopped given rhabdomyolysis, may
consider restarting as an outpatient
- FULL CODE this admission
Medications on Admission:
spironolactone 25 mg daily
hydrochlorothiazide 25 mg daily
lisinopril 40 mg daily
atenolol 25 mg daily
Lipitor 80 mg daily
Of note, pt usually takes aspirin daily but he has not been
taking this in the setting of recent nosebleeds
Discharge Medications:
1. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
3. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Community acquired pneumonia
Rhabdomyolysis
Demand ischemia
Coronary artery disease
Weakness
Acute diastolic CHF
Secondary diagnoses:
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because of shortness of breath
and a fall. We found that you had a pneumonia, so you completed
a course of antibiotics for this. You also had evidence of
strain on your heart, but we ran lab tests and did a heart
ultrasound, and we found you did not have a heart attack or any
heart damage.
While you were here, we found that you also had a lot of muscle
damage from your fall. We had to give you large amounts of
intravenous fluids to keep this muscle damage from also damaging
your kidneys. In the process, you got some fluid in your lungs.
Once the muscle damage was better, we were able to start
getting fluids out of you by giving you medicine to make you
urinate. Your breathing was better again after we removed this
fluid.
Changes to your medications:
STOP Lipitor (atorvastatin) until your PCP tells you to restart
It was a pleasure to take care of you at ___!
Followup Instructions:
___
|
10275673-DS-30 | 10,275,673 | 28,899,055 | DS | 30 | 2159-09-27 00:00:00 | 2159-09-27 17:50:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
adhesive tape / Iodine-Iodine Containing / Latex / Penicillins
Attending: ___.
Chief Complaint:
Neutropenia, elevated LFTs
Major Surgical or Invasive Procedure:
___ Transjugular liver biopsy
___ cardiac cath
History of Present Illness:
___ with h/o HCV cirrhosis c/b HCC and HPS (on home
O2) recently s/p DDLT (___) c/b hepatic artery thrombosis
s/p
take back and HA reconstruction with subsequent hepatic artery
stenosis s/p hepatic artery stenting (on ASA/Plavix) who now
presents from rehab and orthostasis, neutropenia and LFT
elevation. Briefly, patient was discharged to rehab on ___
on tube feeds, 2L O2 (stable requirement from preoperative
setting) and antiplatelet therapy for his HA stent. He was seen
in clinic this afternoon and was found to have mildly elevated
LFTs from discharge as well as neutropenia (WBC 1.3, ANC 870).
He
had a hepatic duplex performed that demonstrated very stable HA
velocities and an unchanged arterial-portal fistula without
other
significant abnormalities. He had also been reporting persistent
dizziness since being discharge and was reportedly orthostatic
at
rehab, thus the decision was made to have the patient present to
the ED for further evaluation.
On arrival, patient was afebrile and hemodynamically stable
without any concerning findings on physical exam. However, he
experienced a syncopal episode in ED Triage presumably due to
orthostasis and experienced a fall/LOC and reportedly head
strike
- patient subsequently underwent NCHCT and CT C-spine that were
both negative for bleed or other injury. On further review, he
otherwise denies fevers/chills, abdominal pain, nausea/vomiting,
diarrhea/constipation, jaundice/pruritis, worsening of baseline
SOB, CP, dysuria.
ROS:
(+) per HPI
(-) Denies pain, fevers, chills, night sweats, unexplained
weight
loss, fatigue/malaise/lethargy, changes in appetite, trouble
with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, vertigo, syncope, weakness, paresthesias, nausea,
vomiting, hematemesis, bloating, cramping, melena, BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary
frequency, urgency
Past Medical History:
HCV cirrhosis c/b esophageal varices s/p TIPS
Hepatopulmonary syndrome on 2L NC O2
HCC s/p TACE and RFA
Diabetes
Hypertension
Sarcoidosis /IPF
OSA
Depression
.
PSH: 1: Deceased donor liver transplant ___
Social History:
___
Family History:
NC
Physical Exam:
Admission PE:
Vitals: 98.4 75 137/80 19 96% 2L NC
Gen: A&Ox3, comfortable-appearing male, in NAD
HEENT: No scleral icterus, Dobhoff secured in place
Pulm: comfortable on 2L NC
CV: NRRR
Abd: soft, nontender/nondistended, no rebound/guarding, no
palpable masses, well healing incision without palpable defected
Ext: WWP bilaterally, no c/c/e, no ulcerations
Neuro: moves all limbs spontaneously, no focal deficits
.
Discharge PE:
4 HR Data (last updated ___ @ 2333)
Temp: 98.4 (Tm 99.8), BP: 151/74 (132-153/71-90), HR: 85
(74-89), RR: 18, O2 sat: 92% (91-97), O2 delivery: 3L, Wt:
152.12
lb/69.0 kg
Fluid Balance (last updated ___ @ 539)
Last 8 hours Total cumulative 1173ml
IN: Total 1373ml, PO Amt 340ml, TF/Flush Amt 1033ml
OUT: Total 200ml, Urine Amt 200ml
Last 24 hours Total cumulative 1533.3ml
IN: Total 2133.3ml, PO Amt 700ml, TF/Flush Amt 1332ml, IV
Amt
Infused 101.3ml
OUT: Total 600ml, Urine Amt 600ml
GENERAL: NAD, A/O x 3, dobhoff in place
CARDIAC: [x]RRR
LUNGS: [x]no respiratory distress
ABDOMEN [x]soft [x]Nontender [x]nondistended [x]no
rebound/guarding
WOUND: [x]CD&I
EXTREMITIES: warm, well-perfused
Pertinent Results:
Labs on Admission: ___
WBC-1.3* RBC-3.22* Hgb-10.2* Hct-32.5* MCV-101* MCH-31.7
MCHC-31.4* RDW-17.2* RDWSD-63.9* Plt ___ PTT-25.0 ___
Glucose-346* UreaN-29* Creat-0.9 Na-138 K-5.8* Cl-101 HCO3-25
AnGap-12
ALT-162* AST-111* AlkPhos-167* TotBili-0.5
Albumin-3.3* Calcium-8.8 Phos-4.1 Mg-1.8 Iron-66
___ tacroFK-12.2
.
Labs at Discharge ___
WBC-3.1* RBC-3.15* Hgb-10.2* Hct-32.3* MCV-103* MCH-32.4*
MCHC-31.6* RDW-15.1 RDWSD-56.7* Plt ___ PTT-27.9 ___
Glucose-248* UreaN-34* Creat-0.8 Na-142 K-4.0 Cl-105 HCO3-27
AnGap-10
ALT-264* AST-97* AlkPhos-186* TotBili-0.3
Calcium-8.5 Phos-3.6 Mg-1.9
tacroFK-6.6
.
___ CMV VL-NOT DETECT
Brief Hospital Course:
___ with h/o HCV cirrhosis c/b HCC and HPS (on home O2)recently
s/p DDLT (___) c/b hepatic artery thrombosis s/p take back
and HA reconstruction with subsequent hepatic artery stenosis
s/p hepatic artery stenting (on ASA/Plavix) presented from rehab
with orthostasis, neutropenia and LFT elevation.
.
On admission, he was afebrile and hemodynamically stable without
significant findings on ultrasound to necessitate
urgent/emergent intervention. Neutropenia was presumed to be
secondary to immunosuppression and orthostasis was likely
secondary to dehydration. He was admitted to Transplant Surgery
and underwent a transjugular liver biopsy on ___ given that
he was on ASA/Plavix for hepatic artery stent. The biopsy was
negative for rejection, but showed early recurrent HCV. Plans
were to pursue treatment for HCV. Hepatitis C genotype studies
were sent and medication insurance coverage was investigated.
.
Neutropenia was likely related to Valcyte and Mycophenolate.
These meds were held and weekly CMV VL was sent and negative.
WBC increased from 1.3 to 3.2. Mycophenolate was resumed at a
lower dose -250mg bid on ___, but discontinued on ___ when
WBC decreased at 2.1. Immuknow was also low at 32. CMV VL was
negative. Repeat CMV VL was negative from ___ and ___.
Prednisone was decreased to 5mg daily for low immuknow and
difficulties with blood sugar management.
.
A Pulmonology consult was obtained as he was still using O2 and
had a scheduled
outpatient f/u on ___. A right heart cath was recommended to
re-evaluate and determine need for treatment for PAH, but given
CXR finding that was c/f pulmonary edema, he was diuresed first.
A TTE demonstrated EF of 54% and PASP of 64. CT with PE protocol
was also performed to r/o PE as he was tachycardic. CT was
negative. A right heart cath was then performed on ___ which
showed that PA pressure was improved ( PA- 28, RA-7, Wedge
___ new left ventricular failure.
.
He was also orthostatic which was attributed to being in bed
most of the time. Carvedilol was resumed for tachycardia and htn
(sbp 140s)
.
Pulmonary recommended continued diuresis until euvolemia, home
O2 supplementation, Advair and prn Duoneb No indication for PAH
therapy. He continued to wear O2 2 L NC with sats above 94%.
Lasix was given daily to diurese him. Weight was 64kg on
admission. This increased to 65-66kg. Weight at discharge
68.7kg. He will continue on PO Lasix.
.
He continued on TF as he was not gaining weight. Nutrition was
consulted. Oral intake was still insufficient to discontinue TF.
Blood sugars were erratic mostly with hyperglycemia alternating
with lows (50s). A ___ consult was obtained and insulin
adjusted daily.
.
Immunosuppression consisted of holding MMF then resuming this on
___ at 250mg bid, Prednisone that was increased to 10mg b/c of
holding MMF. Prednisone was then decreased to 7.5mg for concern
that HCV replication might be worsened with on higher steroid
dosing. Ultimately the prednisone was decreased to 5 mg daily,
Tacrolimus was dosed with daily level checks. Tacrolimus was
dosed per trough levels daily. Discharge dose is 3 mg BID.
.
___ evaluated and recommended rehab initially. He was admitted
from ___, however it was determined that his
Hepatitis C treatment (Harvoni) was not going to be available to
him at rehab. Plans were then finalized for discharge to home
with Epic home care (known to them from pre transplant), ___
for tube feeds and Apria for home oxygen (also known from pre
transplant).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carvedilol 12.5 mg PO BID
5. Citalopram 20 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
8. Famotidine 20 mg PO Q12H
9. Fluconazole 400 mg PO Q24H
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
11. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
12. Glucose Gel 15 g PO PRN hypoglycemia protocol
13. LOPERamide 2 mg PO DAILY
14. Mycophenolate Mofetil 500 mg PO QID
15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
16. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
17. Heparin 5000 UNIT SC BID
18. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
19. Zinc Sulfate 220 mg PO DAILY
20. Tacrolimus 1.5 mg PO Q12H
Discharge Medications:
1. Furosemide 40 mg PO DAILY
2. Glargine 15 Units Breakfast
Glargine 42 Units Dinner
NPH 40 Units Dinner
Novolog 6 Units Breakfast
Novolog 4 Units Lunch
Novolog 6 Units Dinner
Insulin SC Sliding Scale using Novolog Insulin
3. Ledipasvir/Sofosbuvir 1 TAB PO DAILY
Must be given at same time as famotidine for efficacy
4. nebulizers miscellaneous BID
5. PredniSONE 5 mg PO DAILY
6. Tacrolimus 3 mg PO Q12H
7. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
Maximum 4 of the 500 mg tablets daily
8. amLODIPine 5 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. CARVedilol 12.5 mg PO BID
hold for sbp <110 or HR <60
11. Citalopram 20 mg PO DAILY
12. Clopidogrel 75 mg PO DAILY
13. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
14. Famotidine 20 mg PO Q12H
15. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
16. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
17. Glucose Gel 15 g PO PRN hypoglycemia protocol
18. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
19. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
20. HELD- Mycophenolate Mofetil 500 mg PO QID This medication
was held. Do not restart Mycophenolate Mofetil until directed by
transplant clinic
21.Insulin Pens
Insulin Needles for Insulin Pens
Dispense 1 Package (#100)
Refills 5 (Five)
22.Tube Feeds
Continuous tubefeeding: Nepro; Full strength
Tube Type: ___ post-pyloric (ppft); Placement confirmed.
Goal rate: 85 ml/hr
Cycle?: Yes Cycle start: 1800 Cycle end: 1000
Dispense: QS for 1 month
Refills: 3 (Three)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Elevated LFTs
Recurrent HCV
HPS
Left ventricular failure
Severre Malnutrition
DM
Neutropenia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Home with services:
___, ___, fax# ___
___ for tube feed. Contact ___ ___
Apria for Oxygen, already in place
.
Please call the transplant clinic at ___ for fever of
101 or greater, chills, nausea, vomiting, diarrhea,
constipation, inability to tolerate food, fluids or medications,
yellowing of skin or eyes, increased abdominal pain, incisional
redness, drainage or bleeding, dizziness or weakness, decreased
urine output or dark, cloudy urine, swelling of abdomen or
ankles, weight gain of 3 pounds in a day or any other concerning
symptoms.
.
Bring your pill box and list of current medications to every
clinic visit.
.
You will have labwork drawn twice weekly as arranged by the
transplant clinic, with results to the transplant clinic (Fax
___ . CBC, Chem 10, AST, ALT, Alk Phos, T Bili, Trough
Tacro level, CMV viral load weekly (end of week)
.
*** On the days you have your labs drawn, do not take your
Tacrolimus until your labs are drawn. Bring your Tacrolimus with
you so you may take your medication as soon as your labwork has
been drawn.
.
Follow your medication card, keep it updated with any dosage
changes, and always bring your card with you to any clinic or
hospital visits.
.
Check blood sugars and treat per your long acting and sliding
scale insulin.
.
Continue tube feeds as ordered. This is not optional.
Your nutritional status will continue to be evaluated and when
safe to stop,, the transplant clinic will transition you.
Your insulin is written as if you are getting tube feeds, and
you may become severely hypoglycemia if you do not continue your
tube feeds.
.
You may shower with assist. Allow the water to run over your
incision and pat area dry. No rubbing, no lotions or powder near
the incision.
.
No driving until cleared by your surgeon
.
Do not increase, decrease, stop or start medications without
consultation with the transplant clinic at ___. There
are significant drug interactions with anti-rejection
medications which must be considered in medication management
following transplant.
.
Consult transplant binder, and there is always someone on call
at the transplant clinic with any questions that may arise
Followup Instructions:
___
|
10275937-DS-3 | 10,275,937 | 25,098,954 | DS | 3 | 2124-11-06 00:00:00 | 2124-11-11 11:28:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hematemesis, Possible Seizure
Major Surgical or Invasive Procedure:
EGD, Intubation, Extubation
History of Present Illness:
___ is a ___ gentleman with a history of
interstitial lung disease(COP c/b pulmonary fibrosis and
bronchiectasis on 3L home O2 w/activity), non-insulin dependent
type II DM, CKD III (Cr 1.5), HTN, HLD, CVA who presented with
hematemesis with epistaxis in the setting of seizure-like
activity.
The morning of admission he woke up and felt a little nauseated.
On way to bathroom started to feel light-headed. He went to sit
down, but his hand slipped off the chair and he fell to ground.
He did not strike his head. He got up and sat down. After
staying seated, he stood up. He soon thereafter endorsed feeling
clamminess in his hands and briefly lost consciousness (as per
wife). He fell to the floor and went into the fetal position
with subsequently full body shaking as his eyes rolled back in
his head. This lasted <1 minute. He awoke, conversant w/ loss
of urinary continence. He did not recall LOC, but was not
confused. He did not hit head at this point either. After this
fall, while conscious, he had acute onset of "pouring" epistaxis
and subsequently (while nose still bleeding) vomited blood in
"large quantity."
In the ED initial vitals: 101 125/58 20 98% Nasal Cannula
- While in the ED, he became hypotensive with SBPs in the ___
and tachycardic with HRs in the 120s. He is s/p 1 unit
leukoreduced pRBCs.
- Labs notable for: H/H 9.___.2
- Patient was given Pantoprazole 40 mg IV x 1, IVF NS x 1L,
methylprednisolone 125mg IV x 1, pantoprazole 40mg IV x 1.
- The decision was made to admit to the MICU for management.
Past Medical History:
HTN
CVA
HLD
cataracts
CKD3= Cr 1.5
T2DM
ILD (COP/BOOP) w/pulmonary fibrosis and bronchiectasis; on 3L
home O2 typically w/exertion, rarely at rest
chronic cough
vitD deficiency
hx PNA
Social History:
___
Family History:
Father - alcoholism, heart failure and MI, deceased at ___
Mother - deceased from massive CVA
No children
No other family history of early mi, cad, sudden cardiac death
or pulmonary disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITALS: 97.7 106 159/60 86 97%3L NC
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, nares with significant dried
blood/clots. MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
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:
NEURO: AOx3, CNII-XII
DISCHARGE PHYSICAL EXAM:
=========================
VITALS 97.7 120/82 R Lying91 18 993 L
GENERAL- NAD, calm
EYES - PERRLA, EOM intact
NECK - No noticeable or palpable swelling, redness or rash
around throat or on face
CARDIOVASCULAR- RRR no m/r/g, no JVD, no carotid bruits
LUNGS- basilar crackles bilaterally L>R
SKIN- No rashes, skin warm and dry, no erythematous areas
ABDOMEN- Normal bowel sounds, abdomen soft and nontender; no
bruits auscultated
EXTREMITIES- No edema, cyanosis or clubbing; pulses
MUSCULOSKELETAL - ___ strength, normal range of motion, no
swollen or erythematous joints.
Pertinent Results:
ADMISSION LAB VALUES:
=======================
___ 10:20AM BLOOD WBC-21.7* RBC-3.43* Hgb-9.9* Hct-31.2*
MCV-91 MCH-28.9 MCHC-31.7* RDW-15.3 RDWSD-50.4* Plt ___
___ 10:20AM BLOOD Neuts-56 Bands-0 ___ Monos-7 Eos-1
Baso-0 ___ Myelos-0 AbsNeut-12.15* AbsLymp-7.81*
AbsMono-1.52* AbsEos-0.22 AbsBaso-0.00*
___ 10:20AM BLOOD Plt Smr-NORMAL Plt ___
___ 10:20AM BLOOD Glucose-108* UreaN-55* Creat-1.6* Na-139
K-4.6 Cl-102 HCO3-20* AnGap-22*
___ 10:20AM BLOOD ALT-18 AST-24 CK(CPK)-62 AlkPhos-64
TotBili-0.2
___ 10:20AM BLOOD Lipase-27
___ 10:20AM BLOOD CK-MB-4 cTropnT-0.01
___ 10:20AM BLOOD Albumin-3.9 Calcium-9.6 Phos-3.7 Mg-1.7
DISCHARGE LAB VALUES:
=======================
___ 07:15AM BLOOD WBC-8.0 RBC-4.20* Hgb-12.0* Hct-36.6*
MCV-87 MCH-28.6 MCHC-32.8 RDW-15.5 RDWSD-48.3* Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD Glucose-98 UreaN-22* Creat-1.2 Na-138
K-4.7 Cl-100 HCO3-24 AnGap-19
___ 07:15AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.9
PERTINENT LABS:
========================
___ 10:20AM BLOOD Glucose-108* UreaN-55* Creat-1.6* Na-139
K-4.6 Cl-102 HCO3-20* AnGap-22*
___ 10:20AM BLOOD WBC-21.7* RBC-3.43* Hgb-9.9* Hct-31.2*
MCV-91 MCH-28.9 MCHC-31.7* RDW-15.3 RDWSD-50.4* Plt ___
___ 01:22PM BLOOD WBC-17.1* RBC-2.88* Hgb-8.6* Hct-26.7*
MCV-93 MCH-29.9 MCHC-32.2 RDW-16.2* RDWSD-54.6* Plt ___
___ 05:15AM BLOOD WBC-7.7 RBC-2.44* Hgb-7.1* Hct-21.7*
MCV-89 MCH-29.1 MCHC-32.7 RDW-15.9* RDWSD-50.2* Plt ___
IMAGING:
=====================
EEG ___
This is an abnormal video-EEG monitoring session because of mild
diffuse background slowing and slow posterior dominant rhythm.
These findings
are indicative of mild diffuse cerebral dysfunction, which is
nonspecific as
to etiology. No epileptiform discharges or electrographic
seizures are
recorded.
CHEST (PORTABLE AP) ___
Diffuse increased interstitial prominence suggestive of
interstitial lung
disease. There is no focal consolidation. There is no pleural
effusion or
pneumothorax. No priors are available for comparison. There is
mild
cardiomegaly.
CHEST (PORTABLE AP) ___
The tip of the endotracheal tube projects over the mid thoracic
trachea.
There are low bilateral lung volumes. There is mildly increased
interstitial
prominence which may reflect an element of mild pulmonary edema
superimposed
on chronic interstitial lung disease. New retrocardiac
opacities may reflect
atelectasis. No pneumothorax or large pleural effusion. The
size of the
cardiac silhouette is unchanged.
CHEST (PORTABLE AP) ___
In comparison with the study of ___, the tip of the
endotracheal tube is
approximately 2.6 cm above the carina. There again are very low
lung volumes
that accentuate the prominence of the transverse diameter of the
heart.
Continued coarse interstitial markings could well represent
pulmonary vascular
congestion superimposed on the known chronic lung disease.
Probable
atelectatic changes at the left base. No definite acute
pneumonia, though
this would be difficult to exclude in the appropriate clinical
setting,
especially in the absence of a lateral view.
MR HEAD W & W/O CONTRAST ___
Old infarct within the left cerebellar hemisphere within the
vascular
territory of the left ___.
No infarct, hemorrhage, mass effect, or abnormal enhancement.
Probable chronic small vessel ischemic changes.
Medial temporal atrophy.
MICROBIOLOGY:
==================
BLOOD CULTURE ___
No growth
URINE CULTURE ___
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION.
BLOOD CULTURE ___
No growth
MRSA SCREEN
No MRSA isolated
SPUTUM
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
Brief Hospital Course:
Key Information for Outpatient ___ is a
___ gentleman with a history of interstitial lung
disease(COP c/b pulmonary fibrosis and bronchiectasis on 3L home
O2 w/activity), non-insulin dependent type II DM, CKD III (Cr
1.5), HTN, HLD, hx CVA who presented with unwitnessed seizure
and hematemesis with epistaxis. Transferred to ICU for 1uRBC and
EEG which was abnormal. Transferred to medicine floor for
further monitoring, then had an EGD done which showed bleeding
ulcer with visible vessel in the distal esophagus near the GE
Junction s/p epinephrine and four endoclips. Pt remained
intubated and monitored in ICU after procedure and received
additional units of RBC, H/H remained stable. Transferred back
to the floor for further monitoring, neurology did an MRI to
further evaluate convulsive syncope vs. seizure and results
showed old infarct otherwise no hemorrhage/new infarct/mass
effect/ abnormal enhancement.
Patient will be discharged with several medication changes.
Please be aware.
#Acute blood loss anemia
#Hematemesis/Epistaxis
History of large volume epistaxis followed by hematemesis
appeared more consistent with posterior nose bleed and
pseudohemoptysis. ENT was consulted but deferred imaging due to
possible iatrogenic bleeding risk. Given patient's history of
ILD, there was concern for pseudo-hematemesis secondary to
respiratory source. However, CXR was only notable for
interstitial prominence suggestive of interstitial lung disease,
and he experienced no increased cough or hypoxia during
admission. GI was initially resistant to EGD requiring
intubation in a high risk ILD patient but did endoscopy during
admission. On ___, patient was in pre-op for EGD when he became
tachycardia to 120s. Scope noted an ulcer over a vessel which
was actively bleeding. It was injected with epinephrine,
bicaped/cautery, and still was not improving, clipped x5.
Patient was given a unit of blood during procedure because Hb
dropped 10.2 to 8.6. Patient intubated, and then extubated ___.
He was sent back to the medical service and monitored for
hemodynamic stability/ clinical manifestations of bleeding.
Hemoglobin/hematocrit were trended, with plans to transfuse for
Hb <7. Pantoprazole 40 mg IV BID was started based on GI
recommendation.
#Unresponsive episode
Unclear if convulsive syncope vs seizure. No remarkable
findings on physical exam to suggest one etiology over another.
While patient has no concerning cardiac history, his nausea was
considered a possible atypical presentation of angina in a pt
with multiple risk factors. Trop negative x2. ECG in ED was
unremarkable. Tele was unremarkable during admission. EEG on
___ was abnormal due to mildly slow background activity and slow
posterior dominant rhythm, indicative of mild diffuse cerebral
dysfunction. Neurology did an MRI to further evaluate
convulsive syncope vs. seizure and results showed old infarct
otherwise no hemorrhage/new infarct/mass effect/ abnormal
enhancement.
#Hypotension
Reported SBP in ___ in ED prior to IVF resuscitation. Resolved
with fluid and blood product resuscitation. Most likely volume
depletion ___ bleeding. Patient experiencd SBP 150s on ___.
Given his stability at this point, home anti-hypertensives were
restarted.
-amlodipine 5mg/ losartan 75 mg
#Stroke
Patient admitted on atorvastatin 10 mg PO QPM and aspirin 325mg
QD. Atorvastatin continued during admission; ASA held due to
bleeding risk. Given bleeding distal esophageal vessel found
during admission, there was question of when/how to restart home
aspirin, given increased risk for bleeding. Neurology was
consulted, and relayed that there was no evidence indicating
increased efficacy of ASA 81mg vs ASA 325mg for stroke
prevention. Lower dose ASA 81mg was cautiously restarted for
stroke prophylaxis.
#Leukocytosis
Initially attributed to steroid use and hemoconcentration ___
hypovolemia I/s/o bleeding as above. WBC on admission 21.7.
Has been afebrile. Urine culture negative.
#ILD-COP c/b bronchiectasis
-prednisone 20mg
-home O2 (3L)
-tessalon perles 200mg oral bid
-Calcium Carbonate 600 mg PO TID
-Vitamin D ___ UNIT PO DAILY
-Bactrim
-omeprazole 40mg daily
#HTN/HLD
As above
#DMII
Metformin held. Restarted on discharge. Given lability of Cr
consider transition to alternative oral hypoglycemic agent.
#Allergies
-Cetirizine 10 mg PO DAILY
-Fluticasone Propionate NASAL 2 SPRY NU BID
Transitional issues:
--------------------
NEUROLOGY:
- Follow up with neurology for further management of previous
stroke and new seizure vs convulsive syncope.
- Changed Aspirin 325mg to aspirin 81mg given recent GI bleed
and no evidence of higher dose being more efficacious in
preventing stroke.
- Consider contacting outside facility for previous stroke/work
up.
- MRI reading
1. Old infarct within the left cerebellar hemisphere within the
vascular
territory of the left ___.
2. No infarct, hemorrhage, mass effect, or abnormal enhancement.
3. Probable chronic small vessel ischemic changes.
4. Medial temporal atrophy.
- EEG reading
This is an abnormal video-EEG monitoring session because of
mildly
slow background activity and slow posterior dominant rhythm,
indicative of
mild diffuse cerebral dysfunction. This is nonspecific as to
etiology. No
epileptiform discharges or electrographic seizures are recorded.
Compared to
the prior day's recording, there is no significant change.
GASTROENTEROLOGY:
- Follow up with gastroenterology for further management of
esophageal ulcer.
- New medication of pantoprazole 40mg PO BID until follow up
with outpatient GI.
- Discharge Hemoglobin 12.0/36.6
- Consider work up for h.pylori.
-EGD findings:
Bleeding ulcer with visible vessel was found in the distal
esophagus near the GE Junction. 8 cc of Epinephrine ___ were
injected for hemostasis with success. BI-CAP Electrocautery was
applied for hemostasis though there was still some oozing from
the ulcer base. Four endoclips were successfully applied for the
purpose of hemostasis.
HEALTH MAINTENANCE:
- HbA1c ___ 5.6%
- labs (admission, discharge)
*WBC (21.7, 8.0)
*RBC (9.9, 12.0)
*Cr (1.6, 1.2)
- Consider repeat lipid panel and increasing statin dose.
CODE: FULL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ___ (amlodipine-olmesartan) ___ mg oral DAILY
2. Atorvastatin 10 mg PO QPM
3. Aspirin 325 mg PO DAILY
4. Lactobacillus acidophilus 1 tab oral DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Fluticasone Propionate NASAL 2 SPRY NU BID
7. Tessalon Perles (benzonatate) 200 mg oral BID
8. Cetirizine 10 mg PO DAILY
9. Calcium Carbonate 600 mg PO TID
10. Vitamin D ___ UNIT PO DAILY
11. PredniSONE 20 mg PO DAILY
12. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
13. GlipiZIDE XL 5 mg PO DAILY
14. Doxazosin 1 mg PO HS
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every 12 hours Disp
#*60 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
3. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Calcium Carbonate 600 mg PO TID
6. Cetirizine 10 mg PO DAILY
7. Doxazosin 1 mg PO HS
8. Fluticasone Propionate NASAL 2 SPRY NU BID
9. GlipiZIDE XL 5 mg PO DAILY
10. Lactobacillus acidophilus 1 tab oral DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. PredniSONE 20 mg PO DAILY
13. Tessalon Perles (benzonatate) 200 mg oral BID
14. Vitamin D ___ UNIT PO DAILY
15. HELD- ___ (amlodipine-olmesartan) ___ mg oral DAILY This
medication was held. Do not restart ___ until you speak to your
primary care doctor. Your blood pressures were in the 130s
without this medication
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=====================
Esophageal Ulcer
Possible Seizure vs. Convulsive syncope
SECONDARY DIAGNOSIS
===================
ILD- COP
CVA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you here at ___.
What happened while you were at the hospital?
- You were admitted for seizure-like activity and vomiting
blood.
- For your seizure: you received an EEG, this is a monitor we
put on your scalp to help detect seizure activity. The EEG came
back largely normal. Neurology consulted and recommended a brain
MRI to rule out any masses in your brain. The results of the MRI
showed an old stroke but nothing new or concerning.
- For your bleeding: You underwent an endoscopy to detect any
possible causes of bleeding. An esophageal ulcer was detected
and clipped 5 times to help control the bleeding. You were
briefly intubated and stayed in the ICU for this. We monitored
you after the endoscopy to ensure you were no longer bleeding,
your blood count remained stable.
What to do on discharge?
- Please follow up with your neurologist for your seizure and
ongoing management of your previous stroke.
- Please follow up with a gastroenterologist. They will monitor
your esophageal ulcer.
- You should not drive or use heavy machinery until you are
seizure-free for at least 6 months.
- Please use caution around swimming pools or heights given new
seizure.
- Please look out for black or bloody stools. If this occurs,
please call your primary care doctor or seek medical attention
immediately. This may indicate a gastrointestinal bleed.
- We have made several changes to your medications, please be
mindful of the changes.
- Please avoid all NSAIDs, this includes naproxen, aleve,
motrin, ibuprofen.
We are happy to see you feeling better and wishing you all the
best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10276569-DS-6 | 10,276,569 | 21,184,852 | DS | 6 | 2147-11-23 00:00:00 | 2147-11-23 15:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
Sternal Wound Revision Surgery with Wire Removal, ___
PICC Placement, RUE, ___
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 11:38AM BLOOD WBC-8.0 RBC-3.63* Hgb-11.8* Hct-36.7*
MCV-101* MCH-32.5* MCHC-32.2 RDW-14.4 RDWSD-52.8* Plt ___
___ 11:38AM BLOOD Neuts-70.0 Lymphs-14.9* Monos-11.1
Eos-2.5 Baso-0.9 Im ___ AbsNeut-5.60 AbsLymp-1.19*
AbsMono-0.89* AbsEos-0.20 AbsBaso-0.07
___ 01:10PM BLOOD ___ PTT-44.7* ___
___ 11:38AM BLOOD Glucose-108* UreaN-21* Creat-0.8 Na-141
K-4.4 Cl-105 HCO3-26 AnGap-10
___ 02:55AM BLOOD ALT-12 AST-18 LD(LDH)-181 AlkPhos-113
TotBili-0.7
___ 02:55AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.9
___ 02:55AM BLOOD %HbA1c-6.1* eAG-128*
INTERVAL LABS:
===============
___ 01:10PM BLOOD ___ PTT-44.7* ___
___ 02:55AM BLOOD ___ PTT-48.7* ___
___ 06:49AM BLOOD ___ PTT-38.4* ___
___ 07:58AM BLOOD ___ PTT-33.4 ___
___ 07:19AM BLOOD ___ PTT-32.9 ___
___ 10:14AM BLOOD ___
___ 06:50AM BLOOD ___
___ 05:36AM BLOOD ___
___ 07:19AM BLOOD CRP-30.6*
___ 06:48AM BLOOD CRP-17.7*
DISCHARGE LABS:
===============
___ 05:36AM BLOOD WBC-7.6 RBC-3.03* Hgb-9.8* Hct-31.1*
MCV-103* MCH-32.3* MCHC-31.5* RDW-14.9 RDWSD-55.8* Plt ___
___ 05:30AM BLOOD ___
___ 05:36AM BLOOD Glucose-102* UreaN-35* Creat-0.8 Na-140
K-4.7 Cl-103 HCO3-28 AnGap-9*
___ 05:36AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.0
IMAGING:
========
___ Imaging CHEST (PA & LAT)
IMPRESSION:
No focal consolidation to suggest pneumonia.
___HEST W/CONTRAST
IMPRESSION:
1. Status post median sternotomy. Retrosternal soft tissue
thickening is
nonspecific but slightly more conspicuous from most recent prior
exam.
Mediastinitis cannot be excluded. Correlation with sternal
tenderness
recommended. No drainable fluid collection.
2. No acute fractures. Chronic fractures of the left tenth rib,
right ninth rib, as well as T10, T12, and L2 vertebrae are
unchanged.
3. 7 mm nonobstructing left renal stone.
___ Imaging L-SPINE (AP & LAT)
___ Imaging C-SPINE NON-TRAUMA ___
IMPRESSION:
Lumbar spine: Diffuse demineralization, limits sensitivity for
evaluation of subtle nondisplaced fractures. Vertebral body
height loss well-being T12, L2 and L5 vertebral bodies.
Anterolisthesis of L4 on L5. Multilevel endplate degenerative
changes, most prominent at L2-L3 and L4-L5. Severe facet
degenerative changes, most prominent at L5-S1. Probable
gallstones projecting at the right upper quadrant. Lateral
osteophytes at multiple levels of the lumbar spine.
Atherosclerotic vascular calcifications. Bilateral hip and
sacroiliac joint degenerative changes. Evaluation of sacrum is
limited due to overlying bowel gas shadow.
Cervical Spine: Atherosclerotic vascular calcifications.
Probable fusion of C2-C4 vertebral bodies. Retrolisthesis of C5
over C6 and mild anterolisthesis of C6 over C7. Diffuse
demineralization. Multilevel facet degenerative
changes. Fusion of the posterior elements of C2-C4. Median
sternotomy wires partially imaged. If there is concern for
acute fracture, CT or MRI may be obtained.
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
Comparison to ___. The sternal wires were removed.
There is no evidence for the presence of a pneumothorax. Normal
shape and size of the cardiac silhouette. Normal hilar and
mediastinal contours. No pneumonia, no pleural effusions, no
pulmonary edema.
MICROBIOLOGY:
=============
___ 6:10 pm SWAB R/O SAS.
**FINAL REPORT ___
RESPIRATORY CULTURE (Final ___:
STAPH AUREUS COAG +.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Time Taken Not Noted Log-In Date/Time: ___ 9:08 pm
SWAB Site: NARIS (NARE) NASAL SWAB R/O SA ONLY.
**FINAL REPORT ___
RESPIRATORY CULTURE (Final ___:
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----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ 8:49 am TISSUE STERNAL WOUND.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
___ 2:55 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
Brief Hospital Course:
___ with T2DM, CAD s/p CABG in ___, LV mural thrombus, atrial
fibrillation, CKD stage III, PVD with ___ ORIF right hip with
TFN, presenting with failure to thrive.
TRANSITIONAL ISSUES:
====================
[ ] Check INR 3x weekly while at rehab and adjust warfarin dose
as needed. Suggested discharge dose is 4mg daily, although can
adjust as needed based on INR. Next INR check should be ___.
[ ] Held home lisinopril and reduced home dose of metoprolol on
discharge given soft/normal BPs throughout admission off this
medication. Suspect that patient does not need as aggressive BP
medication regimen now that he has lost weight. Can consider
up-titration as needed if BPs rise in the outpatient setting.
[ ] Please check vanco trough on ___ prior to
vancomycin dose that day, send results to ATTN: ___
CLINIC - FAX: ___
[ ] Has ___ in the spine clinic arranged for ___, needs
to remain in cervical collar until then
[ ] If fecal incontinence continues as an outpatient, would
recommend gastroenterology referral/evaluation
[ ] If urinary incontinence continues as an outpatient, would
recommend urology referral evaluation
[ ] Given concerns for unintentional weight loss, please ensure
that he is up-to-date on all age-appropriate cancer screening
[ ] On discharge from rehab, patient should be screened for
moving to an assisted living facility, as we do not feel as
though he is safe to live at home.
ANTIBIOTIC COURSE/INFORMATION:
OPAT Diagnosis: Sternal wound infection, r/o sternal osteo
OPAT Antimicrobial Regimen and Projected Duration:
Agent & Dose: IV Vancomycin 1g q24H* and IV Ertapenem 1g q24H
Start Date: ___
Projected End Date: ___ (6 week course)
*Please see Vancomycin monitoring note from Pharmacy from ___
Given high levels ___, suggest resuming vancomycin 1g IV
q24h dosing ___ @1200 (after dose given ___ @2358) to ensure
clearance and avoid midnight dosing administration.
Please repeat vancomycin trough before the dose on ___ (prior
to
___ dose). If renal function worsens may need to check
sooner.
Essential Dates for OPAT therapy:
___ Cardiac surgery I&D, removal sternal wires
Plan for Transition to Oral Therapy: No
Have susceptibilities been obtained?
Is the use of rifampin planned? (Yes/No & Date started)
Plan for Future Imaging: No
Has the study been ordered/scheduled?
LAB MONITORING RECOMMENDATIONS: NOTE: For lab work to be drawn
after discharge, a specific standing order for Outpatient Lab
Work is required to be placed in the Discharge Worksheet -
Post-Discharge Orders. Please place an order for Outpatient Labs
based on the MEDICATION SPECIFIC GUIDELINE listed below:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
WEEKLY starting ___ before vancomycin dose: CBC with
differential, BUN, Cr, Vancomycin trough, AST, ALT, Total Bili,
ALK PHOS, CRP
FOLLOW UP APPOINTMENTS: The ___ will schedule follow up
and
contact the patient or discharge facility. All questions
regarding outpatient parenteral antibiotics after discharge
should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
ACUTE ISSUES:
=============
#Infected Sternotomy Wire
#C/f Sternal Osteomyelitis vs Mediastinitis
On presentation to the ED, Mr. ___ was noted to have a small
area of drainage on the middle of his chest which has been
treated with dressing changes. CT showed "Retrosternal soft
tissue thickening is nonspecific but slightly more conspicuous
from most recent prior exam.
Mediastinitis cannot be excluded." On the recommendation of CT
Surgery, he was admitted for sternal wound irrigation at
debridement with hardware removal. Given concern for possible
mediastinitis based on the CT read, he was initially broadly
covered with vancomycin and ceftazidime. CRP on admission was
elevated, at 30. He had no obvious signs of systemic infection,
including fevers, chills, nausea, vomiting. He did endorse
generalized weakness, though it is unclear if this was due to an
infectious process, or FTT. Cardiac surgery followed closely
throughout his admission, and ultimately performed a sternal
wound revision procedure with removal of 2 sternotomy wires on
___. Soft tissue cultures were taken at that time, but no bone
biopsy was performed; Unfortunately, yield from cultures
likely to be limited, as he had ___ been on broad-spectrum
antiemetics for 4 days at the time of his procedure.
Ultimately, the infectious disease team was consulted, and
recommended that he be treated with a 6-week course of IV
antibiotics (vancomycin/ertapenem), for presumed sternal
osteomyelitis versus mediastinitis, through ___.
# Atrial Fibrillation
# LV Mural Thrombus
# Supratherapeutic INR/Coagulopathy iso Malnutrition
Patient presented with supratherapeutic INR of 7.0, likely in
setting of poor PO intake over the past month. CHADs Score of 4.
There is no indication for bridging. He was initially treated
with 3 days of PO vitamin K with appropriate reversal of
supratherapeutic INR prior to surgery. His warfarin dosing was
resumed on ___, Daily dose determined based on INR, but
suspect discharge dose will be about 4 mg daily.
# Fecal Incontinence
# Urinary Incontinence
Patient reported on admission that he has had fecal and urinary
incontinence for at least last 2 months, which has been noted in
prior neurosurgery notes, and has been felt to be a chronic
issue related to his immobility and resultant difficulties
getting to the bathroom on time. In review of prior
documentation, the symptoms have
been discussed during his prior admissions, and an MRI was not
recommended. Given that there was no acute change, and his
neuro exam
remained stable during his admission, we deferred further
imaging. He was noted to have good rectal tone on his admission
exam. Reassuringly, while inpatient, he did not have fecal
incontinence. He did continue to have urinary incontinence,
however, this was managed with a condom catheter. On discharge,
he would likely benefit from referral to gastroenterologist for
further work-up of his fecal incontinence, as well as urology
for further work-up of possible overflow incontinence.
# Failure to Thrive
On admission, the patient noted generalized weakness and
unsteadiness, and feels that he has not been able to
appropriately take care of himself alone at home. He had not
taken his medications for several days, and was noted to not be
eating while alone at home.
Notably, he was just recently discharged from rehab on ___. It
is possible that his weakness is due to deconditioning and poor
PO intake, which was supported by his extremely low albumin
levels and ketones in the urine (supporting evidence of
malnutrition and starvation ketosis). It strongly appears that
he did not have enough support or resources at home to manage
his own care. Also suspect that his chest infection, as above,
was playing a role in his way to thrive. Patient admitted to
restricting his p.o. intake intentionally at home, given
concerns for fecal incontinence, as noted above; restarting his
diet, he hope to minimize his incontinence. Nutrition evaluated
the patient, and recommended starting supplements. He was
evaluated by ___ and recommended for discharge to rehab. We
considered depression as possible etiology of symptoms, as the
patient's son raised concerns that he was still actively
grieving at home over the recent passing of his wife. However,
the patient denied this, and stated that he was just feeling
lonely because many of his friends have passed and he did not
have a robust social network. He declined antidepressant
therapy. He agreed that he would probably eventually benefit
from transitioning to a an assisted living facility going
forward, where he would have more opportunities to socialize.
There were concerns raised for possible elder neglect or abuse
at home. A safety report was filed and this should be considered
prior to discharging him home from rehab. SW consult would be
helpful at rehab.
# Thoracic and Lumbar Spine Compression Fractures
# C/f cervical DJD
Patient presented in a cervical collar, as he had not yet
received neurosurgery clearance from his prior admission after a
fall with possible compression fractures in his thoracic and
lumbar spine on imaging. Neurosurgery evaluated patient on
admission, and recommend that he continue to wear his cervical
collar until he follows up in the outpatient setting with Dr.
___.
CHRONIC ISSUES:
===============
#HTN
- Held home lisinopril as BPs were soft throughout admission, in
the ___.
- Continued home metoprolol on fractionated dose.
#HLD
- Continued home statin
#CAD
- Continued home ASA, statin
- Continued home metoprolol, at fractionated dose.
> 30min spent on clinical care on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Furosemide 20 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Warfarin 5 mg PO DAILY16
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Cyanocobalamin 250 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Ertapenem Sodium 1 g IV ONCE Duration: 1 Dose
3. Vancomycin 1000 mg IV Q 24H
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Warfarin 4 mg PO DAILY16
Please check INR 3x weekly at rehab and adjust dose as needed.
Goal INR ___.
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Cyanocobalamin 250 mcg PO DAILY
9. Furosemide 20 mg PO DAILY
10. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until you see your PCP.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Infected Sternotomy Wire
Possible Sternal Osteomyelitis vs Mediastinitis
Failure to Thrive
SECONDARY DIAGNOSIS:
====================
Atrial Fibrillation
Fecal and Urinary Incontinence
Thoracic and Lumbar Spine Compression Fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
================================
- You were feeling fatigued at home, and had been losing weight.
He came to the emergency room for evaluation, and was noted to
have an infection around your sternotomy wires from your prior
cardiac surgery.
WHAT HAPPENED TO ME IN THE HOSPITAL?
=======================================
- The cardiac surgery team performed a sternal wound revision
and sternotomy wire removal procedure.
- The physical therapy team evaluated you, and felt that you
would benefit from going to rehab.
- The neurosurgery team evaluated you, and felt that you needed
to remain in your cervical collar until you were cleared by the
spine clinic in 2 weeks.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
================================================
- Continue to take all your medicines and keep your
appointments.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- After leaving your rehab, you should be evaluated for moving
to an assisted living facility, as it will not be safe for you
to go home.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10276690-DS-18 | 10,276,690 | 23,567,288 | DS | 18 | 2190-09-18 00:00:00 | 2190-09-22 18:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Aspiration of hematoma at left axilla
History of Present Illness:
___ yo F with h/o follicular lymphoma diagnosed in ___ but was
asymptomatic thus actively followed w/o treatment. Developed
increased ax LAD ___, PET showed increased LAD and repeat
biopsy showed lambda-restricted B-cell lymphoproliferative
disorder, CD10(+). IGH/BCL2 gene rearrangement present but no
MYC translocations. Peripheral blood had circulating lymphoma
cells w/ similar immunophenotype.
She received bendamustine ___ and ___.
Patient presents to ED with reported fevers of up to 103
starting last night w/ chills. Fever persisted today.
Initial VS in ED 13:00 7 97.8 93 126/60 16 100% RA
spiked fever to 101.2 at 1400 and given tylenol
BP down to 96/48 at 1530 but improved after 1L NS
had negative flu PCR.
CXR clear
On arrival to floor is afebrile. Denies headache, cough, SOB.
Did feel like she was going to vomit last night when she had
fever but has resolved since. has soreness/fullness over L
abdomen but no other pain. eating ok. no dysuria, hematuria or
frequency. no sore throat or congestion. does have night sweats
present since LAD worsened last month. states she typically has
constipation and is taking stool softeners. has bruising over L
breast, seen by surgery last week and noted to have floating
hematoma at biopsy site. She feels that LN are unchanged in size
the past few weeks and are not tender.
Only other complaint is back pain. She reports left lower back
pain for the past ___ years which has worsened in the past 3
weeks.
Underwent ___ in ___ for several months for low bakc and L
gluteal pain. states pain did get better at that time. Typically
present w/ walking. states that pain has been worse last few
weeks. No radicular pain, no numbness or paresthesias.
Past Medical History:
PAST ONCOLOGIC HISTORY: per OMR ___ she was noted to have
a right neck mass. She was seen by Dr. ___ FNA
showed atypical lymphoid population of lambda restricted B-cell
population that co-express CD10. She had a CT scan of the neck
done on ___, which did reveal multiple right-sided level 5
lymph nodes, the largest one measuring 1.4 x 1.2 x 1.0 cm in
size. This was concerning for either a neoplastic process,
infectious or inflammatory etiology. At that point, she was lost
to followup and then re-presented in early ___ to Dr.
___ ultimately a right neck excisional mass biopsy
was performed. This revealing follicular lymphoma,
follicular growth pattern, cytological grade 1 of 3. PET at
___ ___ showed nuerous enlarged FDG avid LN in the
cervical, axillary, internal mammary, retroperitoneal, pelvic,
inguinal, and femoral stations compatible with lymphoma.
2. Diffuse splenic FDG uptake consistent with disease
involvement. Given lack of B symptoms she was observed
___ she developed increased axillary LAD and drenching
night sweats and elevated LDH >400. Repeat PET ___ showed
Diffuse interval increase in size and number of FDG-avid lymph
nodes throughout the body, significantly increased FDG-avid
splenomegaly, and new focal and possibly widespread FDG avidity
in the liver, consistent with significant interval progression
of disease. L axillary LN biopsy ___ done to r/o transformation
#PAST MEDICAL HISTORY: Type 2 diabetes, GERD, arthritis, and
hypothyroidism.
#PAST SURGICAL HISTORY: Cholecystectomy ___ years ago, she
fractured her hand approximately two to ___ years ago on the
left and required surgical repair. She has had several teeth
extractions.
Social History:
___
Family History:
Mother alive at ___. Father deceased at ___ from leukemia. She has
10 siblings, four sisters and six brothers, six of her siblings
are alive, no history of malignancies that she is aware of.
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
VITAL SIGNS: 98.1 104/50 86 18 97%RA
HEENT: MMM, no OP lesions,
Neck: supple, no JVD
Lymph: + cervical, and large axillary LAD, largest L ax node
nontender, no fluctuance or eryhthema
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
EXT: warm well perfused, no edema, no spinal tenderness, mild
ttp L gluteal/ischial region she says is deep pain, straight leg
raise negative
SKIN: No rashes or skin breakdown, L breast w/ evolving large
ecchymoses nontender few other ecchymoses over ext
NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, face
symmetric, no tongue deviation, full hand grip, shoulder shrug
and bicep flexion, full toe dorsiflexion and hip flexion against
resistance bilateral, sensation intact to light touch, no clonus
DISCHARGE PHYSICAL EXAM:
==========================
VS: 98.7 97.6 79 114/45 18 98% ra
General: NAD
HEENT: MMM, no OP lesions
Neck: Supple, no JVD
Lymph: +Cervical, and large axillary LAD, largest L ax node
nontender, +induration but no fluctuance or eryhthema
CV: RRR, no murmurs
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
EXT: Warm, well perfused, no edema
SKIN: No rashes or skin breakdown, L breast w/ evolving large
ecchymoses nontender, few other ecchymoses over ext. Site of
aspiration at left axilla nontender.
NEURO: ___, EOMI, symmetric face and clear speech
Pertinent Results:
ADMISSION LABS:
=================
___ 01:30PM BLOOD WBC-3.4* RBC-3.16* Hgb-9.5* Hct-27.6*
MCV-87 MCH-30.1 MCHC-34.5 RDW-19.1* Plt ___
___ 01:30PM BLOOD Neuts-54 Bands-0 ___ Monos-4 Eos-2
Baso-0 Atyps-3* ___ Myelos-0
___ 01:30PM BLOOD Glucose-125* UreaN-15 Creat-0.7 Na-134
K-3.7
Cl-96 HCO3-25 AnGap-12
___ 01:30PM BLOOD LD(LDH)-1311*
___ 01:30PM BLOOD Albumin-3.3* UricAcd-3.7
___ 01:39PM BLOOD Lactate-1.8
DISCHARGE LABS:
================
___ 06:41AM BLOOD WBC-1.6* RBC-2.94* Hgb-8.7* Hct-25.0*
MCV-85 MCH-29.4 MCHC-34.7 RDW-18.1* Plt Ct-92*
___ 06:41AM BLOOD Neuts-40* Bands-6* Lymphs-47* Monos-6
Eos-0 Baso-0 Atyps-1* ___ Myelos-0
___ 06:41AM BLOOD ___ PTT-29.2 ___
___ 06:41AM BLOOD Glucose-86 UreaN-18 Creat-0.5 Na-140
K-3.9 Cl-107 HCO3-25 AnGap-12
___ 06:41AM BLOOD ALT-9 AST-30 LD(LDH)-353* AlkPhos-42
TotBili-0.4
___ 06:41AM BLOOD Calcium-7.6* Phos-4.0 Mg-2.3 UricAcd-4.0
MICROBIOLOGY:
==============
Left axilla hematoma aspiration:
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
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..
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION.
___: Blood cultures x 2 negative
___: Blood cultures x 2 negative
IMAGING:
=========
CHEST (PA & LAT) (___):
IMPRESSION: No evidence of acute cardiopulmonary disease.
Similar lymphadenopathy.
CT ABD & PELVIS WITH CONTRAST (___):
IMPRESSION:
Diffuse bulky mesenteric, retroperitoneal, and pelvic
lymphadenopathy is
similar to the recent ___ PET-CT and consistent with known
history of
lymphoma.
CT CHEST W/CONTRAST (___):
IMPRESSION:
1. Extensive bilateral axillary and mediastinal lymphadenopathy
is relatively unchanged compared to the prior examination.
2. There is interval development of a 3 x 7.2 x 3.6 cm high
density fluid collection at the site of left maxillary biopsy
which may represent an evolving hematoma or high-density seroma.
Infected fluid collection is not excluded.
3. Stable trace bilateral pleural effusions.
Brief Hospital Course:
Ms. ___ is a ___ woman with follicular lymphoma now w/
progressive LAD, worsening splenomegaly and new liver
involvement on last PET but no Richter's transformation who was
recently started on Bendamustine and was admitted for 24 hours
of high fevers.
# Fever/SIRS: Patient with high fever, HR >90 on arrival.
There were no localizing signs or symptoms of infection. A
chest CT showed interval development of a 3 x 7.2 x 3.6 cm high
density fluid collection at the site of prior left axillary
biopsy. ___ aspirated this collection, which was a hematoma.
Antibiotics were initially held, though patient was briefly on
vancomycin/cefepime after spiking a temperature overnight. Gram
stain from hematoma was negative and grew rare growth of
coagulase-negative Staph, most consistent with skin flora. She
was discharged on Augmentin (to continue through ___.
Etiology of her fevers were most likely progression of her
lymphoma. She received a dose of Rituximab as treatment of her
lymphoma (see below).
# Follicular lymphoma: Diagnosed by neck biopsy ___. Given
lack of B symptoms, she was watched conservatively for many
months. However, most recent PET scan showed wide-spread
lymphadenopathy. Repeat biopsy showed lambda-restricted B-cell
lymphoproliferative disorder, CD10(+). IGH/BCL2 gene
rearrangement present but no MYC translocations. Peripheral
blood had circulating lymphoma cells with similar
immunophenotype. She started Bendamustine on ___. CT torso
on ___ revealed axillary and mediastinal lymphadenopathy
(unchanged), as well as bulky mesenteric, retroperitoneal, and
pelvic lymphadenopathy (similar to recent PET-CT). She received
a dose of Rituximab while inpatient on ___.
# Low back pain: Most likely due to disease involvement in
pelvic bones, as seen on most recent PET. Pain was controlled
with Tylenol and Tramadol as needed.
# Type 2 diabetes: Continued home pioglitazone.
# Hypothyroidism: Continued home levothyroxine.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Allopurinol ___ mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Lorazepam 0.5 mg PO Q8H:PRN nausea, vomiting
5. Ondansetron ___ mg PO Q8H:PRN nausea
6. Pioglitazone 15 mg PO DAILY
7. Acetaminophen 325-650 mg PO Q6H:PRN pain
8. Docusate Sodium 100 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Allopurinol ___ mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Lorazepam 0.5 mg PO Q8H:PRN nausea, vomiting
6. Ondansetron ___ mg PO Q8H:PRN nausea
7. Pioglitazone 15 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 8.6 mg PO BID
10. Acetaminophen 325-650 mg PO Q6H:PRN pain
11. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every 12 hours Disp #*8 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
===================
Fever
SECONDARY DIAGNOSIS:
=====================
Follicular lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during hospitalization at
___. You were admitted for fevers. We could not identify any
clear source of infection, but are treating you until ___ in
case of any infection. You were found to have a small
collection at blood near the site of your prior lymph node
biopsy under your left arm. This was drained but is unlikely to
be contributing to your fevers. Your fevers may be due to
progression of your lymphoma. You received a dose of Rituxan
while you were here as part of your lymphoma treatment.
Please continue to take your medications as prescribed and keep
your follow-up appointments as outlined below.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10276690-DS-19 | 10,276,690 | 23,234,730 | DS | 19 | 2190-10-29 00:00:00 | 2190-11-04 15:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ year old ___ speaking female with
follicular lymphoma on Bendamustine/Rituximab C2D13 who
presented to ___ with fevers on ___.
The patient reported that she first felt her fever coming on the
night before, ___, at around midnight. She checked her
temperature and it was 101. She called her doctor on ___, who
told her to go to the ED. She otherwise had no complaints. Two
nights ago she had a headache and right sided shoulder pain
which resolved spontaneously. On the morning of ___ she had
1 episode of diarrhea and some abdominal gas/cramping, but that
resolved. At the time of admission, she had no cough, chest
pain, SOB, or dysuria. She does recall having fevers during her
last chemotherapy cycle.
Of note, the patient was admitted to ___ for fevers after her
last chemotherapy cycle in ___. She was found to have a left
axillary fluid collection on CT torso which was drained by ___
and grew rare growth of coag negative staph. She was prescribed
augmentin. No other infectious etiologies were discovered. The
true etiology of her fevers was felt to be progression of
lymphoma.
In the ED upon admission (___), initial VS were:
T 101.6, HR 102, BP 125/66, RR 18, O2 100% RA
Labs were notable for: wbc 13, lactate 2.3. UA negative.
Imaging included: CXR with no focal consolidation.
On arrival to the floor, the patient felt comfortable and
improved after IVF and tylenol. At the time she denied swelling
or redness in the left axilla but does feel a lump there which
comes and goes.
REVIEW OF SYSTEMS:
As per HPI. In addition, no throat pain or mouth sores. No
portacath, although she is scheduled to have one in late ___.
Remainder of 10 point ROS.
Past Medical History:
PAST ONCOLOGIC HISTORY: per OMR ___ she was noted to have
a right neck mass. She was seen by Dr. ___ FNA
showed atypical lymphoid population of lambda restricted B-cell
population that co-express CD10. She had a CT scan of the neck
done on ___, which did reveal multiple right-sided level 5
lymph nodes, the largest one measuring 1.4 x 1.2 x 1.0 cm in
size. This was concerning for either a neoplastic process,
infectious or inflammatory etiology. At that point, she was lost
to followup and then re-presented in early ___ to Dr.
___ ultimately a right neck excisional mass biopsy
was performed. This revealing follicular lymphoma,
follicular growth pattern, cytological grade 1 of 3. PET at
___ ___ showed nuerous enlarged FDG avid LN in the
cervical, axillary, internal mammary, retroperitoneal, pelvic,
inguinal, and femoral stations compatible with lymphoma.
2. Diffuse splenic FDG uptake consistent with disease
involvement. Given lack of B symptoms she was observed
___ she developed increased axillary LAD and drenching
night sweats and elevated LDH >400. Repeat PET ___ showed
Diffuse interval increase in size and number of FDG-avid lymph
nodes throughout the body, significantly increased FDG-avid
splenomegaly, and new focal and possibly widespread FDG avidity
in the liver, consistent with significant interval progression
of disease. L axillary LN biopsy ___ done to r/o transformation
#PAST MEDICAL HISTORY: Type 2 diabetes, GERD, arthritis, and
hypothyroidism.
#PAST SURGICAL HISTORY: Cholecystectomy ___ years ago, she
fractured her hand approximately two to ___ years ago on the
left and required surgical repair. She has had several teeth
extractions.
Social History:
___
Family History:
Mother alive at ___. Father deceased at ___ from leukemia. She has
10 siblings, four sisters and six brothers, six of her siblings
are alive, no history of malignancies that she is aware of.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98, 100/50, 84, 22, 97% on RA
GENERAL: NAD, comfortable appearing, ___
HEENT: NC/AT, EOMI, PERRL, MMM. No photophobia or neck
stiffness. No sores or ulcers in the oropharynx. She does have a
healing red cold sore at the left ___ border.
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: +BS, soft, NT/ND, no rebound or guarding
EXT: No lower extremity pitting edema, although the patient
states that her legs are swollen and get this way with chemo. No
calf tenderness, redness, or swelling. Left axilla with palpable
2cm firm, ill-defined round lymph node without tenderness,
erythema, or warmth.
NEURO: CN II-XII intact, MAEE, no focal deficits
SKIN: Warm and dry, without rashes
DISCHARGE PHYSICAL EXAM:
T: 98.1, BP: 106/62, HR: 76 RR: 18 O2: 98% on room air
I/O:
I: 650, O: 550 +, balance: approximately even
GENERAL: NAD, comfortable appearing, ___
HEENT: EOMI. MMM. No sores, ulcers, or thrush in the am.
CARDIAC: RRR, normal S1 & S2, no murmurs, no S3 or S3
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: +BS, soft, NT/ND, no rebound or guarding
EXT: No lower extremity pitting edema
NECK: pt has full ROM, no tenderness with palpation,
brudzinski's neck sign negative
SKIN: Warm and dry, without rashes
Pertinent Results:
ADMISSION LABS:
___ 05:55PM BLOOD WBC-13.7* RBC-3.74* Hgb-10.6* Hct-33.1*
MCV-89 MCH-28.3 MCHC-32.0 RDW-17.6* RDWSD-56.7* Plt ___
___ 05:55PM BLOOD Neuts-74* Bands-12* Lymphs-8* Monos-4*
Eos-1 Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-11.78*
AbsLymp-1.23 AbsMono-0.55 AbsEos-0.14 AbsBaso-0.00*
___ 05:55PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-1+ Ovalocy-1+ Tear Dr-1+
___ 05:55PM BLOOD Plt Smr-LOW Plt ___
___ 05:55PM BLOOD ALT-12 AST-21 LD(LDH)-295* AlkPhos-122*
TotBili-0.8
___ 05:55PM BLOOD Albumin-4.4
___ 06:14PM BLOOD Lactate-2.3*
DISCHARGE LABS:
___ 06:40AM BLOOD WBC-5.7 RBC-3.52* Hgb-9.8* Hct-31.3*
MCV-89 MCH-27.8 MCHC-31.3* RDW-17.2* RDWSD-56.2* Plt ___
___ 06:40AM BLOOD Neuts-58 Bands-3 ___ Monos-7 Eos-2
Baso-2* ___ Myelos-0 Other-0 AbsNeut-3.48
AbsLymp-1.60 AbsMono-0.40 AbsEos-0.11 AbsBaso-0.11*
___ 06:40AM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL
Polychr-OCCASIONAL Ovalocy-OCCASIONAL
___ 06:40AM BLOOD Glucose-91 Creat-0.4 Na-138 K-3.9 Cl-103
HCO3-25 AnGap-14
___ 06:40AM BLOOD ALT-10 AST-27 TotBili-0.4
___ 06:40AM BLOOD Phos-4.8* Mg-2.1
___ 07:58AM BLOOD Lactate-1.8
IMAGING:
CT of the abdomen and pelvis w/contrast:
1. No fluid collection or other acute abdominal or pelvic
process correlating to recent history of fevers.
2. No change in bulky mesenteric, retroperitoneal, and pelvic
lymphadenopathy in comparison to the ___ CT.
3. Slight increase in trace ascites.
4. Stable moderately splenomegaly.
CT of the chest w/contrast:
Interval treatment response with decrease in the axillary,
mediastinal, and supraclavicular lymphadenopathy when compared
to the prior examination.
Interval decrease in the left axillary hematoma/seroma.
Mild mosaic attenuation suggestive of air trapping likely from
small airways disease.
URINE STUDIES
___ 07:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:15PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
MICROBIOLOGY:
___ 07:15PM URINE RBC-4* WBC-2 Bacteri-FEW Yeast-NONE Epi-0
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Blood cultures: pending
___ 12:15 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.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION:
Ms ___ was admitted on ___ with fevers while receiving
treatment of her follicular lymphoma with
bendamustine/rituximab.
ACTIVE ISSUES
# SIRS: Upon admission she was febrile, had an elevated white
count with bandemia, and a slightly elevated lactate. She was
started on empiric cefepime on ___. A CT scan of the abdomen
and chest did not reveal evidence of infection. Her u/a was
clean and her urine culture was normal. Blood cultures are still
pending. She had one subsequent fever on ___ but after
stopping antibiotics on ___ she remained afebrile. It was
felt the likely source of her fever was the lymphoma responding
to chemotherapy.
CHRONIC ISSUES
# Follicular lymphoma: C2D13 of bendamustine and rituximab.
Diagnosed by neck biopsy ___, after which she was monitored
for a period of time. She began developing B symptoms and PET
scan showed progression of disease in ___. She began
chemotherapy at that time with bendamustine and rituximab. Her
second cycle was significantly delayed due to neutropenia. She
received neulasta with this cycle on ___. Currently with anemia
and thrombocytopenia likely attributable to her recent
chemotherapy and her malignancy.
# Type 2 diabetes: The patient's home oral agents was held
during admission but was restarted on discharge.
# Hypothyroidism: Her home levothyroxine was continued.
# Anxiety: Her home lorazepam was continued.
# Nausea: Her home zofran and lorazepam were continued.
# Constipation: Her home Polyethylene glycol and senna were
continued.
TRANSITIONAL ISSUES:
- Please follow up blood cultures
- Please follow up respiratory viral panel
- Please review CT findings: stable increase in trace ascites,
stable moderate splenomegaly
- Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Allopurinol ___ mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Lorazepam 0.5 mg PO Q8H:PRN anxiety or nausea
5. Ondansetron ___ mg PO Q8H:PRN nausea
6. Pioglitazone 15 mg PO DAILY
7. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
8. Docusate Sodium 100 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID
Discharge Medications:
**There have been no changes to your medications at the
hospital. Please resume taking the medications you were taking
before you were admitted to the hospital.
1. Acyclovir 400 mg PO Q8H
2. Allopurinol ___ mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Lorazepam 0.5 mg PO Q8H:PRN anxiety or nausea
5. Ondansetron ___ mg PO Q8H:PRN nausea
6. Pioglitazone 15 mg PO DAILY
7. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
8. Docusate Sodium 100 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
- fever
- follicular lymphoma
Secondary Diagnoses:
- hypothyroidism
- diabetes
Discharge Condition:
Pt is feeling well with minimal pain and her fevers have
resolved.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure to participate in your care at ___. You were
admitted on ___ for fevers while receiving your
lymphoma treatment. You were treated briefly with antibiotics in
case of infection, but we did not find any source of infection.
We monitored your fevers, and stopped the antibiotics after no
infection was found. Again, it was a pleasure participating in
your care. Please continue taking all medications as prescribed,
and attend all follow-up appointments.
Sincerely,
Your ___ care team
Followup Instructions:
___
|
10276690-DS-21 | 10,276,690 | 24,898,739 | DS | 21 | 2191-08-23 00:00:00 | 2191-08-25 17:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Throat pain and fever
Major Surgical or Invasive Procedure:
Laryngoscopy ___
History of Present Illness:
___ is a ___ ___ speaking with history of T2D,
hypothyroidism, and follicular lymphoma in remission (post 6
cycles Bendamustine/Rituximab, finished ___ who presented
with 3 days of severe throat pain, and 1 day of chills, fever,
and vomiting. She reported her throat hurt when she swallowed
and when she talked. She also reported pain when she touching
along the left side of her neck. She had subjective fevers at
home but has not measured the temperature. The night before
presentation she had the chills and vomited and has vomited
multiple times since, emesis is whitish, non-bloody,
non-bilious. She denied abdominal pain, no diarrhea, no blood in
stool. She denied dysuria or hematuria. She denied SOB but felt
like it was sometimes painful or difficult to breath and also
reported dysphagia. She denied chest pain. She denied sick
contacts. She has noticed no lymph node swelling, bleeding or
easy bruising.
With regards to her malignancy workup, she presented in ___
with right neck mass, and patient was found to be low grade
follicular lymphoma. She was asymptomatic, therefore no
treatment was indicated and she was followed clinically. In
___, she had worsening lymphadenopathy on exam, showed diffuse
interval increase in size and number of FDG-avid lymph nodes
throughout the body, significantly increased FDG-avid
splenomegaly, and new focal and possibly widespread FDG avidity
in the liver, consistent with
significant interval progression of disease. Lymph node biopsy
___ showed follicular lymphoma low-grade, now s/p
chemotherapy currently in remission.
In the ED, initial vitals: pain ___ 119 144/88 16 96% RA
She was well appearing, in NAD, breathing comfortably, no
stridor. He has a hoarse voice, OC/OP clear, tongue soft; FOM
flat, mild bilateral LAD.
Labs were notable for WBC 9.5 N73% and 14% bands, BMP within
normal limits, Flu A/B negative.
CT neck showed 1. Bilateral palatine tonsillitis with left
lateral and posterior hypopharyngeal wall thickening and
adjacent soft tissue inflammation as well as retropharyngeal
edema and phlegmonous changes extending from C2-3 through C5-6.
No focal or discrete peritonsillar or retropharyngeal fluid
collection to suggest an abscess is identified. 2. Moderate
narrowing of the airway lumen is present as a result of the
enlarged palatine tonsils.
ENT was consulted, FOE exam was notable for significant
edema/erythema of epiglottis, arytenoid complexes. VC were
visualized and appeared to move bilaterally.
___ fellow was consulted, onc will follow. Per ___ rec, gave
levoflox and ordered IgG level.
Patient got 125 mg solumedrol, Unasyn 3g then switched to
Levofloxacin (per ___ recs). She also got 2L NS and Tylenol for
fever.
Decision was to admit to ICU for concern of airway compromise.
On transfer, vitals were: pain ___ 83 121/53 20 96% RA
On arrival to the MICU, patient was comfortable and in no acute
distress. She confirmed the history detailed above.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath, or wheezing. Denies chest pain,
chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
PAST MEDICAL HISTORY:
Follicular lymphoma, in remission
Type 2 diabetes
GERD
Arthritis
Hypothyroidism
PAST SURGICAL HISTORY:
Cholecystectomy
Hand fracture s/p surgical repair
Multiple teeth extraxtions
Social History:
___
Family History:
Mother alive at ___. Father deceased at ___ from leukemia. She has
10 siblings, four sisters and six brothers, six of her siblings
are alive, no history of malignancies that she is aware of.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Afebrile, 84 111/53 25 93%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated, no LAD, tender to palpation in
left>right sides of the neck
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: A&Ox3, moving all extremities
DISCHARGE PHYSICAL EXAM:
VS: 98.8 108-126/60-70 ___ 94-97%RA
General: Pleasant, WDWN, NAD
HEENT: MMM, no LAD, tonsils not enlarged, no pharyngeal
erythema. Small area of apthous ulcers over left oral mucosa. R
angular cheilitis.
Cards: RRR, no murmurs
Lungs: CTAB
Abdomen: Soft, NTND, NABS
Extremities: WWP, no edema
Skin: No rashes/lesions visible
Pertinent Results:
ADMISSION LABS:
___ 01:06PM BLOOD WBC-9.5# RBC-4.74 Hgb-13.4 Hct-41.6
MCV-88 MCH-28.3 MCHC-32.2 RDW-14.9 RDWSD-47.6* Plt ___
___ 01:06PM BLOOD Neuts-73* Bands-14* Lymphs-5* Monos-8
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-8.27*
AbsLymp-0.48* AbsMono-0.76 AbsEos-0.00* AbsBaso-0.00*
___ 01:06PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear
Dr-OCCASIONAL
___ 01:06PM BLOOD Plt Smr-LOW Plt ___
___ 02:24AM BLOOD ___ PTT-32.1 ___
___ 01:06PM BLOOD Glucose-166* UreaN-9 Creat-0.6 Na-142
K-3.8 Cl-107 HCO3-19* AnGap-20
___ 01:06PM BLOOD LD(___)-516*
___ 01:06PM BLOOD UricAcd-4.9
___ 02:24AM BLOOD Calcium-9.2 Phos-2.7 Mg-1.6
___ 01:37PM BLOOD Lactate-0.4*
___ 01:06PM BLOOD IgG-526*
PERTINENT INTERVAL LABS:
___ 01:50AM BLOOD LD(___)-188
DISCHARGE LABS:
___ 05:34AM BLOOD WBC-2.9* RBC-4.26 Hgb-11.8 Hct-36.2
MCV-85 MCH-27.7 MCHC-32.6 RDW-14.4 RDWSD-44.2 Plt ___
___ 05:34AM BLOOD Neuts-78* Bands-2 Lymphs-10* Monos-10
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-2.32 AbsLymp-0.29*
AbsMono-0.29 AbsEos-0.00* AbsBaso-0.00___ 05:34AM BLOOD Glucose-135* UreaN-12 Creat-0.5 Na-139
K-3.8 Cl-101 HCO3-27 AnGap-15
___ 05:34AM BLOOD ALT-16 AST-15 AlkPhos-43 TotBili-0.5
___ 05:34AM BLOOD Calcium-9.0 Mg-2.2
IMAGING/STUDIES:
CXR ___
Right-sided Port-A-Cath tip terminates at the SVC/ right atrial
junction.
Lung volumes are persistently low. This accentuates the size of
the cardiac silhouette which appears mildly enlarged. The aorta
remains tortuous. Crowding of bronchovascular structures is
present without overt pulmonary edema. Patchy opacities are
noted in lung bases likely atelectasis. No focal consolidation,
pleural effusion or pneumothorax is seen. There are no acute
osseous abnormalities.
IMPRESSION:
Low lung volumes with patchy opacities at the lung bases, likely
atelectasis, without focal consolidation.
CT CHEST ___. Bilateral palatine tonsillitis with left lateral and
posterior
hypopharyngeal wall thickening and adjacent soft tissue
inflammation as well as retropharyngeal edema and phlegmonous
changes extending from C2-3 through C5-6. No focal or discrete
peritonsillar or retropharyngeal fluid collection to suggest an
abscess is identified.
2. Moderate narrowing of the airway lumen is present as a result
of the
enlarged palatine tonsils.
CXR ___
The right-sided Port-A-Cath is unchanged position. Heart size
is upper limits of normal. There is no focal consolidation.
There is atelectasis at the lung bases. There are no
pneumothoraces.
Brief Hospital Course:
___ ___ speaking with history of T2D, hypothyroidism, and
follicular lymphoma in remission (post 6 cycles
Bendamustine/Rituximab, finished ___ who presented with 3
days of severe throat pain, fevers, dysphagia, and voice
changes, found to have epiglottitis.
#Epiglottitis: Patient presented with 3 days of severe throat
pain, fevers, dysphagia, and voice changes. CT showed bilateral
palatine tonsillitis, and retropharyngeal edema, with no
discrete drainable collection. ENT evaluated patient, and FOE
was notable for significant edema/erythema of epiglottis,
arytenoid complexes; vocal cords were visualized and appeared to
move bilaterally. The patient was evaluated with respiratory
viral panel and blood cultures, which were pending. She was flu
negative. She received Decadron 10mg q8h x3 for airway edema and
unasyn, transitioned to augmentin which will be continued for
total 10 day course. She will follow up with ENT.
#Angular cheilitis: Patient developed painful right angular
cheilitis. Given concern for possible HSV, she was started on
acyclovir. She was also started on topical miconazole. These
medications can be discontinued as outpatient pending clinical
improvement.
# H/O follicular lymphoma: post 6 cycles Bendamustine/Rituximab,
finished ___. Nothing further done here.
# Type 2 diabetes: Held patient's home oral agents (Pioglitazone
15 mg), managed with Humalog sliding scale while in house.
# Hypothyroidism: Continued levothyroxine, switched from PO to
IV while patient NPO.
# Communication: ___ (___) ___
# Code: Full (confirmed)
TRANSITIONAL ISSUES:
-Patient discharged on augmentin to complete 10 day course on
___
-Given acyclovir and topical miconazole for right angular
cheilitis; please follow up to ensure resolution and stop
medications as appropriate
-Consider maintenance rituximab if indicated, to be discussed
with primary oncologist
-Patient to follow up with Dr. ___ on ___
-Follow up appointment to be scheduled with Dr. ___
(___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Pioglitazone 15 mg PO DAILY
3. Acetaminophen 325 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Acyclovir 400 mg PO TID
Can stop after area improves.
RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp
#*15 Tablet Refills:*0
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*11 Tablet Refills:*0
5. Pioglitazone 15 mg PO DAILY
6. Miconazole 2% Cream 1 Appl TP BID
Can stop after area improves.
RX *miconazole nitrate 2 % Apply to sore on right lip twice a
day Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Epiglottitis
Secondary
Follicular lymphoma
TYpe 2 diabetes
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with an infection called
epiglottitis. You were admitted to the ICU to monitor your
breathing, and you were seen by ENT. You were treated with
antibiotics and you improved. You are being discharged home to
finish your course of antibiotics.
You will be scheduled for follow up with ENT and with Dr.
___. The orthopedic doctors are also ___ the
appointment you missed while in the hospital.
It was a pleasure taking care of you during your stay in the
hospital.
- Your ___ Team
Followup Instructions:
___
|
10277119-DS-24 | 10,277,119 | 24,922,958 | DS | 24 | 2185-08-09 00:00:00 | 2185-08-10 14:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
leg swelling, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old woman with PMH significant for
Type 1 diabetes on insulin pump s/p pancreas transplant in ___
(failed), s/p living-related kidney transplant in ___, CHF, and
HTN who presents with 2 days of orthopnea, PND, dyspnea on
exertion, worsening lower extremity edema, and abdominal
swelling.
She said she had similar symptoms and was hospitalized for CHF a
few years ago. Her outpatient cardiologist is Dr. ___.
She denied any chest pain/pressure/tightness. She denied any
recent dietary changes or medication noncompliance. She noted
that she started taking furosemide 20mg daily over the past week
(was taking MWF before). She also noted that in mid ___ she
was changed from Prograf to Rapamune due to skin cancer.
In the ED, initial vitals: 99.6 104 ___ 95%, repeat BP
170/80s.
Vitals on arrival to floor: 98.1, 177/79, 97, 22, 100% on RA.
She feels fine now.
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, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
Type I diabetes s/p pancreatic transplant ___, failed)
s/p living-related kidney transplant in ___
Hypertension
Congestive heart failure
___'s Thyroiditis
Squamous cell carcinoma
h/o MRSA
Chronic foot ulcers and multiple surgeries for Charcot foot
Bilateral fibroadenomas of the breast
H/O Vitrectomies, laser surgery, cataract surgery of bilateral
eyes
h/o Subdural hematoma ___ fall in ___ with left arm and leg
weakness
Social History:
___
Family History:
Type I Diabetes
RA
Autoimmune hepatitis
___'s thyroiditis
no history of MI or CHF
Physical Exam:
ADMISSION
VS: 98.1, 177/79, 97, 22, 100% on RA. Weight: 69.6 kg (standing)
General: NAD, reclining in bed
HEENT: MMM, no oropharyngeal lesions, anicteric
Neck: JVP 7cm, no LAD
CV: RRR, normal S1, S2, ___ SEM best heard at ___ radiating to
the carotids, no rubs or gallops
Lungs: few crackles at bases bilaterally, otherwise clear to
auscultation
Abdomen: +BS, obese, soft, non-tender, non-distended
GU: deferred
Ext: WWP, 2+ dorsalis pedis pulses, 2+ pitting edema to ankles
Neuro: CN II-XII intact, moving all extremities
DISCHARGE
VS: 98.6, 98.0, 130-140/60s, 70-80s, 95% on RA
I/Os: ___ since MN, ___ last 24 hrs
Weight: 68.0 kg (standing) vs. admission 69.6 kg (standing)
General: NAD, sitting up in bed
HEENT: MMM, no oropharyngeal lesions, anicteric
Neck: JVP mid-neck, no LAD
CV: RRR, normal S1, S2, ___ SEM best heard at RUSB radiating to
the carotids, no rubs or gallops
Lungs: CTAB
Abdomen: +BS, obese, soft, non-tender, non-distended
GU: deferred
Ext: WWP, 2+ dorsalis pedis pulses, trace pitting edema to
ankles
Neuro: CN II-XII intact, moving all extremities
Pertinent Results:
ADMISSION
___ 11:48AM BLOOD WBC-7.7 RBC-3.82* Hgb-11.6* Hct-33.0*
MCV-87 MCH-30.3 MCHC-35.0 RDW-12.4 Plt ___
___ 11:48AM BLOOD Neuts-49.5* ___ Monos-4.5
Eos-6.0* Baso-0.7
___ 11:48AM BLOOD Plt ___
___ 11:48AM BLOOD Glucose-267* UreaN-19 Creat-1.2* Na-135
K-5.1 Cl-102 HCO3-20* AnGap-18
___ 11:48AM BLOOD ALT-19 AST-29 AlkPhos-114* TotBili-0.3
___ 11:48AM BLOOD cTropnT-<0.01 proBNP-948*
___ 11:48AM BLOOD Albumin-4.0
___ 12:08PM BLOOD ___ Comment-GREEN TOP
___ 12:08PM BLOOD Lactate-1.4
IMAGING:
CHEST (PA & LAT) ___:
Tiny bilateral pleural effusions are seen. The heart is within
normal limits of size. There may be trace interstitial edema.
No signs of pneumonia. Mediastinal contour appears normal. No
pneumothorax. Bony structures are intact.
IMPRESSION:
Tiny bilateral pleural effusions with trace interstitial edema.
TTE ___:
The left atrium is elongated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild calcific aortic stenosis.
Compared with the prior study (images reviewed) of ___,
mild aortic stenosis is now present. ASD is not visualized on
the current study.
DISCHARGE
___ 08:35AM BLOOD WBC-6.8 RBC-3.60* Hgb-10.5* Hct-31.3*
MCV-87 MCH-29.3 MCHC-33.6 RDW-12.7 Plt ___
___ 08:35AM BLOOD Plt ___
___ 08:35AM BLOOD Glucose-103* UreaN-26* Creat-1.3* Na-142
K-4.0 Cl-106 HCO3-26 AnGap-14
___ 08:35AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.1
___ 08:35AM BLOOD rapmycn-PND
Brief Hospital Course:
ASSESSMENT: ___ yoF with Type 1 diabetes on insulin pump s/p
pancreas transplant in ___ (failed), s/p living-related kidney
transplant in ___, CHF, and HTN who presents with 2 days of
orthopnea, PND, dyspnea on exertion, worsening lower extremity
edema, and abdominal swelling with BNP 948, consistent with
acute exacerbation of CHF.
# CHF exacerbation: Differential diagnosis of etiology includes
hypertensive cardiomyopathy, valvular disease (mild AS on TTE).
Ischemic insult unlikely (trop neg x2, nonconcerning EKG, no
wall motion abnormalities on TTE). TTE was obtained, only
notable for mild AS. Lasix 20mg IV was given for diuresis with
good results, then transitioned to PO Lasix 20mg daily. Weight
on admission was 69.6 kg standing and 68.0 kg standing on
morning of discharge.
# s/p renal transplant: Cr 1.2-1.3, no acute issues at this
time. Continued predisone, Rapamune, and Bactrim. Renal
transplant team followed patient while inpatient. Rapamune
trough on morning of discharge pending. Patient has outpatient
renal transplant follow-up planned ___.
# Hypertension: Stable on multiple agents. Continued home meds
labetalol, amlodipine, and losartan.
# Type I Diabetes: Requiring insulin pump, s/p failed pancreatic
transplant in ___. ___ was consulted. Patient received
diabetic education and worked with a nutritionist. Continued
home insulin pump per ___ team.
# ___'s Thyroiditis: Continued levothyroxine. TSH elevated
at 10.0. Should re-check after hospitalization (patient was
provided with prescription for lab check) and follow up with
PCP/renal transplant.
TRANSITIONAL ISSUES
- Elevated TSH 10.0, should recheck on ___ and follow up
with PCP/renal transplant.
- Follow up ___ trough
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Labetalol 100 mg PO BID
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Losartan Potassium 25 mg PO DAILY
6. Pravastatin 40 mg PO DAILY
7. PredniSONE 2.5 mg PO DAILY
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Sirolimus 2 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Ferrous Sulfate 325 mg PO DAILY
14. Magnesium Oxide 400 mg PO DAILY
15. Fish Oil (Omega 3) 1000 mg PO DAILY
16. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Target glucose: 80-180
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Labetalol 100 mg PO BID
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Losartan Potassium 25 mg PO DAILY
8. Magnesium Oxide 400 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Pravastatin 40 mg PO DAILY
11. PredniSONE 2.5 mg PO DAILY
12. Sirolimus 2 mg PO DAILY
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Basal Rates:
Midnight - 03:00: .8 Units/Hr
03:00 - 6:00: .7 Units/Hr
06:00 - 10:30: .8 Units/Hr
10:30 - 14:00: 1.1 Units/Hr
14:00 - 20:30: 1.2 Units/Hr
20:30 - 23:59: 1.25 Units/Hr
Meal Bolus Rates:
Breakfast = 1:6
Lunch = 1:6
Dinner = 1:6
High Bolus:
Correction Factor = 1:35
Correct To ___ mg/dL
MD has ordered ___ consult
16. Furosemide 20 mg PO DAILY
17. Outpatient Lab Work
Check TSH and free T4 ___. Please fax results to both
___ fax number ___ and ___.
MD fax number ___
Diagnosis: Hypothyroidism
Discharge Disposition:
Home
Discharge Diagnosis:
CHF exacerbation
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 ___
for shortness of breath, leg swelling, and abdominal fullness.
You were found to have a congestive heart failure exacerbation.
You were treated with IV lasix and transitioned to lasix by
mouth 20mg a day. You improved with this treatment. You received
an echocardiogram of your heart, which showed mild aortic
stenosis (mild narrowing of one of your heart valves). Your
cardiologist should follow your symptoms as related to your mild
aortic stenosis. You should keep a low sodium diet and weigh
yourself every morning, call MD if weight goes up more than 3
lbs.
You were found to be hypothyroid. You should get your thyroid
levels (TSH, free T4) checked again on ___ before seeing Dr.
___ on ___. You should also follow up with your PCP
about these results.
Followup Instructions:
___
|
10277119-DS-27 | 10,277,119 | 22,835,757 | DS | 27 | 2188-07-23 00:00:00 | 2188-07-23 14:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending: ___
Chief Complaint:
elevated creatinine
Major Surgical or Invasive Procedure:
___ guided tunneled line placement
AV graft ___
History of Present Illness:
___ woman with a history of type 1 diabetes who
underwent a perfect match living-related transplant from her
brother in ___ and underwent pancreas after kidney transplant
in ___, which subsequently has been failing. She went in for
outside lab work for preop clearance for AVF placement and was
called in for elevated Cr - Cr was 5.6 from 3.5. Has been on
metolazone recently.
Of note, patient also reports 2 weeks of increased lethargy and
weakness, decreased appetite. Reports using a walker recently at
home d/t weakness. Not eating or drinking as usual. Denies N/V
but reports some diarrhea this AM.
In ED initial vitals were 98.3 61 158/43 18 99% RA
Labs notable for K 2.8, Cr 5.6
Patient was given 1 L NS, 40 po K, 40 iv K
Renal transplant recommended admission and transplant U/S which
was negative. U/A showed 8 WBC few bacteria
On floor patient reports no acute symptoms. She says that over
the past 4 weeks she slowly as had less and less appetite and
has been eating less. She denies nay fevers, chills, nausea or
vomiting, or urinary hesitancy or dysuria. She has been
compliant with her medications. No recent sick contacts
Past Medical History:
PMH: IDDM, chronic renal insufficiency, SCC, polyneuropathy, h/o
MRSA, ___ last hospitalization ___, mild AS, HTN, HLD,
hypothyroidism, Charcot foot, subarachnoid hemorrhage secondary
to fall in ___, colonic adenoma s/p endoscopic
resection
PSH: pancreas transplant ___ (failed on on insulin pump),
kidney transplant in ___, multiple skin cancer removals,
multiple foot debridements ___ charcot foot
Social History:
___
Family History:
Type I Diabetes
RA
Autoimmune hepatitis
___'s thyroiditis
no history of MI or CHF
Physical Exam:
ADMISSION EXAM:
Vital Signs: 98.3PO 162 / 59 67 16 100 RA
General: Alert, oriented, no acute distress, lying flat
comfortable
HEENT: Sclera anicteric, dry mucous memrbanes, oropharynx clear,
EOMI, PERRL, neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, systolic ejection
murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, no pain on palpation
of right (sight of renal txt)
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE EXAM:
Vitals: 98.5, BP 122-151/45-55, HR 88, RR 18, Spo2 99% RA.
Weight: 51.62 kg / 56.4kg on admission
I/O: --/200 (24 hrs)
Exam:
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - sclerae anicteric, MMM, OP clear
HEART - RRR, nl S1-S2, IV/VI systolic murmur at LUSB which
radiates into the axilla, carotids and posteriorly
CHEST - tunneled HD line with mild surrounding erythema,
non-tender and no purulent drainage
LUNGS - CTAB
ABDOMEN - Soft, NDNT
EXTREMITIES - LUE with bandage over the graft; WWP, trace edema
R > L; kerlex bandage in place on LLE
NEURO - awake, A&Ox3, no asterixis
Pertinent Results:
ADMISSION LABS:
******************
___ 09:45AM BLOOD WBC-8.7# RBC-3.09* Hgb-8.2* Hct-24.6*
MCV-80* MCH-26.5 MCHC-33.3 RDW-13.3 RDWSD-38.6 Plt ___
___ 09:45AM BLOOD ___
___ 09:45AM BLOOD UreaN-200* Creat-5.6*# Na-129* K-2.8*
Cl-84* HCO3-23 AnGap-25*
___ 09:45AM BLOOD Glucose-223*
___ 09:45AM BLOOD ALT-11 AST-16 LD(LDH)-215 AlkPhos-68
TotBili-0.5
___ 09:45AM BLOOD Albumin-4.0 Iron-76
___ 10:43AM BLOOD Albumin-3.7 Calcium-8.9 Phos-3.3 Mg-3.2*
___ 09:45AM BLOOD calTIBC-261 Ferritn-367* TRF-201
___ 09:45AM BLOOD TSH-0.70
___ 10:43AM BLOOD Cortsol-24.0*
___ 05:30PM BLOOD ___ pO2-107* pCO2-32* pH-7.50*
calTCO2-26 Base XS-2 Intubat-NOT INTUBA
___ 07:34PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:34PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 07:34PM URINE RBC-1 WBC-8* Bacteri-FEW Yeast-NONE Epi-2
___ 07:34PM URINE Hours-RANDOM UreaN-495 Creat-107 Na-27
TotProt-30 Prot/Cr-0.3*
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-6.5 RBC-2.81* Hgb-7.4* Hct-24.3*
MCV-87 MCH-26.3 MCHC-30.5* RDW-14.6 RDWSD-45.2 Plt ___
___ 07:00AM BLOOD Glucose-172* UreaN-41* Creat-2.2* Na-135
K-3.3 Cl-95* HCO3-28 AnGap-15
___ 07:00AM BLOOD Calcium-9.0 Phos-2.7 Mg-2.2
MICROBIOLOGY
**************
Time Taken Not Noted Log-In Date/Time: ___ 12:19 am
URINE Site: NOT SPECIFIED ADDED TO 67485A.
**FINAL REPORT ___
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------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
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---- =>16 R
Blood cultures ___ x2 final no growth
Urine cultures ___ and ___ no growth final
IMAGING:
*************
RENAL TRANSPLANT U/S ___
Normal renal transplant ultrasound.
CXR ___
In comparison with the study of ___, the patient has
taken a better inspiration. Again there is enlargement of the
cardiac silhouette with mild to moderate elevation of pulmonary
venous pressure. Blunting of the costophrenic angles could
reflect small pleural effusions. No evidence of acute focal
pneumonia.
___ CXR
IMPRESSION:
Mild cardiomegaly, with central vascular engorgement, but no
edema or effusion.
___ CT Head
IMPRESSION:
1. Evaluation is mildly limited by motion. No intracranial
hemorrhage.
2. Hypodensities in the left frontal lobe are likely due to
volume averaging and motion streak artifact however acute
infarct cannot be completely excluded. MRI is recommended for
more sensitive evaluation of ischemia.
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of type 1
diabetes s/p perfect match living-related transplant from her
brother in ___ and pancreas after kidney transplant in ___,
who presented with acute on chronic allograft dysfunction in the
setting of anorexia and poor PO intake, concerning for graft
failure ultimately requiring initiation of HD.
# ESRD s/p pancreas after kidney transplant (___)
# Acute on chronic allograft dysfunction: Pt had Cr increase in
___ of unclear etiology, possibly secondary to acute allograft
rejection. In the setting of worsening creatinine clearance, she
likely developed uremia that resulted in decreased appetite and
subsequent poor PO intake with pre-renal injury causing ___ in
addition to graft dysfunction. Her creatinine improved to 4.4
from 5.6 on admission s/p 2L IVF. Renal U/S within normal
limits, reassuring against post-renal process. However, given
concern for an ultimately failing allograft with non-resolving
uremia (confusion, asterixis), a tunneled hemodialysis catheter
was placed on and she began HD on ___. She also had AV graft
placed on ___ for future dialysis needs. She was maintained on
home sirolimus (decreased to 1mg PO QAM) and prednisone regimen.
Bactrim ppx was discontinued per Renal as it is not needed with
such a low prednisone dose.
#DM1
#DKA: Patient developed DKA likely in the setting of pump
malfunction with BG to the 500s, bicarb to 7 (AG 39), and pH
7.3. She was transferred to the ICU for an insulin drip. She
stabilized and was transferred back to the medical floor. ___
followed her very closely as her insulin pump was reattached.
She should have her sugars monitored closely, and her ___ MD
(___) should be contacted if BS is < 80 or > 300. Insulin pump
settings are currently: MN - 3AM: 0.55, 3AM - 6AM: 0.65, 6AM -
MN: 0.75. I:C ratio is 1:12.
#Poor PO intake: The likely etiology is secondary to ongoing
uremia. Infectious etiology was considered less likely given no
fevers, leukocytosis or infectious symptoms. CXR was
unremarkable. LFTs wnl. However, she was found to have E. coli
UTI, which was treated (see below).
#UTI: Patient found to have UA consistent with infection and
urine culture growing E. coli. She was asymptomatic but was
treated with 14 days of ciprofloxacin given her renal transplant
and immunosuppression. Ciprofloxacin ends ___.
#HTN: Home diuretics (bumex and metolazone) were discontinued
given hypovolemic etiology of ___. Home hydralazine was
continued.
TRANSITIONAL ISSUES:
-Per ___, insulin pump settings were changed to MN - 3AM:
0.55, 3AM - 6AM: 0.65, 6AM - MN: 0.75. I:C ratio is 1:12.
-Please follow up blood glucose on new insulin pump settings.
Please call ___ MD (___) if BG is < 80 or > 300.
-Patient's bactrim prophylaxis was discontinued per renal, since
her prednisone dose is sufficiently low.
-Plan for dialysis ___. ___ will plan to accept patient
on ___.
-Patient discharged off bumex and metolazone; hydralazine
continued
-Please follow-up improvement in appetite and PO intake
-CODE: full
-CONTACT: Name of health care proxy: ___
Relationship: daughter
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QSUN
2. Atorvastatin 80 mg PO QPM
3. Bumetanide 4 mg PO QAM
4. Bumetanide 2 mg PO QPM
5. HydrALAZINE 25 mg PO BID
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Metolazone 2.5 mg PO 3X/WEEK (___)
8. PredniSONE 2.5 mg PO DAILY
9. Sirolimus 2 mg PO DAILY
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Aspirin 81 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Ferrous Sulfate 325 mg PO DAILY
14. Magnesium Oxide 400 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 250 mg PO Q24H
3. Docusate Sodium 100 mg PO BID
4. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Basal rate minimum: 0.55 units/hr
Basal rate maximum: 0.75 units/hr
Bolus minimum: 0 units
Bolus maximum: 8 units
Target glucose: ___
Fingersticks: QAC and HS, Q3AM
5. Nephrocaps 1 CAP PO DAILY
6. Senna 8.6 mg PO BID:PRN constipation
7. Sirolimus 1 mg PO DAILY
8. Alendronate Sodium 70 mg PO QSUN
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 80 mg PO QPM
11. Ferrous Sulfate 325 mg PO DAILY
12. HydrALAZINE 25 mg PO BID
13. Levothyroxine Sodium 150 mcg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. PredniSONE 2.5 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Acute on chronic allograft dysfunction
Secondary: ESRD status post perfect-match living-related kidney
transplant, Anemia, hypertension, T1DM, hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
We saw you in the hospital because your kidney functioning was
worsening. Unfortunately, your kidney tranplant is not
functioning well anymore which was causing toxins to build up in
your blood, making you confused. Therefore, we placed a tunneled
catheter and started you on dialysis.
We also had our endocrinologists see you, and they changed the
basal rate of your insulin pump to 0.3 units/hour. At some
point, your pump malfunctioned, and you developed very high
blood sugars requiring you to go to the ICU, where they placed
you on an insulin drip to normalize your blood levels. You
should continue to check your finger stick glucose levels after
meals and give yourself extra insulin as you normally do. You
should follow-up with the ___ team as scheduled to recheck
your insulin needs as your appetite comes back. If your blood
sugar is less than 80 or greater than 300, you should call Dr.
___ at ___ for further instructions.
Additionally, you also had a Arterio-Venous graft created so
that you can receive dialysis through this in the future once it
has healed from the surgery.
It was a pleasure to participate in your care!
Best,
Your ___ team
Followup Instructions:
___
|
10277119-DS-28 | 10,277,119 | 26,158,500 | DS | 28 | 2188-10-19 00:00:00 | 2188-10-21 20:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Toe pain
Major Surgical or Invasive Procedure:
Debridement and closure of right ___ metatarsal (___)- of
note, previous documentation may indicate debridement and
closure of ___ metatarsal. Due to patient's previous
amputation(s), what seemed to be gross ___ metatarsal location,
was actually ___ metatarsal per imaging. This position
discrepancy was thought to be due to shifting anatomy ___ the
setting of prior amputations.
History of Present Illness:
___ with history of IDDM, CKD, renal transplant (___) now on HD
___ who presents with discoloration ___ her right fourth toe
and autoamputation. She was scheduled to have surgical
debridement and removal on ___, but the
discoloration acutely worsened and fourth right toe was
"falling" off this morning. Of note, she received 1 g vanco
after HD on ___. Patient denies any fevers, chills, nausea
or vomiting. Her last dialysis was ___ (W) due to the holiday.
No cough, SOB or CP.
___ the ED, initial VS reg, tachy to 102, SBP 150s, satting well
RA
Exam notable for ___ digit toe ulcer w/ partial autoamputation
Imaging showed no e/o osteomyelitis
Received ciproflox 400 mg IV, MetRONIDAZOLE (FLagyl) 500 mg IV
ONCE
Podiatry consulted, removed part of R ___ toe at bedside, sent
for path and culture. Plan for OR ___ for amputation and
debridement of R ___ digit.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports. feeling comfortable
with no CP, SOB, fever, chills, pain of RLE.
Past Medical History:
PMH: IDDM, chronic renal insufficiency, SCC, polyneuropathy, h/o
MRSA, ___ last hospitalization ___, mild AS, HTN, HLD,
hypothyroidism, Charcot foot, subarachnoid hemorrhage secondary
to fall ___ ___, colonic adenoma s/p endoscopic
resection
PSH: pancreas transplant ___ (failed on on insulin pump),
kidney transplant ___ ___, multiple skin cancer removals,
multiple foot debridements ___ charcot foot
Social History:
___
Family History:
Type I Diabetes
RA
Autoimmune hepatitis
___'s thyroiditis
no history of MI or CHF
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
T 98.6 PO BP 115 / 65 HR 88 RR 16 O2 99 RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, poor dentition
NECK: nontender supple neck, no LAD, JVP at 2cm at 45 degrees
HEART: RRR, normal S1/S2, systolic murmur at LUSB
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender ___ all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, left heel pressure ulcer, right
___ toe s/p autoamputation w/ out active bleeding, purulence.
Erythema surrounding w/ spread lateral foot
DISCHARGE PHYSICAL EXAM:
=======================
VS T 98.3 PO BP 125 / 70 HR 84 RR 18 O2 98RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, poor dentition
NECK: nontender supple neck, no LAD, JVP non-distended.
HEART: RRR, normal S1/S2, III/IV systolic murmur at LUSB
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender ___ all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Warm, well perfused. Dressings on b/l legs-CDI.
NEURO: A+O x3. Diminshed fine touch ___ toes, gross sensation
intact.
Pertinent Results:
ADMISSION LABS:
===============
___ 06:36PM BLOOD WBC-8.8 RBC-3.44* Hgb-10.4*# Hct-30.4*#
MCV-88 MCH-30.2# MCHC-34.2# RDW-13.3 RDWSD-43.4 Plt ___
___ 06:28AM BLOOD WBC-7.1 RBC-3.69* Hgb-10.6* Hct-33.1*
MCV-90 MCH-28.7 MCHC-32.0 RDW-13.3 RDWSD-43.8 Plt ___
___ 06:15AM BLOOD WBC-7.2 RBC-3.92 Hgb-11.2 Hct-34.7 MCV-89
MCH-28.6 MCHC-32.3 RDW-13.6 RDWSD-44.0 Plt ___
___ 06:18AM BLOOD WBC-7.4 RBC-3.77* Hgb-11.3 Hct-33.5*
MCV-89 MCH-30.0 MCHC-33.7 RDW-13.5 RDWSD-43.8 Plt ___
___ 06:36PM BLOOD ___ PTT-26.7 ___
___ 06:36PM BLOOD Plt ___
___ 06:28AM BLOOD ___ PTT-26.9 ___
___ 06:28AM BLOOD Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:18AM BLOOD Plt ___
___ 06:36PM BLOOD Glucose-232* UreaN-71* Creat-2.1* Na-132*
K-4.0 Cl-93* HCO3-23 AnGap-20
___ 06:28AM BLOOD Glucose-188* UreaN-83* Creat-2.1* Na-131*
K-3.7 Cl-92* HCO3-23 AnGap-20
___ 06:15AM BLOOD Glucose-181* UreaN-32* Creat-2.1* Na-140
K-3.7 Cl-99 HCO3-28 AnGap-17
___ 06:18AM BLOOD Glucose-198* UreaN-61* Creat-2.2* Na-135
K-4.0 Cl-95* HCO3-27 AnGap-17
___ 06:36PM BLOOD Calcium-8.8 Phos-4.7* Mg-2.2
___ 06:28AM BLOOD Calcium-9.0 Phos-5.5* Mg-2.5
___ 06:15AM BLOOD Calcium-9.2 Phos-4.8* Mg-2.5
___ 06:18AM BLOOD Calcium-8.9 Phos-5.9* Mg-2.4
___ 06:36PM BLOOD Vanco-6.3*
___ 06:28AM BLOOD Vanco-23.2*
DISCHARGE LABS:
===============
___ 06:18AM BLOOD WBC-7.4 RBC-3.77* Hgb-11.3 Hct-33.5*
MCV-89 MCH-30.0 MCHC-33.7 RDW-13.5 RDWSD-43.8 Plt ___
___ 06:18AM BLOOD Glucose-198* UreaN-61* Creat-2.2* Na-135
K-4.0 Cl-95* HCO3-27 AnGap-17
___ 06:18AM BLOOD Calcium-8.9 Phos-5.9* Mg-2.4
MICRO:
=====
___ 12:38 pm TISSUE Source: R ___ toe.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. HEAVY GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___
___.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
_________________________________________________________
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 (Preliminary): NO ANAEROBES ISOLATED.
___ 12:38 pm TISSUE Source: R ___ toe.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final ___:
STAPH AUREUS COAG +. MODERATE 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.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
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 (Preliminary): NO ANAEROBES ISOLATED.
IMAGING:
=======
___ LEFT FOOT 3-VIEW:
Resection of the distal second through fifth metatarsals are
again noted. Interval resection of the middle and distal
phalanges of the third toe are also seen. Severe degenerative
changes noted at the first metatarsophalangeal joint. There is
fusion at the interphalangeal joint of the great toe as on
prior. Linear lucency through the base of the right second
metatarsal is chronic, potentially from remote prior fracture.
There is no focal erosion. There is no subcutaneous gas. A 1.4
cm linear radiopaque foreign body again
seen within the plantar soft tissues overlying the midportion of
the first metatarsal. Atherosclerotic calcifications are again
noted.
Brief Hospital Course:
___ with history of IDDM, CKD, failed renal transplant (___)
but now on HD ___ who presented with right ___ toe
auto-amputation c/f infection vs. ischemia.
#Right toe infection/ischemia
Patient presented with an auto-amputating right toe. She was
given one dose of ciprofloxacin 400 mg IV, MetRONIDAZOLE
(FLagyl) 500 mg IV and underwent a bed-side wound debridement.
She was admitted to the medical service for further management
where she was started on a 7 day course of
Amoxicillin-Clavulanate and received one dose of IV Vancomycin.
She underwent debridement and closure on ___ without
complications and with clean margins. Per imaging, the affected
toe was actually the ___ metatarsal which had shifted laterally
___ to patient's anatomy (originally thought to be ___
metatarsal on exam ___ drastic shift). There was no evidence of
osteomyelitis on imaging pre or post-operatively. Culture was
positive for MSSA and she was started on doxycycline, ___
addition to augmentin, to complete a 7 day course. Throughout
her hospitalization she was hemodynamically stable without
evidence of systemic infection. She had no pain post-operatively
and was evaluated by physical therapy 3 times during her
hospitalization. She will continue ___ now that she is going
home.
#CKD: The patient has a history of CKD and is s/p a failed renal
transplant ___ ___ and is now on HD. HD was continued as usual
while hospitalized. She was seen by the renal team and he
underwent HD on ___ and was continued on her home dose of
sirolimus and prednisone. Renal followed her during
hospitalization and ultimately recommended stopping sirolimus
and increasing prednisone to 5 mg daily. She will be followed up
as outpatient.
#IDDM: Patient managed at home with insulin pump. During her
hospitalization, independent use of the insulin pump by the
patient was maintained. She was seen daily by consultants from
___, who recommended a modification to to
1:10 ___ from 1:12 at home. Her basal rate remained unchanged.
#HFpEF/chronic diastolic CHF (EF>55%) and Aortic stenosis:
Patient was stable from a cardiac standpoint during her
hospitalization. She was euvolemic on exams and was
hemodynamically stable throughout hospitalization, without need
for anti-hypertensives.
#HLD: She was continued on her home dose of Atorvastatin 40 mg
#Hypothyroidism. Continue home regimen levothyroxine 150 mcg
TRANSITIONAL ISSUES:
====================
#STOPPED MEDICATIONS: sirolimus (stopped by renal; prednisone
inc to 5 mg daily)
#CHANGED MEDICATIONS: Prednisone 2.5 mg daily to 5 mg daily
-patient started on augmentin for 7 day course to end on
___
-augmentin 500 mg daily (renal dosing) to taken post HD on HD
days
-Patient started on doxycycline for 7 day course to end on
___.
-consider outpatient ABI's of lower extremities to assess for
vascular disease
-Tissue/bone Cx and path pending on discharge
-Patient will undergo ongoing ___ at home
#CONTACT/PROXY: daughter ___ Phone: ___
Comments: Alternate Proxy: ___, sister, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Nephrocaps 1 CAP PO DAILY
4. Sirolimus 1 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. PredniSONE 2.5 mg PO DAILY
7. Timolol Maleate 0.5% 1 DROP RIGHT EYE DAILY
8. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Basal rate minimum: 0.85 units/hr
Basal rate maximum: 1 units/hr
Bolus minimum: 0 units
Bolus maximum: 10 units
Target glucose: ___
Fingersticks: QAC and HS
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q24H
take every day and after hemodialysis on hemodialysis days
RX *amoxicillin-pot clavulanate [Augmentin] 500 mg-125 mg 1
tablet by mouth daily Disp #*6 Tablet Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H
Continue for 7 days (until ___. No need to make changes on
dialysis days.
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Basal rate minimum: 0.85 units/hr
Basal rate maximum: 1 units/hr
Bolus minimum: 0 units
Bolus maximum: 10 units
Target glucose: ___
Fingersticks: QAC and HS
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Nephrocaps 1 CAP PO DAILY
8. PredniSONE 2.5 mg PO DAILY
9. Sirolimus 1 mg PO DAILY
10. Timolol Maleate 0.5% 1 DROP RIGHT EYE DAILY
11.Short Pneumatic Walking Boot
Diagnosis: V49.72 Lower limb amputation, other toes
Duration: 13 months
Prognosis: Good
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Skin and soft tissue infection
s/p metatarsal amputation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You came to the hospital with discoloration of your toe. You
underwent a procedure with podiatry with removal of the toe. The
area with concern for infection was removed. You were started on
two antibiotic medications called augmentin and Doxycycline to
complete a 7 day course for both. On days that you have dialysis
it is important that you take the augmentin after dialysis. You
can continue doxycycline without any change on dialysis days.
Please follow up with your primary care physician and podiatry
team ___ the next week.
It was a pleasure being involved ___ your care.
Your ___ Team
Followup Instructions:
___
|
10277204-DS-11 | 10,277,204 | 27,777,384 | DS | 11 | 2134-12-02 00:00:00 | 2134-12-06 15:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Numbness and parasthesias in legs bilaterally
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
___ year-old woman with hx of Breast cancer s/p surgery and
chemo-radiation, recent right leg weakness dx with acute
transverse myelitis treated with prednisone, presented here with
sensory changes in her lower exts.
She noted that 3 days ago in the evening she felt that her sole
of her feet are numb, and there was a burning sensation in her
feet to her ankle.
Over the next day the numbness and burning sensation moved to
her
thight bilaterally and today she feels numb from her upper
abdomen to her feet, she noted that today when she went to
batroom she felt that she can not empty her bladder and can not
control the flow of her urine, she also noted when the ED
physician did the rectal exam she could not squeez and she only
felt a vague pressure instead of the finger.
She noted that she feels a band like pressure around her left
thigh which now moved to her upper abdomen.
She denied having any new weakness.
She denied any recent infection but noted that she has been
under
a lot of stress recently.
Regarding her previous neurologic problem according to her and
her previous records:
In ___ when she was in ___ she after she had a severe
URT infection and UTI and finished a course of Levaquin for that
she started to have difficulty in her gait followed by right leg
weakness and eventually right leg flaccid plegia after 3 days.
She was admitted to the hospital, evaluated by neurologist with
LP and MRI, she had borderline positive oligoclonal band 4, 13
WBC( 90% lymph) in LP, high IgG index, T7-T8 spinal cord
swelling
in MRI and t2 inhancing lesion in brain MRI treated with course
of high dose steroid and discharged to rehab, By ___ she was
back to her baseline except for residual weakness in her RIGHT
IP.
The diagnosis at that time was transverse myelitis, v,s MS.
___ also noted that at ___ she had a band like sensory changes
around her abdomen, she was diagnosed with Zoster without rash
and treated with acyclovir and probably prednisone.
After 3 weeks the sensory changes resolved.
Past Medical History:
-Rectal prolapse, hx of occasional urinary incontinence,
intraductal invasive carcinoma of the left breast, s/p
lumpectomy, chemo-radiation.
Right leg weakness, with borderline positive oligoclonal band,
13
WBC( 90% lymph) in LP, high IgG index, T7-T8 spinal cord
swelling
in MRI and t2 inhancing lesion in brain MRI treated with course
of high dose steroid and rehab.
HPL
She also noted that at ___ she had a band like sensory changes
around her abdomen, she was diagnosed with Zoster without rash
and treated with acyclovir and probably prednisone.
After 3 weeks the sensory changes resolved.
Social History:
___
Family History:
Her mother was diagnosed with MS at the age of ___, it was
progressive and made her disable fast.
There is no history of seizures, developmental disability,
learning disorders, migraine headaches, strokes less than 50,
neuromuscular disorders, or movement disorders.
Physical Exam:
ADMISSION EXAM:
BP:125/65, PR:76, RR:14, O2 SAT: 98% RA
General: Awake, cooperative, no apparent distress.
HEENT: Normocephalic, atraumatic, with no scleral icterus noted.
Mucus membranes moist, no lesions noted in oropharynx
Neck: Supple. No carotid bruits appreciated. No orbital bruits.
Cardiac: Regular rate, normal S1 and S2 no murmurs, rubs or
gallops.
Pulmonary: Lungs clear to auscultation bilaterally.
Abdomen: Soft and nontender with no hepatosplenomegaly and
normal
bowel sounds.
Extremities: Warm, well-perfused. Calves soft and non-tender and
good peripheral pulses.
Skin: No lesions or rashes.
Skull & Spine: No spinal tenderness. Good range of motion of
head
with no pain.
Neck flexion and extension are normal.
Neurological examination:
Mental Status:
The patient is alert, fully oriented and attentive. The patient
had good knowledge of current events. Language is fluent with
intact repetition and comprehension and normal prosody. There is
no evidence of aphasia and patient was able to name both high
and
low frequency objects. There were no paraphasic errors. Speech
was not dysarthric. Patient is able to read without difficulty.
Patient was able to name ___ backward without difficulty.
Memory was intact and patient was able to register3 objects and
recall ___ at 5 minutes. Patient had intact comprehension and
was
able to follow both midline and appendicular commands normally.
There was no evidence of apraxia or neglect. There is no
left-right agnosia.
Cranial Nerves:
The sense of smell is not tested.
Visual acuity was ___ in left and ___ in right eye. The
visual fields are full to confrontation. Fundoscopy revealed
normal optic discs and retinal vessels. The pupils react
normally
to light directly and consensually 3 to 2 mm bilaterally. No red
desaturation
Eye movements are normal and saccades are smooth with no
saccadic
intrusions.
Sensation on the face is intact to light touch. Normal strength
in muscles of mastication.
Facial movements are normal and symmetric and facial power is
full throughout with no evidence of facial weakness.
Hearing is intact to finger rub bilaterally.
The palate elevates in the midline.
Neck rotation, flexion and shoulder shrug are normal and
symmetric.
The tongue protrudes in the midline and is of normal appearance.
Good normal velocity tongue movements.
Motor System:
Appearance, tone, power are normal in all 4 limbs, except for
Mild RIGHT IP, HAMS, ___ which are ___ and left hamstring which
is also ___.
There are no adventitious movements
Reflexes:
The tendon reflexes are present, symmetric and normal. ___
was negative bilaterally and there was no evidence of clonus.
The
plantar reflexes are flexor.
Sensory System:
Sensation is intact to pin prick, light touch, allover, there is
no SADDLE ANESTHESIA, how ever she has hypersthesia in her lower
ext sensation to cold and pinprick.
vibration sense, and position sense is intavt in upper exts and
trunk. position sense decreased(although she is able to say the
direction with significant joint position change, specially in
the right foot), vibration is decreased at the level of big toe
in the left foot and ankle in the right leg)
Coordination:
There is no ataxia. The finger/nose test and heel/shin tests are
performed accurately.
Gait and Stance:
The Romberg is strongly positive. Tandem gait walking is normal.
RECTAL tone is significantly decreased but she is able to
squeeze
and push.
There is some fecal material around the sphingter.
There is no sensation changes in the perineal area.
________________________________________
DISCHARGE EXAM:
Patient is anxious at baseline but mental status exam
demonstrates an alert, oriented and interactive lady with a
coherent stream of thought, fluent speech, appropriate prosody
and intact attention and memory. Her motor and sensory exam is
notable for hypersensistivity to pinprick in b/l legs up to
knees and mild right IP weakness. She is able to ambulate
without difficulty and gait is normal based.
Pertinent Results:
___ 10:45AM BLOOD WBC-8.1 RBC-3.82* Hgb-11.2* Hct-32.2*
MCV-84 MCH-29.4 MCHC-34.8 RDW-12.3 Plt ___
___ 10:45AM BLOOD Glucose-116* UreaN-21* Creat-0.8 Na-138
K-3.5 Cl-104 HCO3-24 AnGap-14
___ 10:45AM BLOOD Calcium-8.5 Phos-1.9* Mg-2.4
___ 09:35PM BLOOD Triglyc-154* HDL-58 CHOL/HD-3.1
LDLcalc-91
___ 09:35PM BLOOD TSH-4.8*
___ 01:00PM BLOOD T3-107 Free T4-1.2
___ 01:00PM BLOOD 25VitD-32
___ 01:00PM BLOOD ___
___ 01:00PM BLOOD RheuFac-11
___ 01:00PM BLOOD HIV Ab-NEGATIVE
___ 12:55PM BLOOD Lactate-1.4
MRI brain ___: Multiple scattered areas of high signal
intensity identified in the subcortical white matter, which are
nonspecific; however, given the clinical history, demyelination
is a consideration; however, unusual in this age group, formally
metastatic lesions cannot be completely ruled out; however,
given the lack of edema, this possibility is remote.
MRI spine ___: MRI OF THE CERVICAL SPINE:
The examination is partially limited due to patient motion. No
focal or
diffuse lesions are noted throughout the cervical spinal cord.
Mild
degenerative changes are visualized at C4/C5, C5/C6 and C6/C7,
consistent with
posterior disc bulging, causing mild anterior thecal sac
deformity, there is
no evidence of severe spinal canal stenosis.
IMPRESSION: Mild degenerative changes throughout the cervical
spine with no
evidence of focal or diffuse lesions throughout the cervical
spinal cord.
MRI OF THE THORACIC SPINE:
FINDINGS: The sagittal IDEAL sequence with water supression,
demonstrates high-signal intensity throughout the thoracic
spinal cord, more significant from T6 through T10 levels (images
#10, 11, series #5), with no evidence of spinal canal stenosis
or evidence of mass lesions. There is no evidence of abnormal
enhancement throughout the thoracic spinal cord to suggest
metastatic disease. The signal intensity in the bone marrow
appears unremarkable.
IMPRESSION: Diffuse high signal intensity is noted throughout
the thoracic spinal cord, more significant from T6 through T10
levels as described above with no evidence of spinal cord
expansion or evidence of abnormal enhancement. These findings
are nonspecific and may represent inflammatory changes with no
evidence of fluid collections or narrowing of the spinal canal,
there is no evidence of abnormal enhancement.
MRI OF THE LUMBAR SPINE:
The alignment and configuration of the lumbar vertebral bodies
appears
maintained, high signal intensity is noted at L4/L5, consistent
with bone
marrow replacement for fat ___ type 2 endplate changes).
Multilevel
degenerative changes are noted, more significant at L2/L3 with
disc
desiccation and minimal posterior disc bulge, there is no
evidence of nerve root compression or spinal canal stenosis.
At L3/L4 level, there is disc desiccation and mild posterior
disc bulge,
contacting the traversing nerve roots, more significant towards
the left,
causing moderate left side neural foraminal narrowing.
At L4/L5 level, there is disc desiccation and narrowing of the
intervertebral disc space with posterior spondylosis and disc
bulging, causing anterior thecal sac deformity and bilateral
neural foraminal narrowing, additionally moderate articular
joint facet hypertrophy and ligamentum flavum thickening are
present. At L5/S1 level, there is disc desiccation and mild
posterior disc bulging with no evidence of nerve root
compression or neural foraminal narrowing.
IMPRESSION: Multilevel disc degenerative changes throughout the
lumbar spine as described in detail above, there is no evidence
of abnormal enhancement or evidence of leptomeningeal disease.
Brief Hospital Course:
Ms. ___ a ___ old woman with a history of breast
cancer, s/p lumpectomy, chemotherapy and radiation,
hyperlipidemia, thyroid nodule, s/p uterine prolapse surgical
repair, who was admitted to ___
after an episode of acute onset numbness bilaterally in her
lower extremities. The numbness extended from her feet up to the
level of T6. While at the hospital, she has had an MRI of her
spine and brain. One white matter lesion (larger than previous)
was seen at T6 in her spine. Additionally, 2 more lesions were
seen in the brain extending perpendicularly from the ventricles.
CSF culture was negative and CSF was negative for VZV, HSV.
Oligoclonal bands were found in CSF and a diagnosis of Multiple
Sclerosis was made. Ms ___ was treated with a 5 day course of
high dose IV Methylprednisone and upon discharge, transitioned
to a PO prednisone taper as follows:
Day 1Day 2Day 3Day 4Day 5Day 6Day 7Day 8Day 9+
60 mg60 mg40 mg40 mg20 mg20 mg10 mg10 mg0 mg
___ and RF were sent which were within normal limits. HIV
testing was negative. Anti NMO antibodies were sent and are
pending at time of discharge. Copper level, Ro and ___
___, ACE levels were also sent and are currently pending.
During her steroid administration, Ms. ___ was noted to have
some unpleasant interaction with her nurses and was also
refusing her vitals but she responded to verbal reasoning.
We plan to start ___ after discharge and consider possible
___ for help recovering from bilateral leg numbness. Ms.
___ will follow up with Dr. ___ as outpatient.
Medications on Admission:
1. Atorvastatin 10 mg PO DAILY
2. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
3. Fluoxetine 20 mg capsule/DAY
Discharge Medications:
1. Atorvastatin 10 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
4. Senna 2 TAB PO BID:PRN CONSTIPATION
5. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
6. PredniSONE 60 mg PO DAILY Duration: 2 Days Start: ___,
First Dose: First Routine Administration Time
7. PredniSONE 40 mg PO DAILY Duration: 2 Days Start: After 60 mg
tapered dose
8. PredniSONE 20 mg PO DAILY Duration: 2 Days Start: After 40 mg
tapered dose
9. PredniSONE 10 mg PO DAILY Duration: 2 Days Start: After 20 mg
tapered dose
Discharge Disposition:
Home
Discharge Diagnosis:
Multiple Sclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
On neurological exam, she is alert and oriented. Follows
commands appopriately. Has some hypersensitivity in her legs b/l
but gait is normal.
Discharge Instructions:
Dear Ms. ___,
You came to the ___ on after an
episode of numbness in both of your legs. While you were here
at the hospital you had an MRI of your spine and your brain
which showed abnormalities in the white matter. Additionally, we
performed a lumbar puncture and took a sample of the
Cerebral-Spinal Fluid from your spine. This was negative for
viruses and bacteria but confirmed your diagnosis of Multiple
Sclerosis. We gave you a 5 day course of high dose IV steroids
with moderate improvement in your symptoms. After discharge we
recommend that you continue with your steroid taper by mouth to
help address this current attack as follows:
Day 1Day 2Day 3Day 4Day 5Day 6Day 7Day 8Day 9
60 mg60 mg40 mg40 mg20 mg20 mg10 mg10 mg0 mg
Additionally, you will be treated with Interferon Beta 1a (also
known as Avonex). You have been given paperwork about this
medication and will be followed in clinic. Possible side effects
include flu-like symptoms within hours of taking the medication
that usually resolve within 24 hours. Ibuprofen can be used to
minimize these symptoms. Skin rashes are rare but can also
occur. Your blood cell count and liver function will be
monitored on an ongoing basis through laboratory blood tests.It
was a pleasure to have a chance to get to know you and we know
you will enjoy Dr. ___ ongoing care.
Followup Instructions:
___
|
10277537-DS-11 | 10,277,537 | 28,225,621 | DS | 11 | 2157-11-09 00:00:00 | 2157-11-09 15:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right Leg Cellulitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old Female with a history of chronic lymphedema, who
presents with 6 days of ereythema and edema of her right leg.
She states that when it began she developed a fever to 102, and
then the redness began. She went to ___, she
was admitted for 4 days and placed on unknown IV antibiotics,
and discharged on and was placed on an oral cefadroxil at
discharge, Tylenol and oxycodone. Her redness did not improve on
oral antibiotics but did not worsen. She has been persistently
febrile since starting the antibiotics, and has had intermittent
vomiting. She denies other symptoms of infection, including
dysuria, headache, visual changes or cough.
Initial Vital Signs in the ___ ED: 97.7, 110, 123/98, 20,
99%RA. Given vancomycin, ceftriaxone, and 1L ___ was not
performed, although it was ordered (or at least there is no
report in OMR).
Past Medical History:
Chronic Lymphedema
Social History:
___
Family History:
Mother: no medical problems
Father: DM, HTN
Physical Exam:
ADMISSION PHYSICAL EXAM:
VSS: 98.4, 124/81, 117, 18, 97%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CC, significant bilateral lymphedema, erythema RLE to
calf within ink lines, no crepitus or open ulcers
NEURO: CAOx3, Non-Focal
DISCHARGE EXAM:
T98.1, BP 139/88, HR 104, RR 18, o2 100% RA
Gen - resting comfortably in bed, well appearing
HEENT - moist oral mucosa, no OP lesion
Eyes - anicteric, PERRL
___ - rrr, s1/2, no murmurs
Pulm - CTA b/l, no w/r/r
GI - obese, soft, non tender, non distended, +bowel sounds
Ext - severe lymphedema b/l with faint erythema of right shin
area - significantly improved compared to prior exam, some
minimal serous drainage on bandage but overall erythema and
warmth receded and improved
Skin - warm, dry RLE erythema receded from drawn line and in
intensity of erythema
Psych - calm and cooperative
Pertinent Results:
___ ___ negative for RLE DVT
___ CT RLE
Massive subcutaneous edema and skin thickening. Suspected edema
in the
muscular compartments, nonspecific and difficult to assess with
this modality. No gas or discrete fluid collection. Patent
vasculature.
Discharge labs
___
WBC 9.5, Hg 9.3, Hct 30.1, Plt 874 (<--- ___)
Blood culture negative/final
Brief Hospital Course:
This is a ___ with hx of chronic lymphedema with recent
admission to ___ for cellulitis now presenting with ongoing
cellulitis.
#Sepsis
#Leg Cellulitis
She presents with ___ SIRS criteria (tachycardia, leukocytosis)
with likely infection from RLE. Recently admitted to ___ from
___ and treated with IV cefazolin and discharged on
cefadroxil. Following discharged she had reported subjective
fevers and ongoing erythema. Duplex was negative for DVT x2
(once at ___). Blood cultures ___ have shwon NGTD. She was
started on vancomycin and ceftriaxone. She had very slow
clinical improvement and ID was consulted to assist in
management. After several days of IV therapy, she was switched
to linezolid (Prior auth obtained) for a total of 2 weeks. Her
leg is significantly improved. A CT scan was done which ruled
out abscess/drainable fluid collection.
-Discharge home with linezolid ___ BID x 12 more days
-Oxycodone 5mg q6hrs prn (#12, ___ reviewed), along with
Tylenol prn
-Set up with ID and ___ clinic follow up, as well as PCP
follow up all within the next 2 weeks
-Ambulance arranged for discharge transportation
-Set up with ___ for wound care
#Lymphedema
She has never really had a formal workup. Per discussion with
her primary care team, it was diagnosed in ___ and she had a
normal echo at that time. Did not really go back for follow up,
but lymphedema has been described as severe. She reports a lot
of difficulty getting around because of her weight and
lymphedema. A ___ clinic appointment was made for her and
she was provided with contact info for an ambulance company to
help arrange for transportation.
#Thrombocytosis
Noted platelets rising, up to mid ___ by discharge. CT scan did
not show abscess/drainable fluid collection, thrombocytosis can
sometimes be a marker of developing/worsening infection so this
was ruled out. She is scheduled to see her PCP on ___ (in 4
days) and will need repeat labs at that visit.
#Dispo - discharge home given clinical improvement. High risk
for readmission in case of recurrence. Encouraged attendance to
outpatient appointments to minimize hospitalization. Meds to bed
were provided to help with compliance as she was unsure if she
could make it to her pharmacy.
Time spent: 45 minutes
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 Q4H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
3. Linezolid ___ mg PO Q12H
RX *linezolid ___ mg 1 tablet(s) by mouth twice a day Disp #*24
Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
Duration: 3 Days
RX *oxycodone 5 mg 1 tablet(s) by mouth q6hrs prn Disp #*12
Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
cellulitis
thrombocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted with right leg redness consistent with
infection called Cellulitis. You were started on IV antibiotics
with improvement of symptoms. You remained stable so were
discharged home. You will complete a total of 2 weeks of
antibiotics, and for pain we will give you a short prescription
of oxycodone.
The infectious disease team will see you in 2 weeks for follow
up. We have also made you an appointment with the ___
clinic and it is very important for you to follow up here, as
this may be able to help you with your swelling overall.
You do have a very elevated platelet count (one of your lab
tests) on your lab work and this will need to be repeated within
a few days. As you are seeing your primary care team on ___
please have a set of labwork checked at this visit.
Best of luck in your recovery,
Your ___ care team
Followup Instructions:
___
|
10277852-DS-19 | 10,277,852 | 28,996,084 | DS | 19 | 2169-10-03 00:00:00 | 2169-10-07 06:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right arm numbness and right inferior quadranopsia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old right-handed man with HTN
well-controlled on medication and a distant history of smoking
who presents with right arm numbness and difficulty with
reading.
He was in his normal state of health when he went to bed last
night at around 11pm. This morning at 3am, he woke up briefly
and noticed that he right upper arm felt different and was not
moving normally. His right lower arm was able to move and feel
normally. He thought that the symptom was a result of his sleep
position and therefore fell back asleep. At 7am, the right
upper arm still felt different with weakness, but it's improved
from 3am.
Later in the morning, when he was reading, he noted that he
could not read normally. It was not a lauguage comprehesion
issue. He just felt as if he was "dropping" some words. He
went to ___ and was referred to the ED.
In the ED, he was noted to have right arm numbness and right
infero-lateral field cut. Neurology is consulted.
ROS - in general good health. No recent illness. No CP, SOB,
abdominal pain. No other neurologic complaints other than what
is stated above.
Past Medical History:
HTN
Hip replacement x2
Cervical stenosis
Social History:
___
Family History:
No FH of stroke.
Physical Exam:
Admission Exam:
Vitals: 98.1, 80, 147/81, 20, 97%
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, No nuchal rigidityCardiac: RRR
Abdomen: soft, NT/ND
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. Pt was able to recall recent and distant history. The
pt had good knowledge of current events. There was no evidence
of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: Mild anisocoria (right 2mm, left 1.75mm) both briskly
reactive to light. Right inferior quadranopsia bilaterally.
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. Orbiting is symmetric (right might be slightly
faster)
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: Decrease pinprick, cold sensation in the right medial
upper arm. He has evidence of cortical sensory loss in the
right upper arm (unable to tell direction of skin stroke)
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
-Coordination: No dysmetria on FNF bilaterally.
-Gait: deferred
Discharge Exam:
Neuro: Unchanged.
Pertinent Results:
ADMISSION LABS:
___ 12:30PM BLOOD WBC-10.5 RBC-5.16 Hgb-16.1 Hct-46.8
MCV-91 MCH-31.2 MCHC-34.4 RDW-14.2 Plt ___
___ 12:30PM BLOOD Neuts-73.5* ___ Monos-6.0 Eos-0.6
Baso-0.5 Im ___
___ 12:30PM BLOOD ___ PTT-31.7 ___
___ 12:30PM BLOOD Glucose-133* UreaN-22* Creat-1.3* Na-140
K-3.7 Cl-103 HCO3-24 AnGap-17
___ 12:30PM BLOOD ALT-28 AST-22 AlkPhos-62 TotBili-1.3
___ 12:30PM BLOOD Lipase-42
___ 12:30PM BLOOD Albumin-4.9
___ 12:30PM BLOOD cTropnT-<0.01
___ 01:15AM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:20AM BLOOD CK-MB-3 cTropnT-<0.01
___ 02:21AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 02:21AM URINE RBC-3* WBC-<1 Bacteri-FEW Yeast-NONE
Epi-0
RISK FACTORS:
___ 06:20AM BLOOD %HbA1c-5.4 eAG-108
___ 06:20AM BLOOD Cholest-135
___ 06:20AM BLOOD Triglyc-89 HDL-59 CHOL/HD-2.3 LDLcalc-58
IMAGING:
CTA HEAD/NECK ___
1. Multifocal atherosclerosis, including in the proximal left
internal carotid artery, in bilateral carotid siphons , at the
right vertebral artery origin, and in the intracranial left
vertebral artery, without flow-limiting stenosis.
2. Fusiform dilatation of the intracranial left vertebral
artery, up to 7 mm. No saccular aneurysm.
MRI Head ___
IMPRESSION:
Moderately sized acute infarction in the left occipital lobe
without significant mass effect or evidence of blood products.
ECHO ___
Conclusions
The left atrium is mildly dilated. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). No masses or thrombi are seen in the left ventricle.
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. 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. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
Carotid Dopplers:
FINDINGS:
RIGHT:
The right carotid vasculature has no atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is
90 cm/sec.
The peak systolic velocities in the proximal, mid, and distal
right internal
carotid artery are 68, 52, and 60 cm/sec, respectively. The
peak end
diastolic velocity in the right internal carotid artery is 17
cm/sec.
The ICA/CCA ratio is 0.75.
The external carotid artery has peak systolic velocity of 74
cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has focal some loose plaque with
mixed
heterogeneous atherosclerotic plaque.
The peak systolic velocity in the left common carotid artery is
84 cm/sec.
The peak systolic velocities in the proximal, mid, and distal
left internal
carotid artery are 77, 60, and 55 cm/sec, respectively. The
peak end
diastolic velocity in the left internal carotid artery is 18
cm/sec.
The ICA/CCA ratio is 0.91.
The external carotid artery has peak systolic velocity of 72
cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
No significant plaque or stenosis on the right. The left ICA
has a focal
heterogeneous plaque with less than 40% stenosis
Brief Hospital Course:
___ presented with symptoms of difficulty reading,
right arm numbness and weakness. He was found to have a right
inferior quadranopsia. MRI showed an acute left parietal
infarct, thought to be embolic to the inferior division of the
left MCA. Workup was notable for A1C of 5.7%, LDL of 58,
echocardiogram with no intracardiac thrombus and carotid
ultrasound which did not show flow-limiting stenosis. He will
complete his embolic workup on discharge with ___ of Hearts
monitor.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enalapril Maleate 5 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Simvastatin 20 mg PO QPM
4. Allopurinol ___ mg PO DAILY
5. Colchicine 0.6 mg PO DAILY:PRN gout
6. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
3. Aspirin 81 mg PO DAILY
4. Colchicine 0.6 mg PO DAILY:PRN gout
5. Enalapril Maleate 5 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Simvastatin 40 mg PO QPM
RX *simvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
ACUTE ISCHEMIC STROKE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of difficulty reading and
right arm numbness resulting from an ACUTE ISCHEMIC STROKE, a
condition in which a blood vessel providing oxygen and nutrients
to the brain is blocked by a clot. Damage to the brain from
being deprived of its blood supply can result in a variety of
symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- high blood pressure, which is well controlled with medication.
- atherosclerosis in the blood vessels to the brain
We are changing your medications as follows:
- please start aspirin 81 mg
- please increase your dose of simvastatin to 40 mg daily
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10277951-DS-16 | 10,277,951 | 28,312,070 | DS | 16 | 2169-11-24 00:00:00 | 2169-11-24 20:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
cough, fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with ESRD due to ADPKD
(s/p LRRT in ___ and s/p DDLT in ___, c/b
tonsillar PTLD s/p T&A) and persistent EBV serum PCR positivity
___ EBV PCR 3904) presents with cough and malaise. Patient
notes 1 week of cough, worsening over the weekend, evaluated by
X-ray ___ and treated with outpatient antibiotics
including
azithromycin and Augmentin with worsening status. Patient
reports
fever, chills, and epigastric pain in his muscles from chronic
coughing. Fatigue and difficulty sleeping. No nausea, vomiting.
No headache.
In the ED, initial vitals: 101.7 | 115 | 132/91 | 20 | 99% RA
- Labs were significant for H/H 9.2/26.5 (baseline ~11), Cr up
to 3.0 (baseline 1.8), bicarb 19 with AG 20, UA with
proteinuria,
normal lactate
- Imaging showed: transplant U/S showing decreased
corticomedullary differentiation in the transplanted kidney with
normal resistive indices, CXR with a RML + other opacities
concerning for multifocal PNA
- In the ED, he received: CTX, levofloxacin, and 2L of NS. He
was also given 1 mg of dilaudid, guainesfin/codeine, albuterol
and duonebs
- Vitals prior to transfer: 98.4 | 89 | 125/62 | 18 | 97% RA
Upon arrival to the floor, the patient is somnolent but
arousable. He endorses cough, not productive of sputum, worse
since ___. Denies fevers and chills while lying in bed,
most bothersome symptoms are cough and malaise, unchanged since
initiating antibiotics. With regards to his urination, he notes
that he urinated in the ED, urine not significantly
lighter/darker than baseline.
REVIEW OF SYSTEMS: No weight changes. No changes in vision or
hearing, no changes in balance. No shortness of breath, no
dyspnea on exertion. No 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:
PMH:
ESRD due to ADPKD
Persistant EBV positivity, history of tonsilar PTLD, steroid
induced DM, history of kidney stones, anemia and warts on
palmar
surface of both hands, followed by Dr. ___ at ___.
___:
___ - hip surgery: curettage of lesion and internal fixation
of
left femoral neck
___ - IJ HD catheter insertion, LD transplant
___ - triple lumen subclavian CL
Multiple oral and nasal septal biopsies, bilateral Eustachian
tube placement, debridement of necrotic gingeva, T&A, open neck
LN biopsy.
___ insertion of CVL, parathyroidectomy, cystoscopy and J
stent
placement into txp kidney, ureterscopy with basket stone
removal
___ stent removal
___ bilateral native nephrectomies, kidney stone removal with
another stent placement
___ EGD, CVL placement, OLT with right tri-segment graft
Social History:
___
Family History:
No family history of renal or liver disease. No
family history of diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 98.0 | 129/75 | 81 | 20 | 95%, room air
General: Tired, lying in bed with eyes closed, oriented, no
acute distress. Slightly diaphoretic, worst on back.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
Nodes: No cervical, subclavian lymphadenopathy
CV: Regular rate, normal rhythm, no murmurs, rubs, gallops
Lungs: R lung with rhonchi at base, L lung clear to
auscultation, no wheezes, rales
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. Long incisions of liver
and kidney transplants well-healed
GU: No foley
Ext: Warm, well perfused, 2+ DP pulses, no clubbing, cyanosis
or
edema
Neuro: CNII-XII grossly intact, grossly normal sensation, gait
deferred.
DISCHARGE PHYSICAL EXAM
=======================
Vital Signs: 98.4 | 135/75 | 69 | 16 | 95% on RA
General: Sitting up in bed, alert, oriented, comfortable.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
Nodes: No cervical or subclavian lymphadenopathy
CV: Regular rate, normal rhythm, no murmurs, rubs, gallops
Lungs: CTAB, mild bibasilar crackles, improved from prior
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. Long incisions of liver
and kidney transplants well-healed
GU: No foley
Ext: Warm, well perfused, 2+ DP pulses, no clubbing, cyanosis
or edema
Neuro: CNII-XII grossly intact, grossly normal sensation, gait
deferred.
Pertinent Results:
ADMISSION LABS
==============
___ 10:10PM POTASSIUM-5.5*
___ 10:10PM HAPTOGLOB-170
___ 03:15PM GLUCOSE-94 UREA N-40* CREAT-2.4* SODIUM-139
POTASSIUM-6.7* CHLORIDE-108 TOTAL CO2-19* ANION GAP-12
___ 03:15PM CALCIUM-8.2* PHOSPHATE-3.4 MAGNESIUM-1.3*
___ 09:10AM CYCLSPRN-75*
___:55AM URINE HOURS-RANDOM
___ 06:55AM URINE UHOLD-HOLD
___ 06:55AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 06:55AM URINE RBC-2 WBC-3 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 06:55AM URINE CA OXAL-RARE*
___ 02:47AM LACTATE-1.7
___ 02:30AM GLUCOSE-107* UREA N-46* CREAT-3.0*#
SODIUM-133 POTASSIUM-5.2* CHLORIDE-94* TOTAL CO2-19* ANION
GAP-20*
___ 02:30AM estGFR-Using this
___ 02:30AM ALT(SGPT)-12 AST(SGOT)-32 LD(LDH)-444* ALK
PHOS-72 TOT BILI-1.1
___ 02:30AM WBC-7.0 RBC-2.82* HGB-9.2* HCT-26.5* MCV-94
MCH-32.6* MCHC-34.7 RDW-13.7 RDWSD-46.8*
___ 02:30AM NEUTS-77.3* LYMPHS-12.5* MONOS-7.1 EOS-2.0
BASOS-0.4 IM ___ AbsNeut-5.37 AbsLymp-0.87* AbsMono-0.49
AbsEos-0.14 AbsBaso-0.03
___ 02:30AM PLT COUNT-293
NOTABLE LABS
============
___ 10:10PM BLOOD Hapto-170
___ 06:50AM BLOOD Cyclspr-122
___ 05:24AM BLOOD Cyclspr-242
___ 09:10AM BLOOD Cyclspr-75*
MICRO
=====
___ SPUTUM Immunoflourescent test for
Pneumocystis jirovecii (carinii)-FINAL INPATIENT
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {YEAST}; Immunoflourescent test for Pneumocystis
jirovecii (carinii)-FINAL INPATIENT
___ URINE Legionella Urinary Antigen -FINAL
INPATIENT
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
IMAGING
=======
CXR ___
IMPRESSION:
Multifocal infection as described above concerning for
multifocal pneumonia.
RENAL U/S ___
IMPRESSION:
-Decreased corticomedullary differentiation in the transplanted
kidney which
could be secondary to edema. Recommend clinical correlation
with renal
function tests.
-Patent transplant vasculature, with normal resistive indices.
DISCHARGE LABS
==============
___ 06:50AM BLOOD WBC-7.5 RBC-3.18* Hgb-10.4* Hct-30.1*
MCV-95 MCH-32.7* MCHC-34.6 RDW-13.8 RDWSD-47.8* Plt ___
___ 06:50AM BLOOD Glucose-73 UreaN-30* Creat-2.1* Na-144
K-5.3* Cl-106 HCO3-17* AnGap-21*
___ 06:50AM BLOOD Calcium-9.5 Phos-4.2 Mg-1.5*
Brief Hospital Course:
HOSPITAL COURSE
===============
___ man with ESRD due to ADPKD (s/p LRRT in ___
and s/p DDLT in ___, c/b tonsillar PTLD s/p T&A) and
persistent EBV serum PCR positivity ___ EBV PCR 3904)
presented with cough and malaise with CXR findings c/w PNA.
ACTIVE ISSUES
=============
# Multifocal pneumonia: Pt presented with one week of fever,
malaise, with CXR findings consistent with multifocal pneumonia,
no symptomatic or radiographic improvement after several days on
empiric coverage with azithromycin and Augmentin. Tmax in ED
101.7, HR 115. Met SIRS criteria for sepsis in ED (___). WBC 7
with left shift, on cyclosporine and azathioprine. Initially
started on linezolid/zosyn given allergy to vanc, transitioned
to CTX and azithro due to low suspicion for HAP as per ID
recommendations, and discharged on lexofloxacin. Diagnostic
studies were negative for strep pneumo and legionella, blood
cultures were negative.
# ___: Creatinine to 3.0, from baseline of 1.8. Suspect
pre-renal etiology i/s/o infection and poor PO intake. Improved
to 2.1 on discharge with IVF. Renal U/S showing decreased
corticomedullary differentiation but no evidence of obstruction.
Continued home sodium bicarbonate 1300 mg bid. Encouraged to
continue good PO intake.
# Anemia: H/H in ED 9.2/26.5, with MCV 94, RDW 13.7. Most
concerning for normocytic anemia of chronic disease. Of note,
patient prescribed epoetin alfa injections, 6000 U weekly, but
hasn't been taking these as he has been feeling well without
them. Recommend restarting outpatient.
CHRONIC ISSUES
==============
# S/P bilateral kidney transplant, liver transplant: Continued
azathioprine 75 mg po qd, cyclosporine 125 mg po bid after
trough level, prednisone 15 mg po bid (on odd days), sodium
bicarb as above. Trough on discharge was 122. Cyclosporine dose
changed from 125mg to 100 mg po bid.
TRANSITIONAL ISSUES
===================
[] Patient to get usual transplant labs drawn on ___,
followed up by nephrology
[] CycloSPORINE (Neoral) MODIFIED 125 mg PO Q12H decreased to
100 mg PO Q12H
[] Prescribed Benzonatate 100 mg PO TID and Guaifenesin-CODEINE
Phosphate ___ mL PO/NG Q6H:PRN for cough
[] Prescribed three tablets Levofloxacin 500 mg PO Q48H to
finish pneumonia course
[] Hyperkalemia: K peaked at 6.7, trended down to 4.6 and back
to 5.3 on day of discharge. Given one dose of kayexelate on day
of discharge. To continue to monitor with regular outpatient
labs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 15 mg PO EVERY OTHER DAY
2. Sodium Bicarbonate 1300 mg PO BID
3. amLODIPine 5 mg PO DAILY
4. Epoetin Alfa 6000 UNIT IV WEEKLY
5. AzaTHIOprine 75 mg PO DAILY
6. CycloSPORINE (Neoral) MODIFIED 125 mg PO Q12H
7. Multivitamins 1 TAB PO DAILY
8. Sodium Polystyrene Sulfonate 15 gm PO AS DIRECTED BY
TRANSPLANT COORDINATOR
9. Probiotic DAILY
Discharge Medications:
1. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
2. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin 10 mg-100 mg/5 mL 5 ml by mouth three
times a day Refills:*0
3. Levofloxacin 500 mg PO Q48H Duration: 5 Days
RX *levofloxacin 500 mg 1 tablet(s) by mouth Every 2 days Disp
#*3 Tablet Refills:*0
4. CycloSPORINE (Neoral) MODIFIED 100 mg PO Q12H
5. amLODIPine 5 mg PO DAILY
6. AzaTHIOprine 75 mg PO DAILY
7. Epoetin Alfa 6000 UNIT IV WEEKLY
8. Multivitamins 1 TAB PO DAILY
9. PredniSONE 15 mg PO EVERY OTHER DAY
10. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 20 billion cell
oral DAILY
11. Sodium Bicarbonate 1300 mg PO BID
12. Sodium Polystyrene Sulfonate 15 gm PO AS DIRECTED BY
TRANSPLANT COORDINATOR
Discharge Disposition:
Home
Discharge Diagnosis:
Community Acquired Pneumonia
Acute on chronic kidney injury
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 fevers and cough. We did imaging
of your lungs that showed an pneumonia. We treated you with
intravenous antibiotics and transitioned you to oral antibiotics
on discharge. You will take Levaquin (levofloxacin) for 5 days.
You also had injury to your kidney from the infection which
improved with fluids. It is now safe for you to go home. Please
obtain your regularly-scheduled labs and follow-up at the
appointments below.
Wishing you the best,
Your ___ Team
Followup Instructions:
___
|
10278097-DS-16 | 10,278,097 | 20,833,341 | DS | 16 | 2150-02-04 00:00:00 | 2150-02-06 15:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Banana / tramadol / Horse/Equine Product Derivatives
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
cardioversion
History of Present Illness:
___ y/o woman ___ of A fib on dabigatran and metoprolol, who
presents with 2 days of dyspnea at rest and worsening lower
extremity edema. No associated chest pain, palpitations. No
fevers or chills. Since ___, her weight has gone from
182-->188 Ib. This AM she took lasix 10mg Po once, per Dr ___
___. She notes that she has had worsening ___ edema for approx
one month, and just recently this week has been having dyspnea.
She notes that she usually can walk all around the mall, but had
to stop this week to catch her breath. Patient denies changes
in her diet. Denies cough, denies fevers/chills or dysuria. The
patient denies orthopnea (one pillow) and PND.
.
A fib dx in ___, pt initialy on ASA but then switched to
coumadin after TIA in ___. In ___ pt switched to Dabigatran
for anticoagulation. She has tried diltiazem in the past for
rate control but had pedal edema, so switched to metoprolol in
___.
.
In the ED, initial vitals were 98 83 137/87 18 100%
Labs and imaging significant pedal edema, CXR showed some fluid
overload. BNP elevated at ___. HR in 150s.
Patient took her 25mg metop succ this AM, in the ED she received
25mg PO tartate and 5mg IV x2. HR improved to 100s.
Vitals on transfer were 106 ___
.
On arrival to the floor, ___ vitals have been 97.3 138/99
51 18 100%RA. Pt is comfortable and accompanied by daughter.
.
REVIEW OF SYSTEMS
On review of systems, she states she had a stroke in ___. She
denies deep venous thrombosis, pulmonary embolism, bleeding at
the time of surgery, myalgias, cough, hemoptysis, black stools
or red stools. She has occasional small blood on toilet paper
only from known hemorrhoids. She has occasional L knee pain
post-op. 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 chest pain,
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: HTN
2. CARDIAC HISTORY:
-CABG:none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Paroxysmal Atrial Fibrillation- (dx ___ atrial
fibrillation. Noted incidentally without symptoms at routine
clinic visit in ___. On aspirin alone by CHADS2 score.
Then in ___ had TIA/stroke and started on coumadin. Then, in
___ after knee replcaement, switched to dabigtran. Tried
Dilt in the past, but had pedal edema, so in ___ decided to
switch to metoprolol.
Hypertension.
Hypothyroidism.
Osteoarthritis.
History of colon polyps ___
Left knee Replacement (___)
Social History:
___
Family History:
___ Heritage.
Father- died after heart surgery
Mother- Died in her ___ from stroke, had history of
hypertension
Physical Exam:
ADMISSION PHYSICAL EXAM
97.3 138/99 51 18 100%RA. weight 85.9kg
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 xanthalesma.
NECK: Supple with JVP of 8 cm H2O.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Irregularly irregular rhythm, tachycardic, normal S1, S2.
No m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Good air movement.
Diffuse mild wheeze b/l in all posterior lung fields.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No clubbing or cyanosis. 2+ pitting edema to knees
b/l. Negative ___ sign, no erythema, induration or pain to
palpation of calves.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. +
tattoo L wrist
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
DISCHARGE PHYSICAL EXAM:
97.3 130/77 72 18 97%RA Wt 85.9 --> 85.5
I/O: ___ yesterday
___ since MN
Next -2.3L
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 xanthalesma.
NECK: Supple with JVP of 8 cm H2O.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Irregularly irregular rhythm, tachycardic, normal S1, S2.
No m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Good air movement.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No clubbing or cyanosis. 1+ pitting edema to knees
b/l. Negative ___ sign, no erythema, induration or pain to
palpation of calves.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. +
tattoo L wrist, R shoulder
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
Pertinent Results:
PERTINENT LABS:
___ 10:15AM BLOOD WBC-5.4 RBC-4.10* Hgb-10.9* Hct-34.4*
MCV-84# MCH-26.5*# MCHC-31.6 RDW-14.0 Plt ___
___ 06:18AM BLOOD WBC-4.5 RBC-3.89* Hgb-10.5* Hct-32.9*
MCV-84 MCH-26.9* MCHC-31.9 RDW-14.2 Plt ___
___ 10:15AM BLOOD Neuts-57.7 ___ Monos-6.1 Eos-3.7
Baso-0.8
___ 10:15AM BLOOD ___ PTT-50.1* ___
___ 10:15AM BLOOD Glucose-130* UreaN-17 Creat-0.8 Na-142
K-4.5 Cl-107 HCO3-24 AnGap-16
___ 06:18AM BLOOD Glucose-102* UreaN-17 Creat-0.8 Na-144
K-4.5 Cl-109* HCO3-28 AnGap-12
___ 10:15AM BLOOD proBNP-2386*
___ 10:15AM BLOOD cTropnT-<0.01
___ 06:35PM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:18AM BLOOD Calcium-9.2 Phos-5.0*# Mg-2.0
___ 06:18AM BLOOD TSH-10*
ECG (___):
Atrial fibrillation with rapid ventricular response. There is a
single
aberrated beat suggesting ___ phenomenon. Borderline low
precordial
voltage. ST-T wave abnormalities. Since the previous tracing of
___
ST-T wave abnormalities may be more prominent.
CXR (___):
SEMI-UPRIGHT AP VIEW OF THE CHEST: There are low lung volumes.
This slightly limits assessment of lung bases where there are
streaky opacities likely reflecting atelectasis. The heart size
is top normal. The mediastinal and hilar contours are unchanged,
with mild tortuosity of the thoracic aorta again noted.
Pulmonary vascularity is not engorged. No pleural effusion or
pneumothorax is identified.
IMPRESSION: Low lung volumes with mild bibasilar atelectasis.
ECHO (___):
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
mild global left ventricular hypokinesis (LVEF = 50 %). There is
no ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are structurally normal. Mild to moderate
(___) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
atrial fibrillation is new. The LVEF now appears mildly
decreased. The degree of MR seen has slightly increased.
Brief Hospital Course:
======================
BRIEF HOSPITAL SUMMARY
======================
___ F with history of A fib, who presented with dyspnea, found to
have A fib with RVR and signs of right and left sided heart
failure on exam, in setting of tachycardia. Patient was
cardioverted succesfully to sinus rhythm.
======================
ACTIVE ISSUES
======================
# A fib: Dx in ___, history of TIA in past, recently on
metoprolol 25mg succ (previously 50mg) daily and dabigatran
(previously warfarin). CHADs2 score=4 for HTN, stroke, CHF. On
day of admission, increased metoprolol to 37.5 TID, with poor
rate control. Also diuresed with ___ lasix BID. cardiac
enzymes negative. Cardioverted patient on day of discharge,
with conversion to sinus rhythm. Pt recovered well after
cardioversion. Echocardiography performed, which demonstrated
50% EF and ___ MR. ___ home dabigatran 150mg BID
continued. continued with 10mg PO lasix x 7 days, w/
PCP/cardiology f/u as an outpatient. home on metop succinate
50mg qd.
# Acute on chronic diastolic heart failure: Pt with some
increased pedal edema, dyspnea, weight gain and elevated BNP.
Pt's tachycardia and A fib likely precipitated her current heart
failure state. No e/o infection, dietary indiscretion, ACS. Pt
diuresed well to ___ IV lasix, >2L over course of
hospitalization. Echo as above (EF 50% and MR ___. Patient
cardioverted and continued with 10mg PO lasix x 7 days.
=========================
INACTIVE ISSUES
=========================
# Hypothyroidism. continued levothyrox 100mcg daily. TSH
elevated at 10, but is a acute phase reactant. Would recheck
the ___ TSH when the patient is outside of the hospital,
and consider titration of levothyroxine at that time.
# Hypertension: normotensive. Continued metoprolol and lasix.
# Asthma: pt w/ mild wheeze and moving a fair amount of air.
continued flovent and flonate. held on albuterol inhaler while
in house
===========================
TRANSITIONAL ISSUES
===========================
1. MEDICATION CHANGES
ADD lasix, take 10mg by mouth once per day for 7 days. Have
electrolytes checked next ___. Follow-up with PCP to
evaluate volume status.
CHANGE metoprolol to 50mg metoprolol succinate by mouth once per
day
2. FOLLOW-UP
Department: ___
When: ___ at 11:50 AM
With: ___
Building: ___
Campus: ___ Best Parking: ___
Department: CARDIAC SERVICES
When: ___ at 10:30 AM
With: ___
Building: ___
Campus: ___ Best Parking: ___
3. F/u repeat TSH in outpt setting.
Medications on Admission:
albuterol PRN asthma
dabigatran 150mg BID
Flonase 2 puff daily
Flovent 2 p BID
Lasix 10mg daily (order written ___
Levothyroxine 100mcg
metoprolol succ 50mg
asa 81
Discharge Medications:
1. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
twice a day.
2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
8. Lasix 20 mg Tablet Sig: ___ Tablet PO once a day for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Outpatient Lab Work
Please check chem 10 on ___ and have results faxed
to PCP ___ at ___
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: atrial fibrillation with rapid ventricular
response; acute on chronic diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you.
You were admitted to the ___
for shortness of breath and worsening lower extremity edema.
You had a procedure called a cardioversion, which took your
heart out of the atrial fibrillation rhythm and back into a
normal rhythm.
You should go home on one week of lasix (10mg by mouth once per
day). You should follow-up closely with your primary care
physician. We have also arranged for an appointment in the
office of Dr. ___. Next ___, you should get your
blood drawn and have the results faxed to your PCP.
You should continue to take your medications as you previously
had prior to this hospitalization, EXCEPT:
- ADD lasix, take 10mg by mouth once per day for 7 days. Have
electrolytes checked next ___. Follow-up with PCP to
evaluate volume status.
- CHANGE metoprolol to 50mg metoprolol succinate by mouth once
per day
Followup Instructions:
___
|
10278097-DS-17 | 10,278,097 | 28,212,005 | DS | 17 | 2151-07-21 00:00:00 | 2151-07-21 13:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Banana / Horse/Equine Product Derivatives
Attending: ___.
Chief Complaint:
cholecystitis
Major Surgical or Invasive Procedure:
___ Laparascopic cholecystectomy
History of Present Illness:
___ with known history of gallstones, presents to the ED upon
transfer from ___ with 6 days of episodic RUQ and
epigastric pain. Her first episode was ___ night, three
hours after eating. Pain was severe, associated with nausea, and
radiated to the shoulder. Pain subsided and she had similar
episodes on ___ and ___ evenings after eating falafel
and
pizza. She is having normal flatus and BMs. ___ episodes of
emesis over the course of the past few days during the pain
episodes. They lasted for ___ hours each. After last night's
episode she presented to ___ and was found to have
ultrasound findings concerning for cholecystitis, transferred to
___ for further care.
Patient states it had been years since she had symptoms from her
gallbladder, but that these episodes are similar to her past
ones. During my evaluation, the patient's pain had improved with
pain medication and antiemetics.
Past Medical History:
1. CARDIAC RISK FACTORS: HTN
2. CARDIAC HISTORY:
-CABG:none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Paroxysmal Atrial Fibrillation- (dx ___ atrial
fibrillation. Noted incidentally without symptoms at routine
clinic visit in ___. On aspirin alone by CHADS2 score.
Then in ___ had TIA/stroke and started on coumadin. Then, in
___ after knee replcaement, switched to dabigtran. Tried
Dilt in the past, but had pedal edema, so in ___ decided to
switch to metoprolol.
Hypertension.
Hypothyroidism.
Osteoarthritis.
History of colon polyps ___
Left knee Replacement (___)
Social History:
___
Family History:
___ Heritage.
Father- died after heart surgery
Mother- Died in her ___ from stroke, had history of
hypertension
Physical Exam:
Physical Exam upon admission:
VS: 98, 63, 93/56, 16, 97RA
NAD
sclera anicteric
CTA ___
RRR
abdomen soft nondistended TTP RUQ with voluntary guarding,
nontender in remaining quadrants
no peripheral edema
Physical Exam upon discharge:
VS: 97.9, 69, 111/64, 18, 100/RA
Gen: NAD, resting in chair.
Heent: EOMI, MMM
Cardiac: Normal S1, S2. RRR
Pulm: Lungs CTAB No W/R/R
Abdomen: Soft/nontender/nondistended
Ext: + pedal pulses
Neuro: AAOx4, normal mentation.
Pertinent Results:
___ 06:30AM BLOOD WBC-9.5# RBC-3.86* Hgb-12.4 Hct-36.5
MCV-94 MCH-32.1* MCHC-34.0 RDW-14.2 Plt ___
___ 06:33AM BLOOD WBC-5.6 RBC-3.71* Hgb-12.0 Hct-33.9*
MCV-91 MCH-32.5* MCHC-35.5* RDW-14.2 Plt ___
___ 08:30AM BLOOD WBC-6.3 RBC-4.05* Hgb-12.8 Hct-37.3
MCV-92 MCH-31.6# MCHC-34.3# RDW-14.3 Plt ___
___ 08:30AM BLOOD Neuts-65.9 ___ Monos-7.7 Eos-2.7
Baso-0.6
___ 06:33AM BLOOD Glucose-82 UreaN-10 Creat-0.7 Na-140
K-3.9 Cl-107 HCO3-26 AnGap-11
___ 08:30AM BLOOD Glucose-89 UreaN-17 Creat-0.7 Na-142
K-4.0 Cl-104 HCO3-25 AnGap-17
___:33AM BLOOD ALT-33 AST-32 AlkPhos-66 TotBili-0.5
___ 08:30AM BLOOD ALT-37 AST-60* AlkPhos-69 TotBili-0.5
___ 06:33AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.3
___ 08:30AM BLOOD Albumin-3.6
___ Imaging LIVER OR GALLBLADDER US
IMPRESSION:
1. Findings consistent with acute cholecystitis.
2. Several nonmobile stones within the gallbladder neck. No
stones are seen in the common bile duct as far as can be imaged.
3. No intrahepatic bile duct dilation. The common bile duct is
mildly dilated
to 8 mm.
Brief Hospital Course:
Mrs. ___ was admitted on ___ under the acute care
surgery service for management of her acute cholecystitis. She
was taken to the operating room and underwent a laparoscopic
cholecystectomy. Please see operative report for details of this
procedure. She tolerated the procedure well and was extubated
upon completion. She we subsequently taken to the PACU for
recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced on the morning of
clears to regular, which she tolerated without abdominal pain,
nausea, or vomiting. She was voiding adequate amounts of urine
without difficulty. She was encouraged to mobilize out of bed
and ambulate as tolerated, which she was able to do
independently. Her pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed. Her INR
on the day of discharge was 1.8; her cardiologist, Dr. ___
was notifed and did not feel that bridging therapy was
necessary. The patient was discharged home on her current
warfarin regimen with instructions to have her INR checked in
the next week.
On ___ , she was discharged home with scheduled follow up in
___ clinic.
Medications on Admission:
coumadin 3mg MWF, coumadin 2mg TRSS, metoprolol 25', calcium,
vitamin D, losartan 12.5 daily, lasix 20', synthroid ___,
flovent 2 puffs BID, pepcid 10', fluoxetine 20', lipitor 20',
albuterol prn, asa 81
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Famotidine 10 mg PO DAILY
5. Fluoxetine 20 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Levothyroxine Sodium 112 mcg PO DAILY
8. Losartan Potassium 12.5 mg PO DAILY
9. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. Metoprolol Succinate XL 25 mg PO DAILY
12. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
13. Warfarin 3 mg PO 3X/WEEK (___)
14. Warfarin 2 mg PO 4X/WEEK (___)
15. Acetaminophen ___ mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10278097-DS-19 | 10,278,097 | 26,950,762 | DS | 19 | 2153-09-08 00:00:00 | 2153-09-08 13:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Banana / Horse/Equine Product Derivatives / lisinopril
Attending: ___.
Chief Complaint:
Left knee pain, hematoma, blister s/p fall on ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with history of CAD s/p CABG, AFib, on ASA
and Coumadin with hx of bilateral total knee arthroplasty (left
___, Right ___ s/p fall with left knee hematoma &
blistering.
Past Medical History:
OA, A-fib, h/o stroke, HTN, CAD (MI) s/p CABG, h/o CHF, asthma,
hypothyroid, s/p L TKR
Social History:
___
Family History:
Non-contributory
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Wound with dry blisters
* Scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 07:47AM BLOOD WBC-5.6 RBC-2.74* Hgb-8.2* Hct-25.2*
MCV-92 MCH-29.9 MCHC-32.5 RDW-13.2 RDWSD-43.8 Plt ___
___ 07:05AM BLOOD WBC-5.5 RBC-2.84* Hgb-8.4* Hct-25.9*
MCV-91 MCH-29.6 MCHC-32.4 RDW-13.1 RDWSD-43.4 Plt ___
___ 07:46AM BLOOD WBC-7.4 RBC-2.82* Hgb-8.5* Hct-26.1*
MCV-93 MCH-30.1 MCHC-32.6 RDW-13.2 RDWSD-44.5 Plt ___
___ 06:35PM BLOOD WBC-8.4 RBC-2.88* Hgb-8.7* Hct-26.3*
MCV-91 MCH-30.2 MCHC-33.1 RDW-13.2 RDWSD-43.8 Plt ___
___ 08:10AM BLOOD WBC-7.6 RBC-2.89* Hgb-8.8* Hct-27.2*
MCV-94 MCH-30.4 MCHC-32.4 RDW-13.6 RDWSD-46.6* Plt ___
___ 08:00AM BLOOD WBC-7.5 RBC-2.80* Hgb-8.4* Hct-26.3*
MCV-94 MCH-30.0 MCHC-31.9* RDW-13.5 RDWSD-46.4* Plt ___
___ 07:30PM BLOOD WBC-6.6 RBC-2.87* Hgb-8.8* Hct-27.3*
MCV-95 MCH-30.7 MCHC-32.2 RDW-13.5 RDWSD-47.3* Plt ___
___ 05:48AM BLOOD WBC-6.6 RBC-2.99* Hgb-9.1* Hct-27.6*
MCV-92 MCH-30.4 MCHC-33.0 RDW-13.6 RDWSD-45.9 Plt ___
___ 10:45PM BLOOD WBC-6.3 RBC-2.76* Hgb-8.5* Hct-25.4*
MCV-92 MCH-30.8 MCHC-33.5 RDW-13.8 RDWSD-46.5* Plt ___
___ 04:55PM BLOOD WBC-6.6 RBC-3.05*# Hgb-9.2*# Hct-28.7*#
MCV-94 MCH-30.2 MCHC-32.1 RDW-13.9 RDWSD-47.8* Plt ___
___ 06:35PM BLOOD Neuts-71.3* Lymphs-16.7* Monos-9.5
Eos-1.9 Baso-0.2 Im ___ AbsNeut-6.01# AbsLymp-1.41
AbsMono-0.80 AbsEos-0.16 AbsBaso-0.02
___ 10:45PM BLOOD Neuts-56.7 ___ Monos-12.1 Eos-3.0
Baso-0.5 Im ___ AbsNeut-3.56 AbsLymp-1.72 AbsMono-0.76
AbsEos-0.19 AbsBaso-0.03
___ 04:55PM BLOOD Neuts-65.5 ___ Monos-10.6 Eos-2.0
Baso-0.3 Im ___ AbsNeut-4.35 AbsLymp-1.42 AbsMono-0.70
AbsEos-0.13 AbsBaso-0.02
___ 07:47AM BLOOD ___
___ 07:05AM BLOOD ___
___ 07:46AM BLOOD ___
___ 08:10AM BLOOD ___
___ 08:00AM BLOOD ___
___ 07:30PM BLOOD ___
___ 04:55PM BLOOD ___ PTT-38.9* ___
___ 07:46AM BLOOD Glucose-99 UreaN-13 Creat-0.6 Na-138
K-4.3 Cl-102 HCO3-29 AnGap-11
___ 08:10AM BLOOD Glucose-105* UreaN-13 Creat-0.6 Na-135
K-4.3 Cl-102 HCO3-29 AnGap-8
___ 08:00AM BLOOD Glucose-100 UreaN-17 Creat-0.6 Na-138
K-4.3 Cl-104 HCO3-29 AnGap-9
___ 07:30PM BLOOD Glucose-120* UreaN-23* Creat-0.7 Na-139
K-4.4 Cl-103 HCO3-28 AnGap-12
___ 04:55PM BLOOD Glucose-109* UreaN-15 Creat-0.7 Na-138
K-4.7 Cl-103 HCO3-27 AnGap-13
___ 07:46AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.1
___ 08:10AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.0
___ 08:00AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.0
___ 07:30PM BLOOD Calcium-8.6 Phos-2.4* Mg-1.9
___ 10:45PM WBC-6.3 RBC-2.76* HGB-8.5* HCT-25.4* MCV-92
MCH-30.8 MCHC-33.5 RDW-13.8 RDWSD-46.5*
___ 10:45PM NEUTS-56.7 ___ MONOS-12.1 EOS-3.0
BASOS-0.5 IM ___ AbsNeut-3.56 AbsLymp-1.72 AbsMono-0.76
AbsEos-0.19 AbsBaso-0.03
___ 10:45PM PLT COUNT-161
___ 05:03PM ___ COMMENTS-GREEN TOP
___ 05:03PM LACTATE-1.4
___ 04:55PM GLUCOSE-109* UREA N-15 CREAT-0.7 SODIUM-138
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
___ 04:55PM estGFR-Using this
___ 04:55PM WBC-6.6 RBC-3.05*# HGB-9.2*# HCT-28.7*#
MCV-94 MCH-30.2 MCHC-32.1 RDW-13.9 RDWSD-47.8*
___ 04:55PM NEUTS-65.5 ___ MONOS-10.6 EOS-2.0
BASOS-0.3 IM ___ AbsNeut-4.35 AbsLymp-1.42 AbsMono-0.70
AbsEos-0.13 AbsBaso-0.02
___ 04:55PM PLT COUNT-170
___ 04:55PM ___ PTT-38.9* ___
Brief Hospital Course:
The patient was admitted to the orthopedic surgery service for
left knee hematoma & blistering after sustaining a fall.
Her left knee wound was dressed with xeroform & bacitracin,
followed by ABD & ACE wrap. We continued her Amoxicillin for
tooth abscess. We initially held her Coumadin for INR of 2.3
given her hematoma and restarted Coumadin at low dose on
___. On ___, her INR was 1.3- she was restarted on her
home dose of Coumadin (3mg).
On ___, she had two noted temperatures. An infectious
work-up was done including CBC, urinalysis, urine culture, and
blood cultures. The urine culture was negative. Blood cultures
were pending at time of discharge.
On ___ overnight, she triggered for a low blood pressure
(systolics in ___. Blood pressure medications (Lasix & Toprol
XL) were held. Her blood pressure continued to trend low, but
the patient remained asymptomatic. Instructed the patient to
follow-up with her PCP after discharge to see if any changes
need to be made to her blood pressure medications.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. The patient was seen daily by physical
therapy. Labs were checked throughout the hospital course and
repleted accordingly. At the time of discharge the patient was
tolerating a regular diet and feeling well. The patient was
afebrile with stable vital signs. The patient's hematocrit was
acceptable and pain was adequately controlled on an oral
regimen.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity.
Ms. ___ is discharged to home with services in stable
condition.
Medications on Admission:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Acetaminophen 1000 mg PO Q8H
9. Docusate Sodium 100 mg PO BID
10. Senna 8.6 mg PO BID
11. Vitamin D 1000 UNIT PO DAILY
12. Warfarin 3 mg PO DAYS (___)
13. EpiPen (EPINEPHrine) 0.3 (1:1,000) INJECTION PRN allergy
14. Warfarin 2 mg PO DAYS (MO,FR)
15. Cephalexin ___ mg PO ONCE
16. fluticasone 88 mcg inhalation BID
17. Losartan Potassium 12.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. EpiPen (EPINEPHrine) 0.3 (1:1,000) INJECTION PRN allergy
6. Furosemide 20 mg PO DAILY
7. Levothyroxine Sodium 112 mcg PO DAILY
8. Losartan Potassium 12.5 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Warfarin 3 mg PO DAILY
11. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN pain
12. Amoxicillin 500 mg PO Q8H Duration: 2 Doses
13. Docusate Sodium 100 mg PO BID
14. fluticasone 88 mcg inhalation BID
15. Metoprolol Succinate XL 25 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Senna 8.6 mg PO BID
18. Cephalexin ___ mg PO ONCE prior to dental procedures/
cleanings Duration: 1 Dose
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left knee hematoma, blistering
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from qound, chest
pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. You may wrap the knee with an ace bandage
for added compression. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc).
8. ANTICOAGULATION: Please continue your Coumadin. It should be
dosed based on your INR levels. The ___ will draw your INR and
report the result to your ___. If you were
taking aspirin prior to your surgery, it is OK to continue at
your previous dose while taking anticoagulation medication.
9. WOUND CARE: ___ nurse ___ provide daily dressing changes.
Dressing changes include Xeroform, bacitracin, ABD pad, and ACE
wrap from toes to thigh.
10. ___ (once at home): Home ___, dressing changes as
instructed, wound checks.
11. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Two crutches or walker at all times for 6 weeks.
Mobilize. ROM as tolerated. No strenuous exercise or heavy
lifting until follow up appointment.
Physical Therapy:
WBAT LLE
Mobilize frequently
Treatments Frequency:
daily dressing changes daily
wound checks daily
dressing changes include: Xeroform dressing, bacitracin, ABD
pad, LLE wrapped from toes to thigh with ACE wrap
INR monitoring (next date to be checked is ___ pt is
followed by ___ (___)
Followup Instructions:
___
|
10278264-DS-10 | 10,278,264 | 24,199,783 | DS | 10 | 2162-03-24 00:00:00 | 2162-03-24 15:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
malaise, pleurisy
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ with h/o HTN, pituitary macroadenoma s/p resection ___
and cyberknife ending in ___ who presented with one day of
weakness and malaise. Patient was in his usual state of health
until last night when he developed a cough. Overnight he felt
sweaty in bed. This morning, he was unable to get out of bed due
to generalized weakness and noted left chest wall tenderness
with inspiration. Denies fevers, chills, sick contacts, travel.
He received a short course of PO antibiotics from his PCP for ___
sinus infection in ___, but after filling the prescription
did not take them. He has not had recent hospitalization.
Of note, when pt underwent cyberknife therapy ___ he was given
4 mg of decadron B.I.D. He was then put on a steroid taper
begining ___ and completed it on ___ and began feeling
ill within a week of discontinuing them.
In the ED initial vitals were: 98.6 114 100/68 20 93% 3L. Tmax
102.8. Labs were significant for WBC 14.8 N 74.1%, lactate 2.3.
CT head showed no acute abnormality. CXR was concerning for LLL
PNA and pt recieved vancomycin, cefepime and 500cc NS as well as
IV hydrocortisone and was admitted to medicine. Vitals prior to
transfer were: 101.2 98 98/68 18 93% RA.
On the floor, pt arrives accompanied by his sister, ___, and
reports that he is feeling better.
Review of Systems:
(+) per HPI
(-) fever, chills, shortness of breath, chest pain, abdominal
pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria.
Past Medical History:
#Pituitary macroadenoma s/p partial resection by Dr. ___ at
___ ___ Cyberknife therapy x5 ended ___
#Hypertension
#Brucellosis as a child
#Nephrolithiasis ___ years ago x 1
Surgical history:
#Appendix removed in ___ grade
#Cataract surgery L eye ___
#Right rotator cuff repair ___
Social History:
___
Family History:
FHx:
Daughter with thyroid disease, unsure what kind. Sister with
nephrolithiasis.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T98.3 93/66 HR 87 RR 18 95% RA
GENERAL: fatigued appearing male, laying in bed NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: lung sounds diminished L base, no wheezes, rales, rhonchi,
breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: alert and oriented to person, place, month and year
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
GENERAL: well appearing middle aged man lying in bed in no
distress.
HEENT: moist mucous membranes, no sinus pain, no conjunctival
erythema, oral cavity within normal limits
COR: regular rate and rhythm without murmurs, rubs, or gallops
CHEST: symmetric expansion. breathing with ease. Lung sounds
diminishes at left base without crackles, wheezes, rhonchi.
Resonant to percussion throughout.
ABDOMEN: soft, nontender, nondistended
EXTREMITIES: warm and without edema
NEURO: alert, oriented, cooperative, normal gait, CN2-12 intact,
strength is ___ throughout with normal sensation
SKIN: no lesions
Pertinent Results:
ADMISSION LABS
--------------
___ 04:15PM BLOOD WBC-14.8*# RBC-4.54* Hgb-13.8* Hct-38.9*
MCV-86 MCH-30.5 MCHC-35.5* RDW-13.8 Plt ___
___ 04:15PM BLOOD Neuts-74.1* ___ Monos-6.7 Eos-0.6
Baso-0.4
___ 04:15PM BLOOD Glucose-137* UreaN-18 Creat-1.2 Na-138
K-4.0 Cl-101 HCO3-24 AnGap-17
___ 04:23PM BLOOD Lactate-2.3*
___ 04:15PM BLOOD Cortsol-25.1*
___ 04:15PM BLOOD T4-8.5 calcTBG-0.98 TUptake-1.02
T4Index-8.7 Free T4-1.1
___ 04:15PM BLOOD TSH-3.6
___ 05:13PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:13PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:13PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 05:13PM URINE Mucous-RARE
DISCHARGE LABS
--------------
___ 07:40AM BLOOD WBC-16.3* RBC-4.36* Hgb-13.2* Hct-37.2*
MCV-85 MCH-30.2 MCHC-35.5* RDW-13.6 Plt ___
___ 07:40AM BLOOD Glucose-186* UreaN-18 Creat-1.0 Na-144
K-3.6 Cl-104 HCO3-25 AnGap-19
MICROBIOLOGY
------------
___ BLOOD CULTURES X2: PENDING AT DISCHARGE
IMAGING
-------
___ CHEST XRAY:
FINDINGS:
PA and lateral views of the chest provided. Airspace
consolidation in the left lower lung is concerning for pneumonia
likely within the left lower lobe. Areas of lower lung
atelectasis also noted. The cardiomediastinal silhouette appears
stable. No definite pneumothorax. Mild edema difficult to
exclude. Bony structures intact.
IMPRESSION:
Lower lung atelectasis with probable left lower lobe pneumonia.
Mild edema difficult to exclude.
___ CT HEAD NON-CONTRAST (PRELIMINARY REPORT):
No acute intracranial abnormality. Sellar partially resected
mass better
characterized on recent MR dated ___. No hemorrhage
or new mass effect is identified. Extensive sinus disease
involving the right maxillary sinus, sphenoid sinus, and
ethmoidal air cells noted.
Brief Hospital Course:
___ year old man with hypertension and recently diagnosed
macroadenoma s/p partial resection in ___ and Cyberknife
ending in ___ who presented to ___ with 1 day of malaise,
chills, and pleurisy.
# COMMUNITY ACQUIRED PNEUMONIA: The patient had leukocytosis,
pleurisy, fever, tachycardia on admission. His urine did not
show infection. Chest x-ray showed left lower lobe
consolidation. He was initially given vancomycin and cefepime
because of his recent Cyberknife therapy, but we felt that his
treatment should be for community acquired pneumonia rather than
healthcare associated because of his limited risk factors. After
<24 hours of care he was feeling significantly better in terms
of malaise and his SIRS criteria had resolved with the exception
of leukocytosis. However, the leukocytosis is confounded by
hydrocortisone administration on admission. He appeared stable
for discharge, therefore we discharged him with a 7 day course
of levofloxacin. Endocrinology recommended a rapid steroid taper
because of his stress dose steroids in the ER. This will
continue for 3 days after discharge.
# MACROADENOMA: Secrertory. Has had slightly elevated TSH and
prolactin in past. His random cortisol was 25. His thyroid
studies were normal. He will continue 40mg of hydrocortisone PO
BID x1 day, 20mg BID x1 day, 20mg daily x1 day, then off.
# HYPERTNESION: He was normotensive on admission. Verapamil and
valsartan-HCTZ were held initially. They were restarted on
discharge.
TRANSITIONAL ISSUES:
-complete steroid taper
-follow up in ___ clinic ___
-CODE STATUS: FULL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Verapamil SR 240 mg PO Q24H
2. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
3. valsartan-hydrochlorothiazide 160-12.5 mg oral daily
4. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
2. Vitamin D 1000 UNIT PO DAILY
3. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*6
Tablet Refills:*0
4. valsartan-hydrochlorothiazide 160-12.5 mg oral daily
5. Verapamil SR 240 mg PO Q24H
6. Hydrocortisone 20 mg PO Q12H Duration: 7 Doses
Day 1: 2 pills twice daily
Day 2: 1 pill twice daily
Day 3: 1 pill
RX *hydrocortisone 20 mg 1 tablet(s) by mouth q12 hours Disp #*7
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
#Community acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___, you were admitted to ___ because of a left lower
lobe pneumonia. You were initially started on broad antibiotics,
but because you looked quite well, we started an oral
antibiotic. You should continue this for 1 week. Side effects
include diarrhea. Endocrinology also saw you in the ER and
recommended a brief steroid taper because of your recent
pituitary surgery and radiation. You should follow up with your
primary care doctor within ___ weeks.
Followup Instructions:
___
|
10278264-DS-11 | 10,278,264 | 21,752,530 | DS | 11 | 2164-11-24 00:00:00 | 2164-11-25 18:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Code stroke for garbled speech
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI:
___ gentleman, past medical history of pituitary
macroadenoma status post partial resection, and hypertension,
presents with an episode of garbled speech.
This morning, he was feeling "great". Per his sister he was
jumping around the room, which they attributed to him starting
prednisone 5 mg daily within the last week, which was started in
response to his low a.m. cortisol per his endocrinologist for
central adrenal insufficiency.
He went to the gas station, and he has used the same pump for
several years. He was holding the pump in his right hand, and
he
noted it "was not running right". He thought perhaps the pump
was not working. He denies any weakness or sensory changes in
his right hand. During this time he leaned against the pump
lost
his balance and went to the ground. He was able to get himself
back up by himself. He denied any weakness in his legs at that
moment. Somebody came over to him, and when he tried to speak
he
noted that his speech was garbled. This lasted for a period of
10 minutes. He understood what the person was trying to say to
him. He knew what he wanted to say, but he was unable to get
the
proper words out. He then got into his truck and drove home.
When he he notes when he was driving he was able to steer and
drive properly. He denied any weakness in any of his limbs.
When he reached home, he spoke with his outpatient providers,
who
recommended he go to the hospital for a workup. His sister saw
him at the home and she noted that there is no facial weakness
but she thought he was drooling out of the right side of his
mouth. His speech was at baseline at that time.
On my visit, he states he is back to his baseline.
ROS: On neurologic review of systems, the patient denies
headache, lightheadedness, or confusion. Denies difficulty with
producing or comprehending speech. Denies loss of vision,
blurred
vision, diplopia, vertigo, tinnitus, hearing difficulty,
dysarthria, or dysphagia. Denies focal muscle weakness,
numbness,
parasthesia. Denies loss of sensation. Denies bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. Denies nausea, vomiting,
diarrhea, constipation, or abdominal pain. No recent change in
bowel or bladder habits. Denies dysuria or hematuria. Denies
myalgias, arthralgias, or rash.
Past Medical History:
#Pituitary macroadenoma s/p partial resection by Dr. ___ at
___ ___ Cyberknife therapy x5 ended ___
#Hypertension
#Brucellosis as a child
#Nephrolithiasis ___ years ago x 1
Osteopenia/vitamin D deficiency
?Possible Hashimoto Thryoiditis
Growth hormone deficiency.
Hypogonadism
At risk for central adrenal insufficiency
Surgical history:
#Appendix removed in ___ grade
#Cataract surgery L eye ___
#Right rotator cuff repair ___
#s/p partial resection of pituitary macroadenoma by Dr. ___
at
___ ___
Social History:
Retired ___, worked at ___ operating ___ and other jobs
for ___ years. Nonsmoker, never smoked. Nondrinker. No prior IVDU
or RDU. For exercise, does home ___ projects. Likes to
work on ___. Divorced, lives with daughter. Son died at
___ yo due to suicide. Sister lives next door
- Modified Rankin Scale:
[x] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
Denies Strokes and MI. Daughter with thyroid disease, unsure
what kind. Sister with nephrolithiasis.
Physical Exam:
PHYSICAL EXAMINATION
Vitals:
98.2 76 155/114 20 99% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR
Pulmonary: Breathing comfortably on room air
Abdomen: Soft
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. No dysarthria. Normal prosody. Able to register 3
objects and recall ___ cue at 5 minutes. No apraxia. No
evidence of hemineglect. No left-right confusion. Able to follow
both midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 5- 5 5 5 5- 4+ 5 5 5 5 4+
R 5 5 5 5 5- 4+ 5 4+ 5 5 4+
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 1 1 1 0 0
R 1 1 1 0 0
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: Deferred
Discharge neurologic exam: unchanged from admission.
Pertinent Results:
BLOOD:
___ 05:19AM BLOOD WBC-9.6 RBC-5.03 Hgb-14.0 Hct-42.4 MCV-84
MCH-27.8 MCHC-33.0 RDW-13.4 RDWSD-41.3 Plt ___
___ 11:30AM BLOOD WBC-8.1 RBC-4.77 Hgb-13.6* Hct-40.1
MCV-84 MCH-28.5
MCHC-33.9 RDW-13.2 RDWSD-40.4 Plt ___
___ 05:19AM BLOOD ___ PTT-30.2 ___
___ 11:30AM BLOOD ___ PTT-28.0 ___
___ 05:19AM BLOOD Glucose-77 UreaN-22* Creat-1.0 Na-145
K-4.3 Cl-104 HCO3-23 AnGap-18*
___ 05:19AM BLOOD ALT-13 AST-19 LD(LDH)-201 CK(CPK)-100
AlkPhos-77 TotBili-0.5
___ 05:19AM BLOOD GGT-19
___ 05:19AM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:30AM BLOOD cTropnT-<0.01
___ 05:19AM BLOOD TotProt-7.3 Albumin-4.4 Globuln-2.9
Calcium-9.6 Phos-4.0 Mg-2.4 Cholest-185
___ 11:30AM BLOOD Albumin-4.3 Calcium-9.5 Phos-3.7 Mg-2.2
___ 05:19AM BLOOD %HbA1c-5.9 eAG-123
___ 05:19AM BLOOD Triglyc-84 HDL-68 CHOL/HD-2.7 LDLcalc-100
___ 05:19AM BLOOD TSH-7.4*
___ 11:30AM BLOOD TSH-6.4*
___ 05:19AM BLOOD CRP-2.4
___ 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
URINE:
___ 02:00PM URINE Color-Straw Appear-Clear Sp ___
___ 02:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 02:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
IMAGING:
CT HEAD
No acute intracranial hemorrhage.
CTA HEAD:
Aside from mild atherosclerotic calcification in the bilateral
carotid
siphons, the vessels of the circle of ___ and their principal
intracranial branches appear normal without stenosis, occlusion,
or aneurysm formation. The dural venous sinuses are patent.
CTA NECK:
Aside from bilateral carotid artery atherosclerotic
calcifications, the
carotid and vertebral arteries and their major branches appear
normal with no evidence of stenosis or occlusion. There is no
evidence of internal carotid stenosis by NASCET criteria.
MRI BRAIN W/O CONTRAST
1. A couple of small punctate acute infarcts in relation to the
left
anterior/posterior central gyrus.
2. A few punctate periventricular and deep white matter T2 and
FLAIR
hyperintensities are nonspecific, but most likely are secondary
to
microangiopathy.
3. This study was not tailored to evaluate the pituitary, but
appears
relatively similar compared to most recent prior imaging. For a
full report please refer to study dated ___.
Brief Hospital Course:
___ is a ___ y/o man with medical history of pituitary
macroadenoma (status post partial resection), adrenal
insufficiency, and hypertension, presenting with a 10 minute
episode of garbled speech. Neurologic exam is unremarkable.
CT/CTA head and neck without evidence of acute bleed,
significant stenosis or occlusion. MRI with evidence of small
punctate acute infarcts in relation to the left
anterior/posterior central gyrus. Labs notable for LDL of 100,
HBA1C 5.9%. Etiology of his stroke unclear. Differential
diagnoses include cardioembolic or artery to artery source. At
this time we will plan for workup with: TEE and 30-day cardiac
event monitor. He should follow with his primary care within one
week of discharge. He has been instructed to call and set up an
appointment with Dr. ___ in stroke neurology.
Transitional issues:
- Started on Simvastatin 80mg for LDL of 100
- Started ASA 81mg
- Follow TTE
- Follow ___ monitoring
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? (x) Yes - () No
4. LDL documented? (x) Yes (LDL = 100) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? () Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 25 mcg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. PredniSONE 5 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
2. Simvastatin 80 mg PO QPM
RX *simvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. PredniSONE 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute punctate LT pre/postcentral gyrus stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of garbled speech
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms. We have imaged your brain and blood
vessels which confirms these findings. At this point we have
started you on medications to prevent future strokes which
include: aspirin 81mg, simvastatin to control your cholesterol.
We also checked your blood sugar numbers which were normal. In
order to find the cause of your stroke we will send you for an
echocardiogram as well as long term cardiac monitoring to assess
for arrhythmias. We will see you for follow up in neurology
clinic (please call the number below to schedule an
appointment).
Please take your other medications as prescribed. Please follow
up with Neurology and your primary care physician as listed
below. If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10278306-DS-15 | 10,278,306 | 29,167,714 | DS | 15 | 2158-08-03 00:00:00 | 2158-08-10 05:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin
Attending: ___.
Chief Complaint:
Lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a history of Type II DM, hypertension,
hyperlipidemia, and stage 3 CKD who presents with one day of
intermittent episodes (x2) of blurry vision, shakiness, and
lightheadedness lasting ___ minutes per episode with
accompanying palpitations. Patient denies any prodromal symptoms
including nausea, vomiting, tremor, or diaphoresis. The episode
did not occur with positional changes or on exertion and she
denies syncope, incontinence, confusion, weakness, numbness or
tingling, headache or slurred speech. She does not have a
history of syncope of lightheadedness. Patient reports that she
started torsemide one day prior to admission and switched from
metformin to glyburide on the day of admission. Her blood
glucose during this episode of lightheadedness was 78 (this is
low for her- usually FSBG in 100's) Symptoms resolved after
eating. Recommended by PCP to call ambulance and go to the ED,
which she did.
In the ED, initial vitals: 98 187/72 18 100% IL NC. Labs were
notable for creatinine 1.6, BUN 23, Hct 31, and a negative UA.
Patient has remained asymptomatic since 1 pm when her second
episode resolved.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, headache, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
DM, type II
Stage III CKD
HTN
Hyperlipidemia
Social History:
___
Family History:
Non-Contributory.
Physical Exam:
Admission Physical Exam:
VS 98.4 158/81 75 16 100% RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM CTAB no adventitious breath sounds
CV RRR normal S1/S2, III/VI early peaking crescendo-decrescendo
systolic murmur @ RUSB w/ radiation to carotids, no rubs or
gallops appreciated
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Discharge Physical Exam:
VS 98.1 134/72 72 16 100% RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM CTAB no adventitious breath sounds
CV RRR normal S1/S2, III/VI early peaking crescendo-decrescendo
systolic murmur @ RUSB w/ radiation to carotids, no rubs or
gallops appreciated
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
Admission Labs:
___ 02:55PM BLOOD WBC-8.0 RBC-3.35* Hgb-10.4* Hct-31.1*
MCV-93 MCH-30.9 MCHC-33.4 RDW-12.2 Plt ___
___ 02:55PM BLOOD Neuts-65.8 ___ Monos-4.2 Eos-0.7
Baso-0.8
___ 02:55PM BLOOD ___ PTT-30.2 ___
___ 02:55PM BLOOD Glucose-116* UreaN-23* Creat-1.6* Na-142
K-3.8 Cl-103 HCO3-28 AnGap-15
___ 02:55PM BLOOD Glucose-116* UreaN-23* Creat-1.6* Na-142
K-3.8 Cl-103 HCO3-28 AnGap-15
___ 02:55PM BLOOD Calcium-9.9 Phos-3.0 Mg-2.5
___ 05:00PM URINE Color-Straw Appear-Clear Sp ___
___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
___ 05:00PM URINE RBC-<1 WBC-3 Bacteri-NONE Yeast-NONE
Epi-2
Additional Studies:
___
Cardiovascular ReportECGStudy Date of ___ 2:39:40 ___
Sinus tachycardia. Leftward axis. Right bundle-branch block. No
previous
tracing available for comparison.
Read ___
IntervalsAxes
___
___
CT Head w/o Contrast ___
IMPRESSION:
1. No acute intracranial process.
2. A 5 x 3 mm calcified extra-axial lesion within the inner
table of the
right temporal bone may represent a meningioma.
Chest X Ray (PA & LAT) ___
IMPRESSION: No acute intrathoracic process.
Discharge Labs:
___ 07:15AM BLOOD WBC-6.7 RBC-3.17* Hgb-9.8* Hct-29.4*
MCV-93 MCH-30.8 MCHC-33.2 RDW-11.9 Plt ___
___ 07:15AM BLOOD Glucose-79 UreaN-19 Creat-1.4* Na-143
K-4.0 Cl-106 HCO3-30 AnGap-11
___ 07:15AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.5
___ 07:15AM BLOOD %HbA1c-6.2* eAG-131*
Brief Hospital Course:
___ year old female with a history of Type II Diabetes,
hypertension, hyperlipidemia, and stage 3 Chronic kidney disease
who presents with one day of intermittent episodes of blurry
vision, shakiness, and lightheadedness lasting ___ minutes per
episode with accompanying palpitations. Noted to have started
glyburide on the morning of admission and torsemide (from
Hydrochlorothiazide) the night before. She had recorded a blood
sugar of 78 during one of these episodes. She underwent an ECG
in the emergency room which was unchanged from previous ECG
without evidence of arrhythmia or structural heart disease which
would contribute to pre-syncope. A urinalysis was negative and
there was no other nidus of infection present. CT of the head
did not show an acute intracranial process. Neurology was
consulted and was not concerned for a posterior circulation
stroke given her benign neurological exam and negative CT. She
received 1L of NS overnight. Glyburide was held given her good
glucose control (HgA1c of 6.2%)and feeling that her episodes
were likely a reaction to her new glyburide. Patient remained
afebrile with stable vital signs throughout her admission. She
did not have further episodes of lightheadedness. She was
discharged with close primary care follow-up and ___
___ event monitor given her report of palpitations.
All other chronic conditions were managed without complications.
She remained full code throughout her admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D ___ UNIT PO DAILY
2. GlyBURIDE 2.5 mg PO DAILY
3. Torsemide 5 mg PO DAILY
4. olmesartan *NF* 20 mg Oral daily
5. Simvastatin 40 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. olmesartan *NF* 20 mg Oral daily
4. Simvastatin 40 mg PO DAILY
5. Torsemide 5 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Lightheadedness
Hypoglycemia
Secondary diagnoses:
Diabetes mellitus
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 because of lightheadedness and low
blood sugar. We think your symptoms are most likely due to
starting glyburide. We have decided to stop glyburide and you
will follow up with your primary care to determine the best
management for your diabetes going forward. Your glucose is
well controlled now without medications. We are also going to
discharge you with a heart monitor in which you will activate
the monitor when you are feeling symptoms. This will be further
explained to you at discharge.
It was a pleasure caring for you.
Followup Instructions:
___
|
10278306-DS-18 | 10,278,306 | 22,277,977 | DS | 18 | 2160-07-03 00:00:00 | 2160-07-03 13:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Motrin / lisinopril / amlodipine / glyburide
Attending: ___.
Chief Complaint:
Dizziness and vertigo
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with a history of vertigo,
DM, HLD, and HTN presents with 1 day of dizziness and vomiting.
She was in her usual state of health until she woke up this
morning at 8:30 am feeling dizzy and unsteady. She sat on her
couch upright and was feeling dizziness described as
unsteadiness. When a neighbor came to visit her, she felt
unsteady while walking and fell trying to answer the front door.
She did not endure any trauma to the head or otherwise as a
result of the fall. She went back to sleep shortly after
12:00pm. She awoke again at approximately 2:15pm and was still
experiencing dizziness. She turned her head abruptly when trying
to get out of bed and began to feel like the room was spinning.
She became extremely nauseous, after which she crawled to the
bathroom and vomited once. She then crawled back into bed and
called paramedics, who brought her to ___ ED.
In the ED, she received normal saline for volume resuscitation
in the setting of potential dehydration. She also endorses
receiving ativan at unknown dosage and another medication which
she cannot recall (neither medication described in ED note). CT
head without contrast was obtained.
Presently (8:00pm), she describes herself as light-headed and
mildly dizzy. She is unable to sit up by herself and cannot
stand independently without falling backwards. She reports
intermittent headache throughout the day and describes the pain
as dull, constant, and non-pulsatile.
Ms. ___ was diagnosed with vertigo in the mid-late ___ and
has experienced several similar episodes in the past, though
this has been one of her most severe. Episodes usually last a
few hours at most while this has lasted all day. Her dizziness
is not positional but is aggravated when she turns her head
abruptly. She reports having a prescription for meclizine in
___ which provided relief of symptoms but this is
unconfirmed per OMR.
Her AM fasting glucose was 114. She has eaten an orange and a
bagel with marmalade today, which is her normal
morning/afternoon intake. She has not eaten supper as she has
been in the ED since approximately 3:00pm.
On general review of systems, she endorses nausea and vomiting
as described above but denies them at present. She also endorses
rinorrhea without asterixis. She denies chest pain, shortness of
breath, or abdominal pain.
On neuro review of systems, she denies vision changes except for
"floaters" seen intermittently last week and this week. She
denies dysarthria, dysphagia, tinnitus or hearing difficulty.
Denies difficulties producing or comprehending speech. Denies
focal weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention.
Past Medical History:
Osteoarthritis -- ___
DM Type II -- circa ___
Hypertension -- circa ___
HLD
Stage III CKD
Social History:
___
Family History:
dad - HTN, colon cancer
brothers - colon cancer, HTN, DM, MI
sister - various cancers, DM, HTN
No family history of sudden death.
Physical Exam:
ADMISSION EXAM:
BP=175/95 HR=90 RR=18
General: Well-appearing elderly woman sitting comfortably in
bed.
HEENT: NCAT
CV: Normal S1, S2. RRR.
Lungs: CTA bilaterally
Abdomen: Soft, non-tender, non-distended.
Skin: Intact, without rashes or lesions. Scars consistent with
surgical history.
Extremities: Warm, well-perfused.
Neurological Exam:
- Mental Status -
Alert, oriented to self, place, and date. Attentive to months of
year backwards. Language was fluent with normal prosody.Able to
relate history without difficulty. Intact repetition and
comprehension. No paraphasic errors. Long-term memory intact
(knew the current ___ President). No extinction to
double-simultaneous stimuli. No evidence of apraxia or neglect.
- Cranial Nerves -
I: Not tested
II: Fundoscopic exam unremarkable. Pupils equally round and
reactive, 4mm to 3mm and brisk. Visual fields intact to
confrontation. Visual acuity ___ with both eyes and using
corrective lenses.
III, IV, VI: EOMI intact. No nystagmus. Head impulse test was
mildly positive to head turn to right.
VI: Sensation intact to temperature and light touch throughout.
VII: No facial asymmetry. Symmetric nasolabial folds. Full
facial
strength throughout.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Swallow intact. Palate elevation midline.
XI: SCM and trapezius full strength.
XII: Tongue protrusion midline.
- Motor -
Normal bulk and tone throughout. No fasciculations. No resting
tremor. No pronator drift.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ 5 4+ ___
R ___ 5 4+ ___
- Sensory -
Sensation intact to pinprick, vibration, temperature, and fine
touch in all distal extremities. Joint position sense intact in
all extremities.
- DTRs -
Bi Tri ___ Pat Ach
L ___ 1 1
R ___ 1 1
- Coordination -
Finger-nose-finger and heel-to-shin testing intact bilaterally.
- Gait - Patient could not stand independently, continued to
fall backwards and towards the right
DISCHARGE EXAM:
BP=175/95 HR=68 RR=18
General: Well-appearing elderly woman sitting comfortably in
bed.
HEENT: NCAT
CV: Normal S1, S2. RRR.
Lungs: CTA bilaterally
Abdomen: Soft, non-tender, non-distended.
Skin: Intact, without rashes or lesions. Scars consistent with
surgical history.
Extremities: Warm, well-perfused.
Neurological Exam:
- Mental Status -
Alert, oriented to self, place, and date. Attentive to months of
year backwards. Language was fluent with normal prosody. Able to
relate history without difficulty. Intact repetition and
comprehension. No paraphasic errors. No acalculia or
agraphesthesia. Pt was able to register 4 objects and recall ___
at 5 minutes.
- Cranial Nerves -
I: Not tested
II: Pupils equally round and reactive, 3mm to 2mm and brisk.
Visual fields intact to confrontation.
III, IV, VI: EOMI intact. No nystagmus.
VI: Sensation intact to temperature and light touch throughout.
VII: No facial asymmetry. Symmetric nasolabial folds. Full
facial
strength throughout.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palate elevation midline.
XI: SCM and trapezius full strength.
XII: Tongue protrusion midline.
- Motor -
Normal bulk and tone throughout. No fasciculations.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ 5 5
R ___ 5 5
- Sensory -
Sensation intact to pinprick, vibration, temperature, and fine
touch in all distal extremities.
- DTRs -
Bi Tri ___ Pat Ach
L ___ 2 2
R ___ 2 2
Bilateral downgoing reflex.
- Coordination -
Finger-nose-finger and heel-to-shin testing intact bilaterally.
No dysmetria.
- Gait - good intention and balance. Normal stride, arm swing,
and turns.
Pertinent Results:
___ 04:49PM BLOOD WBC-7.4 RBC-3.56* Hgb-10.9* Hct-31.9*
MCV-90 MCH-30.7 MCHC-34.3 RDW-12.6 Plt ___
___ 04:49PM BLOOD Neuts-43.5* Lymphs-47.6* Monos-5.6
Eos-2.7 Baso-0.6
___ 12:41PM BLOOD Glucose-94 UreaN-22* Creat-1.5* Na-143
K-4.3 Cl-110* HCO3-26 AnGap-11
___ 04:49PM BLOOD Glucose-88 UreaN-23* Creat-1.5* Na-141
K-5.7* Cl-105 HCO3-25 AnGap-17
___ 12:41PM BLOOD ALT-16 AST-21 AlkPhos-79 TotBili-0.2
___ 12:41PM BLOOD Albumin-3.6 Calcium-9.2 Phos-2.9 Mg-2.1
___ 06:30AM BLOOD Lactate-1.1
___ 05:07PM BLOOD Lactate-2.8*
___ 05:30AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 05:30AM URINE RBC-1 WBC-104* Bacteri-FEW Yeast-NONE
Epi-5
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ CT Head
There is no evidence of acute intracranial hemorrhage, edema,
mass effect, or large territorial infarction. The ventricles and
sulci are normal for age in size and configuration. There is
mild subcortical and periventricular white matter hypodensities,
which are most likely sequela of chronic small vessel ischemic
disease. The basal cisterns appear patent and there is
preservation of gray-white matter differentiation.
The visualized bony structures are grossly unremarkable. The
paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The globes are unremarkable.
___ MRI
No significant abnormalities are seen on MRI of the brain
without gadolinium. No significant abnormalities are seen on MRA
of the head and neck.
Brief Hospital Course:
Ms. ___ is a ___ yo woman with history of vertigo, DM, HTN,
HLD who presented with dizziness, nausea, and vomiting. On
admission exam, she could not sit up by herself and would fall
to the right. She had a mildly positive head impulse test when
her head was turned to the right but no nystagmus. She was
admitted for stroke workup. CT Head was negative for acute IPH
or mass; MRI/MRA head and neck were negative for stroke; ECG
demonstrated sinus rhythm with a right bundle-branch block.
Previous labs in ___ showed an LDL of 91 and HbA1c of 6.5%.
Her hospital stay was complicated by a leukocytosis with pyuria
in the setting of a UTI. She was treated with ceftriaxone and
discharged on Macrobid for a 7 day total course. She was
prescribed meclizine 25mg BID prn vertigo. She had persistently
elevated BPs. She was restarted on her home medications but
continued to have elevated SBPs>180. She was treated with IV
hydralazine and the dose of her home medications was increased.
Prior to discharge, her blood pressure was stable with SBP<160.
She was given prescriptions for increased doses of BP
medications. She was encouraged to arrange close follow up with
her PCP for further BP management. She was evaluated by ___ who
recommended outpatient vestibular physical therapy. She was
provided with a prescription for these services and discharged
home in a stable condition.
Medications on Admission:
Benicar 25mg PO QD
Torsemide 5mg PO QD
Metformin 500er QD
Simvastatin 20mg PO QD
ASA 81mg PO QD
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Simvastatin 20 mg PO DAILY
3. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 4
Days
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
twice a day Disp #*8 Capsule Refills:*0
5. Meclizine 25 mg PO Q8H:PRN vertigo
RX *meclizine 25 mg 1 tablet(s) by mouth twice a day Disp #*15
Tablet Refills:*0
6. Outpatient Physical Therapy
Vestibular Physical Therapy
To evaluate and treat
7. Benicar (olmesartan) 40 mg oral DAILY
RX *olmesartan [Benicar] 40 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*5
8. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*5
Discharge Disposition:
Home
Discharge Diagnosis:
Vertigo
Urinary Tract Infection
Diabetes
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were hospitalized due to symptoms of vertigo. When you
arrived, your blood pressure was elevated. CT/CTA of your head
and MRI of your brain did not show any evidence of stroke. Your
symptoms had mostly resolved prior to discharge. You were also
treated for a urinary tract infection while you were admitted.
Although we do not believe you had a stroke, we are very
concerned about your risk factors for future strokes including
hypertension and diabetes. We would like you to continue your
baby aspirin daily (aspirin 81mg) and simvastatin 20mg daily to
prevent future strokes. We have provided you a prescription for
Macrobid to treat your urinary tract infection. Please take all
the pills for the next five days. We have also given you a
prescription for Meclizine which may help treat your vertigo
symptoms. Your blood pressures have been elevated during your
admission even after starting your home doses of blood pressure
medications. We increased the doses of your medications. Please
continue to take the higher dose after discharge. Please
purchase a blood pressure cuff at your nearest pharmacy and
start measuring your blood pressure daily. Keep a log of your
blood pressures and bring them to every appointment. We also
recommend a heart healthy diet (low fat, low salt), daily
exercise, and stress reduction techniques. You were evaluated by
physical therapy who recommended vestibular physical therapy if
you need it in the future. They cleared you to go home with no
additional services. Please follow up with your primary care
physician in the next ___ weeks in order to manage your blood
pressures more closely. We would also like you to follow up in
our clinic in ___ months.
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:
___
|
10278306-DS-21 | 10,278,306 | 23,842,437 | DS | 21 | 2163-12-03 00:00:00 | 2163-12-03 11:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / lisinopril / glyburide
Attending: ___
Chief Complaint:
fevers, dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with the past medical
history of high grade of urothelial carcinoma s/p resection with
urostomy, HTN, HLD, DM2 who presents with dizziness and fevers,
concern for pyelonephritis. Patient reports yesterday she woke
up
and felt off and dizzy. She went to the ___ for her usual swim
but felt weak and as if she was going to pass out. She came home
and the symptoms persisted so she presented to ___ ED. She
denies back or abdominal pain, has chronic groin pain since her
surgery in ___ for bladder cancer but this is unchanged. The
___
nurse helped her change her ostomy bag the day PTA and did not
note any purulence or foul smelling urine. She denies diarrhea -
at baseline has 1 BM per week and this is unchanged. Her
appetite
has been poor for the past several months but she denies weight
loss. Denies rashes, cough, SOB, no sick contacts. Denies
myalgias or arthralgias.
In the ED, patient's vitals were as follows: T 102.7, HR 96, RR
20, BP 137/59, 98% on RA. CBC with leukocytosis to 19.6, CMP
with
Cr to 3 and BUN 46. UA grossly infected with lg ___, 13 WBCs, few
bacteria. Lactate 1--> 1.7. Flu PCR negative. CXR without acute
process. CT A/P with b/l perinephric stranding concerning for
pyelo and also noted to have foci of gas. Patient was given 1g
APAP, 1 L LR, vanc and zosyn, as well as some of her home BP
meds
(torsemide, losartan, amlodipine, Toprol XL). Patient was
admitted to medicine for further work up and management.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Osteoarthritis -- ___
DM Type II -- circa ___
Hypertension -- circa ___
Stage III CKD
CKD, stage III-IV, baseline creatinine of 1.7
Hypertension
Hyperlipidemia
PSH:
Hysterectomy
Bunionectomy x 2
Rotator cuff x 2
Social History:
___
Family History:
dad - HTN, colon cancer
brothers - colon cancer, HTN, DM, MI
sister - various cancers, DM, HTN
No family history of sudden death.
No family history of GU malignancy
Physical Exam:
VITALS: 98.6, 113/65, 70, 18, 100% 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. No ___ edema
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. Urostomy in RLQ, stoma with beefy red
mucosa, clear urine
GU: No suprapubic fullness or tenderness to palpation. R groin
is
examined, no tenderness/redness/swelling.
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs. R posterior thigh is
mildly tender to palpation, no swelling/redness, L thigh normal
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 07:00AM BLOOD WBC-9.6 RBC-2.64* Hgb-8.0* Hct-25.1*
MCV-95 MCH-30.3 MCHC-31.9* RDW-14.1 RDWSD-49.2* Plt ___
___ 07:00AM BLOOD Glucose-86 UreaN-35* Creat-2.0* Na-140
K-4.1 Cl-110* HCO3-19* AnGap-11
___ 9:51 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
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-- 16 I
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---- =>16 R
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ ___ ___
11:45AM.
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
___ 1:00 am URINE SUPRAPUBIC.
**FINAL REPORT ___
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------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
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---- =>16 R
Brief Hospital Course:
Patient admitted with sepsis from pyelonephritis and started on
cefepime. Her fevers quickly resolved. Found to have E coli in
urine and blood sensitive to cipro. Antibiotics then changed to
cipro upon discharge, dose is renally adjusted. She had
pre-renal ___ on admission which improved with hydration to
___ need repeat Cr with PCP. She did not have
any dizziness after IV hydration. Her R hip pain is evaluated
with xray and US, no DVT was found, xray showing OA. She is
instructed to take Tylenol prn for pain. She is stable for f/u
with pcp ___ 1 week.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing
3. Vitamin D ___ UNIT PO DAILY
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. amLODIPine 10 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Torsemide 20 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H
Take 1 tab every day until you finish them.
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth once a day
Disp #*7 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing
4. amLODIPine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Losartan Potassium 100 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Torsemide 20 mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
pyelonephritis
Bacteremia with E. coli
___ on CKD
R hip osteoarthritis
Discharge Condition:
Fair, A/Ox3 and ambulatory without assistance
Discharge Instructions:
You were admitted for kidney infection and we found bacteria in
your blood as well. Please take cipro 500mg daily to finish a
total of 10 day course. Your kidney function was initially worse
but improved to your baseline after IV fluids. We have evaluated
your right hip and found osteoarthritis, no blood clots. Please
take Tylenol as needed for hip pain. Follow up with your PCP in
___ week, and follow with your ostomy nurse as scheduled.
Followup Instructions:
___
|
10278322-DS-7 | 10,278,322 | 23,019,165 | DS | 7 | 2203-08-29 00:00:00 | 2203-09-02 13:29:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Allopurinol And Derivatives / Levaquin
Attending: ___.
Chief Complaint:
confusion/acute renal failure
Major Surgical or Invasive Procedure:
midline placement
History of Present Illness:
This is a ___ /o female with history of DMII, CKD and HTN who was
sent from her nursing home after being found to have elevated
BUN/ Creatinine. The patient is accompanied by her sons who
provide the history.
They report that she fell approximatley one week ago. Since then
she has been having difficulty ambulating. Usually she walks
with a walker, but she has been spending most of her day in bed.
Since her fall, she has been complaining of left hip and groin
pain. Her son reports they did an xray at the nursing home which
did not show a fracture.
Her sons also report over the past few days, she has been
weaker. She has been eating and drinking- but not well. They
bring in food for her and as her eyesight has worsened she has
been taking in less by mouth.
Her only additonal complaint is a stuffy nose. No cough. No
fevers or chills. No nausea or vomiting. No diarrhea.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
Diabetes Melltus
Hypertension
Chronic Kidney Disease Stage IV, baseline Cr 1.9 - 2.1
CAD s/p MI
Osteoporosis
Vitamin D insufficiency
Renal osteodystrophy
Hip Fracture
Social History:
___
Family History:
Neither her nor her sons know what her parents died of. She has
five children in good health.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:99.0 (Tmax 100.0 in ED) BP: 185/86 P:88 R: 20 O2:100%
RA
General: Elderly female laying in bed in NAD
HEENT: Resists eye opening for eye exam. MMM, Tongue midline.
Neck: supple
Lungs: clear B/L on Auscultation
CV: RRR S1, S2 present III/VI systolic murmur
Abdomen: Soft, NT, ND, NO CVAT
Ext: poor muscle tone. Initally resists leg straightening but
is able to straigten both legs. Hip exam limited by patient
reluctance and pain
Skin: No rashes
Neuro: Awake, alert, oriented to person, and place (hospital
but not BI).
DISCHARGE EXAM
Vitals: T:98.1 BP: 120s-180s/50s-60s P:50s-70s R: 16 O2:99% RA
Weight 35.5kg bed weight
I/O: incontinent.
Tele: NSR.
General: Elderly female sitting up in bed eating breakfast, NAD
Neck: supple, No JVD appreciated at 90 degrees.
Lungs: Mild bibasilar crackles.
CV: RRR S1, S2 present III/VI systolic murmur at ___
Abdomen: Soft, NT, ND, No CVAT
Ext: WWP. No edema.
Pertinent Results:
ADMISSION LABS:
___ 06:23PM BLOOD WBC-8.2 RBC-3.96* Hgb-10.3* Hct-34.5*
MCV-87 MCH-26.1* MCHC-30.0* RDW-14.2 Plt ___
___ 06:23PM BLOOD Neuts-79.9* Lymphs-12.6* Monos-4.7
Eos-2.6 Baso-0.3
___ 06:23PM BLOOD ___ PTT-25.6 ___
___ 06:23PM BLOOD Glucose-250* UreaN-76* Creat-3.5*# Na-141
K-5.3* Cl-102 HCO3-25 AnGap-19
___ 06:23PM BLOOD ALT-31 AST-36 AlkPhos-80 TotBili-0.2
___ 06:23PM BLOOD Albumin-3.9
CARDIAC LABS:
___ 06:30PM BLOOD CK(CPK)-211*
___ 06:30PM BLOOD CK-MB-12* MB Indx-5.7 cTropnT-1.28*
___
___ 10:50PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 10:50PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 10:50PM URINE RBC-3* WBC->182* Bacteri-MANY Yeast-NONE
Epi-<1
URINE CULTURE (Final ___:
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
This is a ___ y/o female with history of DMII, CKD and
hypertension who presents 1 week after a fall, found to have a
urinary tract infection and acute on chronic renal failure, with
course complicated by NSTEMI, medically managed.
ACTIVE ISSUES:
# Urinary Tract Infection: Patient was febrile in the ED with
positive urinalysis. While she was given vancomycin, cefepime
and azithromycin in the ED, there was no clear sign of pneumonia
on imaging or exam. She was transitioned to CTX for UTI, and UCx
ultimately grew e.coli sensitive to CTX. With this treatment,
mental status and renal function improved.
# Acute on Chronic Renal Insufficiency: Likely related to
urinary tract infection and subsequent poor PO intake, improved
with abx and gentle IVFs. Her lasix and lisinopril were
initially held, though restarted prior to discharge.
# NSTEMI: Pt developed chest pain on HD4 with subsequent
troponin leak. Cardiology was consulted, and she was started on
a heparin gtt. However, Hct dropped 10 points the following day,
and heparin gtt was held. TTE was performed and showed EF 60%
with no focal wall motion abnormalities. She was given 1 unit of
pRBCs. Given crackles on exam and significantly elevated BNP,
she was given IV lasix as well. She was ultimately transferred
to the cardiology service. While on the cardiology service,
heparin drip continued to be held. She remained chest pain free.
Her medications were optimized including starting of
atorvastatin and plavix. The family opted for medical management
and deferred catheterization. She was chest pain free at time of
discharge.
# anemia: Pt was admitted with baseline hct at 34. She remained
stable for many days, however in setting of starting heparin
drip for ACS, pt developed 9 point hct drop, confirmed on
repeat. Her heparin drip was discontinued and pt recieved 1 unit
PRBC with return of her hct to 30. No source of bleeding was
identified and pt was guaiac negative. Her hct remained stable
for the remainder of her hospital course.
# acute on chronic CHF exacerbation: On HD4, pt also developed
worsening shortness of breath with associated crackles on exam.
CXR with mild fluid overload. This was in the setting of her
lasix having been held for acute on chronic renal failure. She
was started back on her PO lasix regimen and also received extra
IV doses with blood tranfusions. Pt appeared euvolemic at time
of discharge.
# Hip pain: Pt with recent fall; however, hip films were
reported negative at nursing home. Repeat films here were also
negative for fracture. Pain was managed with standing tylenol.
CHRONIC ISSUES
# Hypertension, benign: BP elevated here. Given ___, held
lisinopril and lasix initially. Continued metoprolol and
felodipine. Lasix and lisinopril were ultimately restarted as
above.
#Diabetes II, controlled, with complications (CKD)
Will continue lantus but at lower dose given ___ and unclear PO
intake, sliding scale
#Hyperlipidemia: changed from simvastatin to atorvastatin.
#Gout: colchicine was held during hospitalization due to poor
renal function.
TRANSITIONAL ISSUES:
Pt remained full code during this admission, though family had
expressed a desire to avoid invasive procedures such as cardiac
catheterization. This should continue to be addressed as an
outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q8H:PRN moderate pain
2. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat) 40
mcg/mL injection Qmonthly
3. Aspirin 81 mg PO DAILY
4. Bengay Cream 1 Appl TP PRN pain
5. Bisacodyl 10 mg PR HS:PRN constipation
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Colchicine 0.6 mg PO EVERY OTHER DAY
8. Felodipine 10 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Furosemide 20 mg PO DAILY
11. Lisinopril 40 mg PO DAILY
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Nephrocaps 1 CAP PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Mirtazapine 7.5 mg PO HS
16. Senna 1 TAB PO DAILY:PRN constipation
17. Pentoxifylline 400 mg PO BID
18. Simvastatin 40 mg PO QPM
19. Vitamin D 800 UNIT PO DAILY
20. Glargine 4 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
21. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PR HS:PRN constipation
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Felodipine 10 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Mirtazapine 7.5 mg PO HS
10. Nephrocaps 1 CAP PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Senna 1 TAB PO DAILY:PRN constipation
13. Vitamin D 800 UNIT PO DAILY
14. Atorvastatin 80 mg PO DAILY
15. Clopidogrel 75 mg PO DAILY
16. Nitroglycerin SL 0.3 mg SL Q2H:PRN chest pain
17. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat) 40
mcg/mL injection Qmonthly
18. Bengay Cream 1 Appl TP PRN pain
19. Pentoxifylline 400 mg PO BID
20. Colchicine 0.6 mg PO EVERY OTHER DAY
21. Acetaminophen 1000 mg PO Q8H:PRN moderate pain
22. Glargine 4 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
23. Lisinopril 40 mg PO DAILY
24. CeftriaXONE 1 gm IV Q24H Duration: 1 Day
Discharge Disposition:
___ Care
Facility:
___
___ Diagnosis:
Primary:
___
UTI
NSTEMI
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted after your facility found that
your kidneys were damaged and you were more fatigued. You were
found to have a urinary tract infection, which was treated with
improvement in your energy and kidney function. However, while
at the hospital, you developed chest pain and we found that you
were having a heart attack. We started you on a blood thinner
briefly, but there was concern for bleeding so this was stopped.
You received 1 blood transfusion and your blood counts remained
stable for the rest of your hospitalization.
Because of the heart attack, we made a few changes to your
medications. Your facility will help make sure you get the
correct medications.
Followup Instructions:
___
|
10278344-DS-27 | 10,278,344 | 26,707,489 | DS | 27 | 2157-05-27 00:00:00 | 2157-05-27 23:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chills
Major Surgical or Invasive Procedure:
PTBD placement ___
History of Present Illness:
Mr. ___ is a ___ mam with history of A. fib on
Coumadin and CAD, s/p RY-GP, presenting with chills and status
post fall, found to have cholangitis. In the ED the patient
reported taking Ambien and feeling drowsy 2 days ago resulting
in a fall which he described as rolling off the bed landing onto
his left leg. He has been having persistent left leg pain since
then. He has been able to ambulate. He denied any head strike,
neck pain, headache, vision change, numbness, weakness.
Today, the patient developed chills and called EMS. Tachypneic
on EMS arrival, and the patient notes a cough, but dyspnea at
baseline. However, patient reports that his breathing is not too
far off of his baseline. Denies chest pain, abdominal pain,
dysuria, hematuria, recent illness.
Initial labs in the ED significant for a lactate of 6.9. H/H
12.2/36.9, platelets of 386. BMP with a HCO3 of 19 and an anion
gap of 20. ALT/AST 49/86, alk phos 351, t bili 8.4, d. bili 5.7.
Troponin negative x 1. UA with moderate bilirubin, negative
nitrites.
VBG 7.44/33. He received 1 L x 3, 4.5 g zosyn, 1g of vancomycin,
2 units of FFP and 10 mg vitamin K. ERCP was consulted and
recommended ___ percutaneous biliary drainage given his RY
anatomy. ___ recommended Kcentra for rapid reversal, with a plan
for drainage under general anesthesia.
On transfer, vitals were: 102.2 ___ 28 98% RA
On arrival to the MICU, he feels well. He complaints of left leg
pain, but no shortness of breath or abdominal pain. He is lying
comfortably in bed on room air, mentating well.
Past Medical History:
1. CAD s/p proximal LAD stent (___)
2. CVA x2 with left-sided weakness
3. AFib
4. Morbid obesity
5. Recurrent cellulitis
6. Chronic lymphedema
7. Hypertension
8. Hypercholesterolemia
9. Obstructive sleep apnea on CPAP
10. OA - knees
11. s/p gastric bypass ___
12. s/p Lap cholecystectomy
___. s/p appendectomy
Social History:
___
Family History:
No known h/o GIB or colon CA
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1 86 109/71 19 95% ra
GEN: obese man, lying in bed, NAD
HEENT: scleral icterus, mmm, nl OP
NECK: supple, large
CV: rrr, no m/r/g
PULM: nl wob on ra, LCAB, no wheezes or crackles
ABD: soft, NT/ND, +bs, obese
EXT: chronic venous stasis changes with 1+ edema to knees
NEURO: A&Ox3, moving all 4 extremities
SKIN: jaundice, no rashes
ACCEESS: R IJ, 2 PIVs
DISCHARGE PHYSICAL EXAM:
VS: 98.0 132/66 59 18 100%RA
Gen - sitting up in bed, comfortable
Eyes - EOMI, +icterus
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, normoactive bowel sounds
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, ___ in L upper extremity; ___ in L lower
extremity;
Psych - appropriate
Pertinent Results:
ADMISSION
___ 10:37AM BLOOD WBC-6.7 RBC-4.09* Hgb-12.2* Hct-36.9*
MCV-90 MCH-29.8 MCHC-33.1 RDW-14.5 RDWSD-47.9* Plt ___
___ 10:37AM BLOOD Neuts-93* Bands-6* Lymphs-1* Monos-0
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-6.63*
AbsLymp-0.07* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 10:48AM BLOOD ___ PTT-64.1* ___
___ 10:37AM BLOOD Glucose-70 UreaN-21* Creat-0.9 Na-140
K-3.7 Cl-101 HCO3-19* AnGap-24*
___ 10:37AM BLOOD ALT-49* AST-86* AlkPhos-351* TotBili-8.4*
DirBili-5.7* IndBili-2.7
DISCHARGE
___ 10:55AM BLOOD WBC-8.3 RBC-3.37* Hgb-10.3* Hct-30.7*
MCV-91 MCH-30.6 MCHC-33.6 RDW-14.6 RDWSD-47.7* Plt ___
___ 10:55AM BLOOD ___ PTT-69.5* ___
___ 10:55AM BLOOD Glucose-84 UreaN-14 Creat-0.8 Na-140
K-3.8 Cl-105 HCO3-24 AnGap-15
___ 10:55AM BLOOD ALT-34 AST-39 AlkPhos-143* TotBili-2.4*
___ 11:18 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI. SECOND MORPHOLOGY.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
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
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- =>16 R
___ 8:16 pm FLUID,OTHER BILIARY DRAIN.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Final ___:
ESCHERICHIA COLI. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI. SPARSE GROWTH. SECOND MORPHOLOGY.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ENTEROCOCCUS SP.. QUANTITATION NOT AVAILABLE.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| | ENTEROCOCCUS
SP.
| | |
AMPICILLIN------------ <=2 S =>32 R <=2 S
AMPICILLIN/SULBACTAM-- <=2 S 8 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S =>16 R
MEROPENEM-------------<=0.25 S <=0.25 S
PENICILLIN G---------- <=0.12 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S 2 S
TRIMETHOPRIM/SULFA---- <=1 S =>16 R
VANCOMYCIN------------ 1 S
RUQ U/S ___
Evidence of intra and extrahepatic biliary ductal dilatation.
Examination is somewhat limited given patient's body habitus.
This can be found following cholecystectomy, but correlation
with LFTs and MRCP if required can be performed.
CT Abd/Pelvis ___. Intrahepatic and extrahepatic biliary ductal dilatation,
better evaluated on ultrasound of the right upper quadrant.
This can be seen following cholecystectomy but correlate with
LFTs.
2. No evidence of left lower extremity hematoma. Degenerative
changes are seen in the lumbar spine and the bilateral hips and
knees.
3. Very limited examination as stated above. Asymmetry of the
left iliacus muscle which could reflect hematoma.
PTBD Placement ___. Successful percutaneous treatment of choledocholithiasis
with
sphincteroplasty, CBD stone fragmentation, and balloon sweep.
2. Successful placement of 12 ___ internal-external
percutaneous
transhepatic biliary drainage catheter.
Biliary Catheter Replacement ___
Severe stenosis of the ampulla with no passage of contrast into
the bowel. Small stones and debris in the CBD treated with
___ balloon sweep. The ampullary stenosis was balloon plasty
with a 10 mm balloon. There was good clearing of the stones and
debris, but persistent ampullary stenosis post intervention.
Therefore, a new 12 ___ internal external PTBD was left
across the stenosis to facilitate internal drainage.
RECOMMENDATION(S): The PTBD should remain in place. We will
bring the patient back in 4 weeks for repeat cholangiogram, and
possible tube removal.
Brief Hospital Course:
This is a ___ year old male with past medical history obesity,
OSA, afib, prior stroke, admitted with coagulopathy, sepsis,
cholangitis and bacteremia, now s/p PTBD with clinical
improvement
ACTIVE ISSUES:
===============================
# Severe Sepsis / Gram negative rod Bacteremia /
Choledocholithiasis with Obstruction and Acute cholangitis /
Abnormal LFTs - patient admitted with sepsis to the ICU with
abnormal LFTs, and imaging concerning for biliary obstruction.
Given his complex anatomy seocndary to gastric bypass, he was
not a candidate for ERCP, so he underwent urgent ___ PTBD
placement. A stone was extracted from the CBD with good
resultant biliary flow. He was initially treated with IV fluids
resuscitation and broad spectrum antibiotics. Subsequently his
blood grew Ecoli S to cipro. Bile also grew enterococcus. He
clinically improved on broad spectrum antibiotics to his
baseline, and then was narrowed per the cultures to PO cipro
(per Uptodate guidelines, ___ approach is to target positive
blood cultures if any in cholangitis, and not the flora from the
bile culture). He remained stable and was able to be discharged
home to complete total 2 week course (last day ___. Of note,
during admission, patient underwent cholangiogram of his PTBD,
which showed additional stones (that were extracted) but also
ampullary stenosis that did not completely resolve with balloon
plasty. PTBD extending across the ampulla was felt in place
with plan for ___ to follow-up with patient via telephone to
schedule repeat cholangiogram at 4 weeks.
# Atrial fibrillation / history of stroke / supertherapeutic INR
/ coumadin poisoning accidental - patient was admitted with an
INR>13 in the setting of sepsis without signs of DIC. It was
felt to be due to coumadin in setting of severe illness. He was
given Kcentra for urgent reversal before his ___ procedure above.
He was subsequently started on heparin drip given concern for
thrombosis in setting of being given kcentra. He remained
stable and without signs of bleeding or thrombosis. Prior to
discharge, case was discussed with ___ nurse, who
advised on coumadin dosing 5mg daily (INR 1.4 at discharge) and
that patient did not require outpatient bridging. ___ to
recheck INR on ___ or ___. Continued home home metoprolol
# OSA - continued home cpap at night
# Hypertension - continued home lisinopril and hctz
CAD - continued home statin, ASA
# GERD - continued home PPI
# B12 deficiency - continued B12
Transitional issues:
- Discharged home with services
- Last day of cipro ___
- INR to be rechecked ___ or ___ by ___ and sent to ___'s
office (discharged on 5mg coumadin, INR 1.4)
- ___ will arrange for 4 week follow-up cholangiogram
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 30 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Calcium Carbonate 500 mg PO QID:PRN gerd
4. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
5. Metoprolol Succinate XL 250 mg PO DAILY
6. Warfarin 7.5 mg PO 5X/WEEK (___)
7. Warfarin 3.75 mg PO 2X/WEEK (___)
8. Atorvastatin 20 mg PO QPM
9. TraMADOL (Ultram) 50-100 mg PO Q6H:PRN pain
10. Omeprazole 20 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Cyanocobalamin 500 mcg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Acetaminophen 1000 mg PO Q8H
Discharge Medications:
1. Equipment
Bariatric Rolling Walker
Diagnosis: Difficulty Ambulating
Prognosis Good
Duration: Lifetime
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Calcium Carbonate 500 mg PO QID:PRN gerd
5. Cyanocobalamin 500 mcg PO DAILY
6. Lisinopril 30 mg PO DAILY
7. Metoprolol Succinate XL 250 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
11. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days
last day ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*21 Tablet Refills:*0
12. Acetaminophen 1000 mg PO Q8H
13. Hydrochlorothiazide 12.5 mg PO DAILY
14. TraMADOL (Ultram) 50-100 mg PO Q6H:PRN pain
15. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Severe Sepsis / Gram negative rod Bacteremia /
Choledocholithiasis with Obstruction and Acute cholangitis /
Abnormal LFTs
# Ampullary Stenosis
# Atrial fibrillation / history of stroke
# OSA
# Hypertension
# CAD
# GERD
# B12 deficiency
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. ___:
It was a pleasure caring for you at ___. You were admitted
with a serious infection of your biliary tract and your blood
stream. Your INR (Coumadin level) was also very high. You were
treated with medications to make your blood less thin and strong
antibiotics. You were seen by radiologists who placed a drain
in your biliary tract to remove a blocking stone.
You improved and are now ready for discharge home.
It will be important to follow-up with the radiologists who will
check your drain in 4 weeks. They will call you to schedule
your appointment.
It will be important to follow-up with your primary care
physician.
You will need to complete a total of 2 weeks of antibiotics
(last day ___.
Followup Instructions:
___
|
10278515-DS-8 | 10,278,515 | 21,296,568 | DS | 8 | 2118-05-09 00:00:00 | 2118-05-09 18:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Erythema/pain in L arm
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with a known history of left
sided lymphedema following a lipoma resection in left axillary
region who presents with a day history of erythema of his left
arm and pain.
Patient was in his usual state until ___ when he notice onset
of erythema of his left arm. He had associated pain and was
ultimately concerned for an underlying blood clot prompting
presentation. He notably has not noticed fevers or chills while
at home. No recent skin breakdown, travel, bug bites. He denies
history of travel to filariasis endemic regions, recurrent
superficial infections of the involved limb, trauma to the limb,
prolonged intravenous catheters.
In ___, he underwent L axillary lipoma removal ___,
___, Dr. ___. Shortly thereafter, following a plane
trip, he developed LUE edema. He also noted swelling in the
axiallary region. He subsequently underwent multiple lymphocele
drainages (10 per patient) at ___. Of note, patient was
recently
evaluated by the ___ clinic, previously wearing
compression dressing at night but symptoms have interfered with
ability to work thus surgical management was being pursued.
Past Medical History:
- LUE lymphedema
- s/p removal of L axillary mass ___
- Recurrent lower extremity cellulitis
- L elbow bursitis
Social History:
___
Family History:
No family history of lymphedema, limb swelling, or VTE. His
father required PCI at age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
___ ___ Temp: 97.5 PO BP: 120/76 R Sitting HR: 79 RR: 18
O2
sat: 95% O2 delivery: Ra
VITAL SIGNS: Reviewed in POE
CONSTITUTIONAL: Obese man, muscular, No acute distress
ENT: No oral lesions, no thyromegaly
CARDIOVASCULAR: RRR, normal S1 and S2, no murmurs, rubs,
gallops.
JVP .
VASCULAR: 2+ radial pulses b/l, 2+ DP pulses b/l, no prominent
superficial veins of the chest wall. Negative Adson's maneuver.
+1-2mm pitting edema on LUE and significant non-pitting
component with erythema tracking up forearm to axilla in
lymphatic pattern. 2-3mm edema in ___, L>R, to mid-shins.
RESPIRATORY: Lungs clear to auscultation without wheezes or
rales
GASTROINTESTINAL: soft, nontender, normal active bowel sounds
MUSCULOSKELETAL: no focal joint swelling
SKIN: no lower extremity rashes, wounds/ulcerations.
+onychomycosis
NEUROLOGIC: Alert and oriented X3
DISCHARGE PHYSICAL EXAM:
========================
PHYSICAL EXAM:
Vitals: ___ 0021 Temp: 97.8 PO BP: 115/74 R Lying HR: 60
RR:
18 O2 sat: 94% O2 delivery: Ra
CONSTITUTIONAL: Obese man, muscular, No acute distress
ENT: No oral lesions, no thyromegaly
CARDIOVASCULAR: RRR, normal S1 and S2, no murmurs, rubs,
gallops.
JVP.
EXT: 2+ radial pulses b/l, 2+ DP pulses b/l. +1-2mm pitting
edema on LUE with mild erythema tracking up medial forearm and
area of induration over left-inner bicep. Improved from prior,
no areas of fluctuance. Also 2-3mm edema in ___, L>R, to
mid-shins.
RESPIRATORY: Lungs clear to auscultation without wheezes or
rales
GASTROINTESTINAL: soft, nontender, normal active bowel sounds
MUSCULOSKELETAL: no focal joint swelling
SKIN: no lower extremity rashes, wounds/ulcerations.
+onychomycosis
NEUROLOGIC: Alert and oriented X3
Pertinent Results:
ADMISSION LABS:
===============
___ 08:19AM BLOOD WBC-14.2* RBC-4.74 Hgb-14.8 Hct-44.0
MCV-93 MCH-31.2 MCHC-33.6 RDW-12.3 RDWSD-41.7 Plt ___
___ 08:19AM BLOOD Neuts-65.4 ___ Monos-6.9 Eos-1.8
Baso-0.4 Im ___ AbsNeut-9.27* AbsLymp-3.53 AbsMono-0.98*
AbsEos-0.25 AbsBaso-0.05
___ 08:19AM BLOOD Glucose-138* UreaN-22* Creat-0.8 Na-143
K-4.3 Cl-106 HCO3-20* AnGap-17
___ 10:55AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.1
___ 10:40AM BLOOD Lactate-1.3
DISCHARGE LABS:
===============
___ 06:47AM BLOOD WBC-10.1* RBC-4.59* Hgb-14.2 Hct-42.9
MCV-94 MCH-30.9 MCHC-33.1 RDW-12.1 RDWSD-41.5 Plt ___
___ 06:47AM BLOOD UreaN-11 Creat-0.9
___ 05:55AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.1
IMAGING STUDIES:
================
LEFT UPPER EXTREMITY U/S (___):
1. No evidence of deep vein thrombosis in the left upper
extremity.
2. Moderate subcutaneous edema throughout the left upper
extremity.
MICROBIOLOGY:
=============
____________________________________________
___ 8:40 am BLOOD CULTURE SET#2.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 8:10 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
Brief Hospital Course:
SUMMARY:
========
Mr. ___ is a ___ year old male with a known history of left
sided lymphedema following a lipoma resection in left axillary
region who presents with a 1 day history of erythema of his left
arm and pain concerning for cellulitis/lymphangitis.
ACUTE ISSUES ADDRESSED:
=======================
# Left Upper extremity cellulitis with concern for lympangitis:
History of left elbow bursitis in ___, but no history of
left upper arm cellulitis. Admitted with 1 day of erythema and
pain tracking up the left upper arm, consistent with cellulitis
and lymphangitic spread. No recent injury, trauma, or open
wounds. Treated initially with IV Ampicillin-Sulbactam in ED,
but area of erythema progressed. MRSA coverage was added
(vancomcyin) and patient was admitted for further monitoring.
Pain and erythema significantly improved with 24 hours of
vancomycin/unasyn. Transitioned to PO doxycycline/augmentin with
plan for 14 day total course (___), with PCP and plastic
surgery follow up in 1 week.
CHRONIC ISSUES:
===============
# Left Upper extremity lymphedema:
In brief, the patient developed lymphedema of left upper
extremity after left axillary lipoma removal in ___.
Following the procedure, the patient developed multiple
recurrent fluid collections which were drained (x 10) and
consistent with seroma/lymph fluid. Patient is followed in the
___ and manages his lymphedema with conservative
therapies (MLD, compression, sleeve, and a gauntlet). Repeat
imaging studies completed ___ confirmed lymphedema, and he
is currently undergoing workup for further surgical treatments
with Dr. ___ plastic surgery. Given LUE cellulitis and
lymphangitis as above, he has not been able to wear compression
dressing while hospitalized ___ pain. Pending resolution of
cellulitis, will resume compression
dressing as soon as tolerated. Will also schedule follow up with
Dr. ___.
# HTN: Continue home Amlodipine.
TRANSITIONAL ISSUES:
====================
[] Augmentin/doxycycline x 14 day course
[] Follow up with plastic surgery in 1 week, as well as PCP
[] Pending resolution of cellulitis, will resume compression
dressing as soon as tolerated
[] F/u pending blood cultures at discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*25 Tablet Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*25 Tablet Refills:*0
3. amLODIPine 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
#L arm cellulitis with lyhangitic spread
#L arm lymphadema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
- You were admitted because you had infection of your left arm.
What happened while I was in the hospital?
- You were treated with IV antibiotics during admission, then
transitioned to oral antibiotics prior to discharge.
What should I do after leaving the hospital?
- Continue antibiotics (augmentin and doxycycline) as prescribed
- Follow up with your plastic surgery team and primary care
provider ___ 2 weeks of discharge to determine if you need a
longer antibiotic course
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10278998-DS-3 | 10,278,998 | 21,701,779 | DS | 3 | 2170-06-10 00:00:00 | 2170-06-10 15:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
1. MVC
2. Left lower leg pain and deformity
Major Surgical or Invasive Procedure:
___:
Irrigation and debridement with open reduction internal fixation
and Vac sponge dressing application, left tibia.
.
___:
Irrigation and debridement with vac change, left tibia.
.
___:
1. Irrigation and debridement of skin, subcutaneous tissue,
and muscle (30 sq cm).
2. Application of a negative pressure dressing.
.
___:
1. Irrigation and debridement of skin, subcutaneous tissue
and muscle (14 x 14 cm).
2. Muscle flap reconstruction.
3. Split-thickness skin graft ( 14 by 14 cm).
History of Present Illness:
___ year old male s/p MVC on ___ resulting in a left open
tibia fracture requirng surgical management.
Past Medical History:
None
Social History:
___
Family History:
n/a
Physical Exam:
AWake/alert, moderate distress from pain
No tenderness/swelling in BUEs, RLE.
LLE: Gross deformity of left leg. LArge ~20x15 cm open wound
with exposed muscle/tendon/bone over mid-distal shin
anterior-medially. 2+ DP pulse, unclear presence of ___ pulse.
BCR distally. SILT in DP/SP/T/MPN/LPN distributions.
Pertinent Results:
___ 05:09AM BLOOD WBC-9.5 RBC-4.47* Hgb-12.8* Hct-36.6*
MCV-82 MCH-28.7 MCHC-35.1* RDW-12.9 Plt ___
___ 05:30AM BLOOD Neuts-79.5* Lymphs-12.1* Monos-5.8
Eos-1.9 Baso-0.7
___ 05:09AM BLOOD Plt ___
___ 05:25AM BLOOD ___ PTT-33.2 ___
___ 05:30AM BLOOD Glucose-109* UreaN-13 Creat-1.0 Na-137
K-4.9 Cl-100 HCO3-24 AnGap-18
___ 05:30AM BLOOD Calcium-9.4 Phos-5.0* Mg-2.4
Brief Hospital Course:
Mr. ___ was admitted to the Orthopedic service on ___
for an open left tibia fracture resulting from a MVC on
___. On the day of admission he was given Ancef and
Gentamycin per open fracture protocol then underwent irrigation
and debridement with open reduction internal fixation with VAC
sponge application of the left tibia without complication. He
was extubated without difficulty and transferred to the recovery
room in stable condition. In the recovery room he was given
Magnesium 2 grams IV once for post operative hypomagnesemia and
subsequently transferred to the floor in stable condition. Post
operatively he was placed on Lovenox for DVT/VTE prophylaxis.
On ___ a CTA showed normal lower extremity vasculature. On
___ he returned to the operating room and underwent repeat
irrigation and debridement with VAC change to left tibia without
complication. On ___ the Plastic Surgery service was
consulted for evaluation of open wound coverage. Soleus flap
and STSG coverage to wound was performed for definitive closure
on ___. Please see operative report for details. Vac was
removed ___ with 100 percent STSG take. Dressing with
xeroform/abd/ace wrap were performed daily. Cam boot placed for
weight bearing to LLE as tolerated. ___ evaltuate and treated
during hospital course. ID consulted for wound
cellulitis/erythema ___, reccomendation for IV abx vancomycin
and unasyn. PICC line was placed and case management/social
services were able to secure care from ___ and a ___
infusion company for 6 weeks of abx, 14 days enoxaparin, and
appropirate lab draws per ID reccomendations. Patient was
discharged to home on HD15 with ___ and home infusion services.
Appropriate follow up was provided for orthopaedic, plastic
surgery and Infectious disease. Home infusion will draw weekly
labs per ID reccomendations. ___ for daily dressing changes and
treatement/evaluation as needed. Patient was afebrile,
ambulating with crutches, stable vital signs, tolerating a
regular diet with appropriate po pain control and PICC in place
for outpatient abx therapy at time of discharge.
Medications on Admission:
none
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous HS
(at bedtime) for 14 days.
Disp:*14 syringes* Refills:*0*
3. diazepam 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain/muscle spasm.
Disp:*30 Tablet(s)* Refills:*0*
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
7. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. ampicillin-sulbactam 3 gram Recon Soln Sig: One (1) Recon
Soln Injection Q6H (every 6 hours) for 6 weeks.
Disp:*168 Recon Soln(s)* Refills:*0*
9. vancomycin 500 mg Recon Soln Sig: 1250mg Recon Solns
Intravenous Q 12H (Every 12 Hours) for 6 weeks.
Disp:*84 Recon Soln(s)* Refills:*0*
10. Outpatient Lab Work
Please perform labs weekly and fax to ___
RE: ___ ___
___ with differential, BUN, Creatinine, CRP, ESR, LFTs
11. Saline Flush 0.9 % Syringe Sig: ___ Injection four
times a day: For PICC flushes per biopscript protocol.
Disp:*200 syringe* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Left open tibia fracture.
2. Left fibula fracture.
3. Post operative hypomagnesemia.
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:
Wound Care:
-Keep your left lower extremity wound/skin graft site dry.
-You should change your skin graft dressing daily: Apply
xeroform dressing, cover with gauze or abdominal pads and wrap
with ace wrap.
-Do not soak the incision in a bath or pool.
.
Activity:
-You may weight bear on your left lower extremity as tolerated
with CAM boot in place.
.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. We are not allowed to call in
narcotic (oxycontin, oxycodone, percocet) prescriptions to the
pharmacy. In addition, we are only allowed to write for pain
medications for 90 days from the date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
___ services and Infusion services have been provided. You will
recieve iv antibiotics. Please follow up with Infectious
Disease as instructed below.
Followup Instructions:
___
|
10278998-DS-4 | 10,278,998 | 21,529,194 | DS | 4 | 2171-02-17 00:00:00 | 2171-02-18 12:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fevers/chills and LLE pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p MVC and IM tib nail in ___ c/b infection. 3
washouts/I&D of the leg with a medullary nail in place on outpt
IV vanc then suppressive bactrim until ___. had removal of
2 screws from distal tibia due to hardwear pain on ___. was
doing well/mobile and then last night had f/c. This AM, stood
up
on leg and felt intense pain which he had been pain free for
months. Pt has pictures of the leg from 3d ago which do not
show
any cellulitis.
Past Medical History:
None
Social History:
___
Family History:
n/a
Physical Exam:
On admission
PE: surgical flap is cellulitic, red, warm, tender, some
swelling. Able to ambulate, but with pain. +DP. knee/ankle
mobile and unchanged from his baseline.
On discharge:
Gen: In no acute distress, alert and oriented.
LLE: Cellulitis much improved over past marked area, no areas of
drainage. Slight edema/swelling around the distal aspect of the
flap. minimally tender to palpation. ___ FHL AT ___ fire, SILT
DP SP S S, warm and well perfused
Pertinent Results:
On Admission:
___ 02:05PM BLOOD WBC-12.8*# RBC-5.25 Hgb-15.6 Hct-43.4
MCV-83 MCH-29.7 MCHC-35.9* RDW-12.0 Plt ___
___ 02:05PM BLOOD Neuts-79.5* Lymphs-11.7* Monos-7.7
Eos-0.9 Baso-0.3
___ 02:05PM BLOOD Plt ___
___ 02:05PM BLOOD Glucose-161* UreaN-13 Creat-1.1 Na-136
K-3.7 Cl-99 HCO3-23 AnGap-18
___ 05:09AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0
___ 02:05PM BLOOD CRP-89.2*
___ 02:16PM BLOOD Lactate-2.7*
On Discharge:
___ 05:09AM BLOOD WBC-12.6* RBC-4.93 Hgb-14.8 Hct-41.2
MCV-84 MCH-30.1 MCHC-36.0* RDW-11.8 Plt ___
___ 05:09AM BLOOD Neuts-72.5* Lymphs-17.9* Monos-7.9
Eos-1.1 Baso-0.6
___ 05:09AM BLOOD Plt ___
___ 05:09AM BLOOD Glucose-108* UreaN-10 Creat-0.9 Na-138
K-3.8 Cl-103 HCO3-26 AnGap-13
___ 05:09AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0
___ 06:38PM BLOOD Vanco-12.2
CT LLE:
IMPRESSION:
1. Partially healed, but non-united, distal tibial fracture as
described
above.
2. Near completely healed distal fibular fracture, as described
above.
3. Heterotopic ossification within the interosseous membrane,
from the prior trauma near the fracture site.
4. Intact hardware, however, minimal ___ lucency
about the tibial nail at the level of the fracture site
measuring approximately 2.5 mm.
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service on
___ with suspected infection of the previous plastics
flap. Patient was started on Vancomycin in the ED, and admitted
for the intent of plastics evaluation and possible irrigation
and debridement of the hardware and flap. However on hospital
day 2, the cellulitis was much improved with vancomycin. A CT
LLE was obtained that showed persistent nonunion, possibly
infected. The decision was made to continue antibiotics and
infectious disease consulted for further management, and was
recommended to continue on 3 weeks of Vancomycin at 1g Q8hrs
through a PICC line. He will also need weekly laboratory
monitoring for CBC chemistry and CRP ESR.
At the time of discharge on ___, HD 3, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating with crutches, voiding without
assistance, and pain was well controlled. The LLE had no signs
of active cellulitis, and only moderate edema. He will follow up
in 2 weeks with Dr. ___. He will also follow up with
infectious disease. All questions were answered prior to
discharge and the patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyclobenzaprine 10 mg PO TID:PRN spasm
2. Diazepam 5 mg PO Q8H:PRN anxiety
3. Gabapentin 600 mg PO TID
4. Gabapentin 600 mg PO TID:PRN pain
5. Lidocaine 5% Ointment 1 Appl TP BID
6. Nortriptyline 25 mg PO HS
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Discharge Medications:
1. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth every 8 hours Disp
#*70 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H
3. Docusate Sodium 100 mg PO BID
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Up to
every 4 horus Disp #*90 Tablet Refills:*0
5. Senna 1 TAB PO BID
6. Vancomycin 1000 mg IV Q 8H
RX *vancomycin 1 gram infuse 1 gram every 8 hours Disp #*64 Vial
Refills:*0
7. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
RX *heparin lock flush (porcine) [Heparin Lock] 10 unit/mL flush
2 ml For flushing ___ Disp #*2 Bottle Refills:*2
8. Outpatient Lab Work
Infected nonunion of left Tibia, ICD-___.___
Weekly lab draw every ___ trough level, BUN,
Creatinine, ESR, CRP
Results: Infectious disease at ___
___, Dr. ___ ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left tibial nonunion, possibly infected.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
******SIGNS OF INFECTION********
- Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at leg; chest pain, shortness of breath or
any other concerns.
********Wound Care********
- You can get the leg wet/take a shower starting from 3 days
post-op. No baths or swimming for at least 4 weeks.
******WEIGHT-BEARING*******
You are weight bearing as tolerated in the left leg.
******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 ___.
- You should take your vancomycin through the ___ line 1g every
8 hours
Physical Therapy:
Activity: Activity: Activity as tolerated
Treatments Frequency:
None
Followup Instructions:
___
|
10279130-DS-17 | 10,279,130 | 28,298,742 | DS | 17 | 2147-04-11 00:00:00 | 2147-04-11 17:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
___: Diagnostic Angiogram- negative
___: Diagnostic Angiogram- negative
History of Present Illness:
___ is a ___ male with sudden onset ___ HA aroun 1600
on ___. He was evaluated at OS___ where Head CT showed SAH in
basal cisterns and ___ ventricle. He was transferred to ___
for further evaluation. On arrival he complained of continued
HA
and neck pain/stiffness. He denies N/V, dizziness, visual
changes.
Past Medical History:
None
Social History:
___
Family History:
Denies family history of aneurysm.
Physical Exam:
============
ON ADMISSION
============
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
15 Total
O:
T: 100.2 BP: 134/74 HR:96 R:16 O2Sats:93% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___, equal, reactive EOMs: intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
============
ON DISCHARGE
============
Alert and oriented x3
PERRL
EOMI
Face symmetric
No drift
___ strength
Groin- c/d/I, no hematoma
palpable pedal pulses bilaterally
Pertinent Results:
=======
IMAGING
=======
___ ___ (OSH)
Head CT from OSH: SAH within the basal cisterns and ___
ventricle without hydrocephalus.
___ CTA HEAD AND CTA NECK
IMPRESSION:
1. Diffuse subarachnoid hemorrhage in the basal cisterns, right
greater than left.
2. Unremarkable head and neck CTA without evidence of an
aneurysm.
___
IMPRESSION:
Diagnostic cerebral angiogram within normal limits.
RECOMMENDATION(S):
1. Management of subarachnoid hemorrhage as per usual protocol,
follow-up
angiogram in 1 week.
___ - cerebral angiogram
IMPRESSION:
Follow-up diagnostic cerebral angiogram within the normal
limits.
Brief Hospital Course:
#Subarachnoid Hemorrhage
Mr. ___ was transferred from an OSH with subarachnoid
hemorrhage; he was admitted to the Neuro ICU for close
neurologic monitoring. Diagnostic angiogram was performed on
___, which was negative for aneurysm. He was started on
Nimodpine for vasospasm prophylaxis and he was maintained on IVF
and given fluid boluses to maintain euvolemia. During his ICU
stay, his urine toxicology was positive for cocaine. On ___, he
remained neurologically intact on examination and was
transferred from the neuro ICU to the ___ for close monitoring.
He was closely monitored for vasospasm and underwent TCDs which
were negative for vasospasm. He underwent repeat cerebral
angiogram on ___ which was again negative for aneurysm. His
groin was angiosealed. Post procedure he remained neurologically
intact. Given repeat negative angiogram Nimodipine was stopped.
On ___ Patient was discharged home in good condition with
instructions for follow up. His pain was well controlled, he was
ambulating independently and voiding without issue.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid Hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Subarachnoid Hemorrhage
Surgery/ Procedures:
You had 2 cerebral angiograms which were negative for aneurysm
or other vascular abnormality.
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. ___ try to do too much all at once.
You make take a shower.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you must refrain
from driving.
Medications
Resume your normal medications and begin new medications as
directed.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
Mild to moderate headaches that last several days to a few
weeks.
Difficulty with short term memory.
Fatigue is very normal
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site or puncture site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10279161-DS-14 | 10,279,161 | 26,164,142 | DS | 14 | 2185-04-05 00:00:00 | 2185-04-12 18:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left upper quadrant abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic converted to open cholecystectomy
History of Present Illness:
___ man with past mental history of nephrolithiasis
presenting with burning sensation in his left upper quadrant of
his abdomen radiating to his left flank for the past 4 hours. He
states he has been having severe pain associated with nausea and
nonbloody vomiting vomiting. He has had no fevers, chills, or
diarrhea. He was seen yesterday in the emergency department
where
labs were drawn which showed transaminitis and hyperglycemia but
no other acute abnormalities with a normal troponin.
Additionally, he had a chest x-ray which showed no signs of
pneumonia. He had improvement of his pain and was written for
omeprazole in the setting of likely gastroesophageal reflux
disease. He has not had time to fill the prescription has had
persistent pain and return today. He states this pain feels
similar to prior nephrolithiasis. He has no chest pain,
shortness
of breath, back pain, urinary symptoms, rashes or paresthesias.
He states that when he takes a deep breath sometimes he has
worsening pain in his left abdomen. He has otherwise been in his
normal state of health and does not smoke or drink significant
amounts of alcohol.
Past Medical History:
Nephrolithiasis
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission Physical Exam:
Gen: NAD, AAOx3
CV: RRR, no m/r/g
Resp: CTAB
Abdomen: soft, nondistended, tender to palpation in upper
quadrants bilaterally
Ext: wwp
Discharge Physical Exam:
Vitals: 24 HR Data (last updated ___ @ 2251)
Temp: 98.4 (Tm 99.2), BP: 125/82 (122-144/79-90), HR: 74
(65-79), RR: 17 (___), O2 sat: 93% (92-95), O2 delivery: Ra
Fluid Balance (last updated ___ @ 2044)
Last 8 hours Total cumulative -200ml
IN: Total 0ml
OUT: Total 200ml, Urine Amt 200ml
Last 24 hours Total cumulative -742ml
IN: Total 878ml, PO Amt 480ml, IV Amt Infused 398ml
OUT: Total 1620ml, Urine Amt 1600ml, JP 20ml
Physical exam:
Gen: NAD, AxOx3
Card: RRR, no m/r/g
Pulm: CTAB, no respiratory distress
Abd: Soft, non-tender, non-distended
Wounds: c/d/i
Ext: No edema, warm well-perfused
Pertinent Results:
Admission Labs:
___ 08:43PM BLOOD WBC-10.6* RBC-4.96 Hgb-15.6 Hct-47.1
MCV-95 MCH-31.5 MCHC-33.1 RDW-13.5 RDWSD-47.1* Plt ___
___ 08:43PM BLOOD Glucose-217* UreaN-14 Creat-1.0 Na-140
K-3.9 Cl-103 HCO3-23 AnGap-14
___ 08:43PM BLOOD ALT-61* AST-46* AlkPhos-63 TotBili-0.6
___ 10:32AM BLOOD Albumin-4.7 Calcium-9.6 Phos-2.0* Mg-2.1
Discharge Labs:
___ 04:09AM BLOOD WBC-7.0 RBC-3.91* Hgb-12.1* Hct-37.9*
MCV-97 MCH-30.9 MCHC-31.9* RDW-14.0 RDWSD-49.7* Plt ___
___ 04:09AM BLOOD Glucose-94 UreaN-12 Creat-0.9 Na-139
K-4.0 Cl-104 HCO3-25 AnGap-10
___ 04:09AM BLOOD ALT-33 AST-31 AlkPhos-61 TotBili-0.4
___ 04:09AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.4
Imaging:
=======================================================
___ CT ABD & PELVIS WITH CONTRAST
IMPRESSION:
1. Mildly distended gallbladder with surrounding soft tissue
stranding,
findings concerning for acute cholecystitis. Correlation with
right upper
quadrant ultrasound is suggested.
2. No evidence of nephrolithiasis or hydronephrosis.
3. Diverticulosis of the descending and sigmoid large bowel
without evidence
of diverticulitis.
4. Hepatic steatosis.
IMPRESSION:
1. Minimally distended gallbladder with several stones and
layering sludge.
There is a small amount of pericholecystic fluid without
significant wall
edema. In the correct clinical setting, these findings could
represent acute
cholecystitis, but further assessment can be obtained with a
HIDA scan.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease and
more advanced liver disease including steatohepatitis or
significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
___ LIVER OR GALLBLADDER US
RECOMMENDATION(S):
1. If considering further evaluation for acute cholecystitis,
would recommend
HIDA scan.
2. Radiological evidence of fatty liver does not exclude
cirrhosis or
significant liver fibrosis which could be further evaluated by
___.
This can be requested via the ___ (FibroScan) or the
Radiology
Department with either MR ___ or US ___, in
conjunction with
a GI/Hepatology consultation" *
Pathology:
=
================================================================
PATHOLOGIC DIAGNOSIS:
Gallbladder, cholecystectomy:
- Acute and chronic cholecystitis with cholelithiasis.
Brief Hospital Course:
___ man with past mental history of nephrolithiasis
presenting with burning sensation in his left upper quadrant of
his abdomen radiating to his left flank for the past 4 hours. A
right upper quadrant US and CT abd/pelvis w/ contrast
demonstrated findings consistent with acute cholecystitis. He
was taken to the operating room on ___ and had a laparoscopic
converted to open cholecystectomy.
There were no adverse events in the operating room; please see
the operative note for details. Pt was extubated, taken to the
PACU until stable, then transferred to the ward for observation.
He received 4 days of IV unasyn post op. He received oxycodone,
toradol, and tylenol for post-op pain. He was discharged with a
weeks worth of oxycodone.
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 ___
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth four times a day Disp
#*20 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by
mouth once a day Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed in a laparoscopic converted to open surgery. You
tolerated the procedure well and are now being discharged home
to continue your recovery with the following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o 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:
___
|
10279514-DS-12 | 10,279,514 | 29,624,303 | DS | 12 | 2128-04-02 00:00:00 | 2128-04-02 17:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
tamulosin
Attending: ___.
Chief Complaint:
FTT, concern about safety at home
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Time patient seen and examined today: 1800
CC: FTT, concern about safety at home
HPI: Mr. ___ is a ___ year-old chronically home-bound man
receiving home NP visits with a history of lumbosacral
arachnoiditis, depression, cervical spondylosis, BPH and
multi-factorial gait disorder c/f parkinsonism who was brought
in
by ambulance after Elder Services found him in a soiled bed
without sheets covered in sores.
The patient was last seen in the ED after a fall and UTI in ___
when he was found to have a right decubitus ulcer; he was
discharged to ___. Since then he has been living at
home but requires assistance by EMS and a family member for
lifts
and is in a fairly bad state of affairs. At baseline he claims
he
is able to shower, cook meals and get to the bathroom on his
own,
however he does not walk around much because he "gets tired." He
says his cousin ___ prepares his meds which he takes every
day, faithfully. His cousin was not available for collateral at
the time of this interview.
On the day of admission the patient was found today by elder
services in a hospital bed without sheets, incontinent of urine,
with some bedsores on his back and unable to care for himself.
There is no known trauma. The patient does not understand why he
is hospitalized or how he got here. He denies any pain except
for
on his left anterolateral abdominal wall and groin where
there is a rash. He denies shortness of breath and cough,
abdominal pain, diarrhea, dizziness, falls, leg swelling but
dose
note persistent LUTS related to diagnosis of BPH. Also claims
that he had a fever one day ago but doesn't remember who
measured
his temperature.
ED Course:
Exam notable for T100.7, HR 80, BP 139/71, satting 97% on RA.
Appears disheveled and oriented to person but not situation. Has
a scaly rash under abdominal pannus. WBC 10.8 and UA c/w UTI.
Given ceftriaxone and admitted to medicine.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Parkinsonism
- Cervical spondlyosis
- History of arachnoiditis from L2-S1 (seen on ___ MRI, managed
with analegesics and gabapentin)
- BPH
- urinary incontinence
- GERD
- iron deficiency anemia
- suicide attempt - klonopin overdose ___
- right sensorineuroal hearing loss
- essential tremor
- hoarding behavior
- anxiety
- depression
Social History:
___
Family History:
His mother died of a stroke but also had colon
cancer, melanoma, HLD, and HTN. Her father died at ___ and had
DM2. Other family members with HLD and DM2. No family members
with movement disorders.
Physical Exam:
Gen: Lying in bed in no apparent distress
___ 1534 Temp: 98.1 PO BP: 93/53 HR: 106 RR: 18 O2
sat: 91%
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
NEURO: Alert, oriented to person/year/president but not place,
month or situation, face symmetric, gaze conjugate with EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout. + bilateral cogwheel rigidity and tremor
worse
with intention
PSYCH: pleasant, appropriate affect
SKIN: There is a very well circumscribed, scaly rash on his left
lower abdomen, groin left buttock and thigh.
Pertinent Results:
Admission Labs
___ 12:30PM BLOOD WBC-10.8* RBC-4.82 Hgb-14.9 Hct-43.9
MCV-91 MCH-30.9 MCHC-33.9 RDW-12.7 RDWSD-42.2 Plt ___
___ 12:30PM BLOOD Neuts-73.7* Lymphs-13.5* Monos-7.4
Eos-4.1 Baso-0.3 Im ___ AbsNeut-8.00* AbsLymp-1.46
AbsMono-0.80 AbsEos-0.44 AbsBaso-0.03
___ 12:30PM BLOOD Glucose-113* UreaN-25* Creat-0.9 Na-139
K-4.6 Cl-102 HCO3-21* AnGap-16
___ 06:44AM BLOOD CK(CPK)-665*
___ 06:44AM BLOOD Albumin-3.4* Calcium-9.0 Phos-2.9
___ 06:44AM BLOOD TSH-2.5
___ 12:30PM BLOOD Lactate-1.2
___ 12:30PM URINE Blood-NEG Nitrite-POS* Protein-30*
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 12:30PM URINE RBC-7* WBC-96* Bacteri-FEW* Yeast-NONE
Epi-0
URINE CULTURE (Final ___:
STAPH AUREUS COAG +. >100,000 CFU/mL.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Discharge Labs
___ 07:27AM BLOOD WBC-6.9 RBC-3.55* Hgb-10.8* Hct-33.3*
MCV-94 MCH-30.4 MCHC-32.4 RDW-12.9 RDWSD-44.7 Plt ___
___ 12:30PM BLOOD Neuts-73.7* Lymphs-13.5* Monos-7.4
Eos-4.1 Baso-0.3 Im ___ AbsNeut-8.00* AbsLymp-1.46
AbsMono-0.80 AbsEos-0.44 AbsBaso-0.03
___ 07:27AM BLOOD Glucose-121* UreaN-11 Creat-0.6 Na-142
K-3.5 Cl-106 HCO3-27 AnGap-9*
___ 07:27AM BLOOD Calcium-7.8* Phos-3.0 Mg-1.7
Brief Hospital Course:
Mr. ___ is a ___ year-old chronically home-bound man receiving
home NP visits with a history of depression, cervical
spondylosis, BPH and multi-factorial gait disorder c/f
parkinsonism who was brought in by ambulance after
Elder Services found him in a soiled bed without sheets covered
in sores.
ACUTE/ACTIVE PROBLEMS:
#UTI
Patient presented with positive UA, low-grade fever, and
elevated
white blood cell count that rapidly improved with ceftriaxone.
urine culture is growing staph aureus but he has no other
indications of systemic infection. Blood cultures were sent to
the emergency room and are currently no growth . Made afebrile
while hospitalized and his white blood cell count normalized
narrowed him from ceftriaxone to Bactrim to complete a 10-day
course.
#FTT
#Poor living situation
Found by elder services in a hospital bed without sheets,
incontinent of urine, with some bedsores on his back and unable
to care for himself. Issue has been documented extensively on
past admissions (see SW note from ___. At this time he is
functioning well below prior baseline and will need rehab, after
rehab he will likely need long-term care and will need ongoing
social work. Very concerning for elder abuse and a complaint
has
been filed and accepted by Elder services for elder at risk.
There will need to be an investigation before it will be safe
for
him to return home. Met with his healthcare proxy/caretaker who
is also elderly and has several problems of his own also lacks
the strength to physically care for ___. He will need
ongoing
social work. He will likely need a long-term guardian and this
should be discussed ongoing by social work once he is at rehab.
Very concerned that he should not return home
#Anemia
No evidence of active bleeding was likely hemoconcentrated on
admission and now has received greater than 4 L of fluid. On
previous admission in ___ it appears that his baseline
hemoglobin was
around 10 or 11. He is currently at baseline. He did have a
repeat CBC in 1 week's time
#Hallucinations
#Likely delirium
#Dementia
Patient has been having hallucinations for years his head CT
does
show chronic changes and microvascular disease which could
signal
dementia given his age and comorbidities. His head CT was
negative for any acute process. We started him on medications
to help him sleep which did help with his delirium. He will
need outpatient neurology follow-up for further care of
dementia and possible ___ like features. He will need
neurocognitive testing
-Neurocognitive testing
-Referral to outpatient neurology
-Continue ramelteon and trazodone for sleep
#Fungal dermatitis
Scaly well circumscribed rash in abdominal cleft consistent with
fungal rash. No evidence of cellulitis. Is improving with
clotrimazole ointment which should be applied twice a day
- clotrimazole BID
Back pain: Started him on standing Tylenol 1 g 3 times a day
Primary ppx: c/t aspirin
Vit D deficiency: c/t cholecalciferol
constipation: c/t docusate sodium and senna
Anxiety: Stopped his home At___ given his ongoing confusion and
likely dementia should not be restarted
depression: c/t paroxetine HCl
HTN: Here has been normotensive likely in the setting of poor
p.o. intake stopped his prazosin and should not be restarted
until he becomes hypertensive
BPH: trospium
Greater than 30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Terazosin 10 mg PO QHS
2. Vitamin D 1000 UNIT PO DAILY
3. Senna 17.2 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Docusate Sodium 200 mg PO DAILY
6. LORazepam 2 mg PO Q8H:PRN anxiety
7. PARoxetine 40 mg PO DAILY
8. Propranolol 40 mg PO BID
9. trospium 20 mg oral QAM
10. Methylphenidate SR 20 mg PO QAM
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Ascorbic Acid ___ mg PO BID
3. Clotrimazole Cream 1 Appl TP BID rash on belly
4. Methylphenidate SR 20 mg PO QAM
5. Multivitamins 1 TAB PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. Ramelteon 8 mg PO QHS
8. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0
9. Thiamine 100 mg PO DAILY
10. TraZODone 25 mg PO QHS
11. Aspirin 81 mg PO DAILY
12. Docusate Sodium 200 mg PO DAILY
13. MethylPHENIDATE (Ritalin) 20 mg PO TID
RX *methylphenidate HCl 20 mg 1 capsule(s) by mouth once a day
Disp #*30 Capsule Refills:*0
14. PARoxetine 40 mg PO DAILY
15. Senna 17.2 mg PO DAILY
16. Terazosin 10 mg PO QHS
17. trospium 20 mg oral QAM
18. Vitamin D 1000 UNIT PO DAILY
19. HELD- Propranolol 40 mg PO BID This medication was held. Do
not restart Propranolol until your blood pressure is higher
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
UTI
deconditioning
Fungal rash
Elder at risk
Constipation
Dementia
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 you had trouble caring
for yourself at home. You were found to have a urinary tract
infection and a large fungal rash of your groin area.
You are also found to be dehydrated and have poor oral intake.
You were treated with antibiotics, intravenous fluids, and
nutrition supplements and with this you improved. As we
discussed you are severely deconditioned and will need rehab to
help build her strength.
It was a pleasure caring for you,
Your medical team
Followup Instructions:
___
|
10279742-DS-5 | 10,279,742 | 28,305,646 | DS | 5 | 2164-07-29 00:00:00 | 2164-07-30 19:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy ___
History of Present Illness:
Mr. ___ is a ___ year old gentleman with history of HTN,
bipolar disorder reportedly on lithium and opioid abuse on
methadone 70 mg daily who presents as transfer from ___ for increasing headache and rib pain after a fall 5 and
10 days prior. With his most recent fall, he states he did have
head strike with loss of consciousness. He did not initially
seek
care but has had increasing pain, malaise, and headaches since
then. He reports being unable to perform ADLs and has had
minimal
PO intake. He reports feeling aches and increasing weakness. He
otherwise has had no fevers, chills, shortness of breath, chest
pain, nausea, vomiting, last BM was 3 days ago, no diarrhea.
At ___, he was scanned and found to have small to
moderate acute left SDH without midline shift and acute left
___ rib fractures. According to ED records, he arrived on
___ for reports of suicidal ideation at OSH and bipolar
disorder.
REVIEW OF SYSTEMS:
Pertinent positives and negatives per HPI
Past Medical History:
PAST MEDICAL HISTORY:
Bipolar disorder on lithium
Chronic Hepatitis C
Prev history of opioid dependence; now compliant with methadone
BPH
Hypothyroidism
PAST SURGICAL HISTORY:
- exploratory laparotomy & splenectomy ___ trauma
- ventral hernia s/p repair with mesh c/b infection requiring
mesh removal
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T 98.2, HR 63, BP 160/79, RR 19, SaO2 97% RA
GEN: Somnolent, arousable, uncomfortably appearing
HEENT: NCAT, EOMI, slightly dry mucous membranes, pupils round
and reactive to light. Tenderness to palpation around lower
C-spine/upper T-spine.
CV: regular rate and rhythm
PULM: Easy work of breathing on room air
ABD: Soft, diffusely tender, nonfocal. No guarding or rebound
tenderness.
MSK: Warm, well perfused. Moving all extremities.
NEURO: CII-XII intact, strength ___ in bilateral upper
extremities, ___ in lower extremities, symmetrical
PSYCH: flat affect
DISCHARGE PHYSICAL EXAM
Vitals: 98.4 156/80 (125-173/71-90) 69 (63-69) 19 100%RA
General: Alert and oriented x3, NAD
HEENT: pupils 3->2mm symmetric, upon central gaze the right eye
is slightly deviated to the right
CV: RRR, normal S1 and S2, no murmurs
Lungs: CTAB, no wheezes or rhonchi
Abdomen: soft, nontender, mild distension, course nodular liver
GU: no foley
Ext: 1+bilateral pitting pretibial edema
Neuro: + mild asterixis (improved from prior), blunting of
right nasolabial fold, + expressive aphasia at times, ___ ___
strength
Skin: no rashes, linear abrasions to bilateral knees
Pertinent Results:
ADMISSION LABS:
___ 04:10PM BLOOD WBC-12.5* RBC-3.38* Hgb-10.0* Hct-30.6*
MCV-91# MCH-29.6 MCHC-32.7 RDW-16.2* RDWSD-53.0* Plt ___
___ 04:10PM BLOOD Neuts-54.4 ___ Monos-12.6 Eos-2.2
Baso-0.2 Im ___ AbsNeut-6.79* AbsLymp-3.78* AbsMono-1.58*
AbsEos-0.28 AbsBaso-0.03
___ 04:10PM BLOOD ___ PTT-33.8 ___
___ 04:10PM BLOOD Plt ___
___ 04:10PM BLOOD Glucose-90 UreaN-23* Creat-1.1 Na-138
K-3.6 Cl-100 HCO3-29 AnGap-13
___ 04:10PM BLOOD ALT-57* AST-76* AlkPhos-247* TotBili-0.6
DirBili-0.3 IndBili-0.3
___ 09:37AM BLOOD Calcium-10.5* Phos-2.6* Mg-2.0
NOTABLE LABS:
___ 10:07AM BLOOD Albumin-4.0 Calcium-11.3* Phos-3.0 Mg-2.1
___ 09:00PM BLOOD Ammonia-53
___ 09:10AM BLOOD TSH-4.0
___ 10:07AM BLOOD PTH-79*
___ 10:07AM BLOOD 25VitD-27*
___ 01:04PM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Positive*
___ 04:10PM BLOOD Lithium-LESS THAN
___ 04:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:04PM BLOOD HCV Ab-Positive*
___ 09:29AM BLOOD freeCa-1.28
MICRO:
___ 1:24 pm IMMUNOLOGY
**FINAL REPORT ___
HCV VIRAL LOAD (Final ___:
1,620,000 IU/mL.
Performed using Cobas Ampliprep / Cobas Taqman HCV v2.0
Test.
Linear range of quantification: 1.50E+01 IU/mL - 1.00E+08
IU/mL.
Limit of detection: 1.50E+01 IU/mL.
CT HEAD ___:
IMPRESSION: No significant interval change in the extent of the
acute to subacute left-sided subdural hemorrhage, compared to
the prior exam performed earlier the same day with stable shift
of normally midline structures to the right by approximately 8
mm. No new areas of hemorrhage.
CTA NECK ___:
IMPRESSION:
1. No evidence for cervical carotid or vertebral artery stenosis
or
dissection.
2. Diffuse centrilobular emphysema.
MR HEAD ___:
IMPRESSION:
1. Study is moderately degraded by motion.
2. Redemonstration of patient's known left hemisphere subdural
hemorrhage.
3. Within limits of study, no definite evidence of acute
infarct.
Specifically, no evidence of brainstem acute infarct.
EEG ___:
IMPRESSION: This telemetry captured no pushbutton activations.
It showed a
disorganized and mildly slow background for most of the daytime
recording.
This suggests a mild encephalopathy affecting all areas.
Medications,
metabolic stretches, and infection are among the most common
causes. There
were no areas of prominent focal slowing, and there were no
epileptiform
features. There were no electrographic seizures.
RUQUS ___: IMPRESSION: Coarsened hepatic echotexture without
focal liver lesion identified. Cholelithiasis. The common bile
duct measures up to 1.3 cm. Correlation with LFTs is
recommended. If needed MRCP could be performed for further
evaluation.
CXR ___:
There no prior chest radiographs available for review. Lungs
are severely
hyperinflated due to emphysema. No focal pulmonary abnormality.
Vascular
clips denote prior surgery in the right lower chest. Heart size
normal.
Thoracic aorta very tortuous but not clearly dilated. Pulmonary
arteries top- normal size. No mediastinal abnormality.
CT HEAD ___: 1. Left frontal subdural hematoma is stable
compared to ___. Rightward midline shift is slightly
improved.
MRCP ___: 1. Cirrhotic morphology of the liver. No focal
liver lesions on this limited
non breath hold exam.
2. Mild dilation of the biliary tree and pancreatic duct
without
choledocholithiasis or an obvious mass. This suggests ampullary
stenosis. A tiny mass at the papilla cannot be completely
excluded, especially given the limitations of this exam.
3. Cholelithiasis without evidence of cholecystitis.
4. Numerous small retroperitoneal lymph nodes, which are of
uncertain
clinical significance. Continued attention on follow-up exams
is recommended.
EUS ___:
EUS was performed using a linear echoendoscope at ___ MHz
frequency: The head and uncinate pancreas were imaged from the
duodenal bulb and the second / third duodenum. The body and tail
[partially] were imaged from the gastric body and fundus.
Fatty infiltration was noted, no mass was seen in the head of
pancreas.
The pancreas duct measured 4 mm in maximum diameter in the head
of the pancreas and 3 mm in maximum diameter in the body of the
pancreas.
The duct was normal in echotexture and contour but mildly
dilated
The bile duct was imaged at the level of the porta-hepatis,
head of the pancreas and ampulla.
The maximum diameter of the bile duct was 12 mm.
The bile duct was normal in appearance.
No intrinsic stones or sludge were noted.
The bile duct and the pancreatic duct were imaged within the
ampulla both endoscopically and sonographically
ERCP ___:
Normal major papilla was found.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
Contrast medium was injected resulting in complete
opacification.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire
A diffuse dilation was seen at the CBD/CHD level. No obvious
stricture was noted, cholangiogram excluded stones.
Small amount of sludge was seen.
Balloon sweeps were performed until no further sludge was seen.
Otherwise normal ercp to third part of the duodenum
DISCHARGE LABS:
___ 10:10AM BLOOD Glucose-122* UreaN-20 Creat-1.1 Na-138
K-5.1 Cl-107 HCO3-23 AnGap-13
___ 04:59AM BLOOD WBC-13.4* RBC-3.27* Hgb-9.4* Hct-30.4*
MCV-93 MCH-28.7 MCHC-30.9* RDW-16.2* RDWSD-55.1* Plt ___
Brief Hospital Course:
PATIENT: Mr ___ is a ___ y/o male with HTN, bipolar
disorder, opioid abuse on methadone who presents as a transfer
from ___ after multiple falls.
ACS/Trauma Surgery Hospital Course
Mr. ___ was transferred to ___ from ___
___ for increasing headache and rib pain after a fall 5 and
10 days prior. He was found to have a small SDH and left ___
and 11th rib fractures. There was concern about SI at ___,
and he was transferred with ___ in place. He was
evaluated by the inpatient psychiatry consult service, who did
not find any acute psychiatric issues. Patient's injuries were
non-operative. He was noted to have new dysconjugated gaze and
slurred speech day after admission. Repeat Head CT stable.
Patient's mental status continued to be altered. MRI showed no
acute infarct. CTA showed no carotid stenosis. Neuro recommended
EEG. Neurology attributed his dysarthria to expressive aphasive
from the ___ and the dysconjugate gaze to possible strabismus.
The patient also was diagnosed with a UTI and was started on
macrobid (day 1: ___. It was requested that the patient be
transferred to the medicine service for management of his
complex medical issues, SDH, and encephalopathy.
MEDICAL SERVICE HOSPITAL COURSE
# Altered Mental Status: Patient's symptoms were not felt to be
true encephalopathy, but rather a constellation of neurologic
symptoms (including word finding difficulty, slow mentation, and
diplopia). Felt multifactorial from SDH, UTI, hepatic
encephalopathy, metabolic abnormalities, and delirium. Patient
with notable asterixis and started on lactulose; with marginal
improvement in symptoms. Nitrofurantoin was changed to
ciprofloxacin for appropriate treatment of UTI in a male.
Collateral confirmed that patient was near baseline. Evaluated
by both OT and ___. Although patient was occasionally
independent, he had poor insight to his condition and would
occasionally become somnolent and unable to participate in
activities. These symptoms gradually improved throughout his
lengthy hospitalization, but it was felt that discharge to rehab
would be appropriate for patient safety until his symptoms
resolved. Patient was also weaned off of oxycodone, and at time
of discharge only remained on clonazepam. Sedating and
deliriogenic medications were minimized.
# SDH/prior seizure disorder: Patient had stable SDH on repeat
brain imaging. Neurology initially consulted for management
while on ACS service, but signed off at time of medicine
transfer. Patient was taken off of Keppra after seven days for
seizure prophylaxis, but was kept on carbamazepine (a home
medication) for the duration of his hospitalization. There was
no evidence of seizures at any point this hospitalization.
Several EEGs performed while patient was on ACS service, which
were notable only for non-specific encephalopathy
# HCV Cirrhosis/Ampullary Stenosis: Given LFT elevation and
cirrhotic appearing liver on RUQUS. HCV Ab was sent and
positive. HCV viral load was checked and > 1,200,000. Patient
was notably HepB immune with HBV-core ab positive indicating
prior infection. MRCP demonstrated biliary duct dilation.
Subsequent ERCP without obstruction, but spinchterotomy
performed for ampullary stenosis. No subsequent procedural
complications. Patient was treated with 5 days of ciprofloxacin
for post-ERCP coverage. (Final dose of cipro ___ ___
# UTI: Patient was diagnosed with an Enterococcal UTI while on
the surgical service. Patient was asymptomatic but started on
nitrofurantoin. Changed to amoxicillin and then ciprofloxacin
for adequate penetration/coverage in a male UTI. No signs of
ascending infection. Patient was extended for an additional 5
days of ciprofloxacin for post-ERCP coverage. (Final dose of
cipro ___ ___
# HTN: Patient with very poorly controlled blood pressure, with
labile swings. Mediation regimen changed significantly while
inpatient. Ultimately changed to lisinopril, carvedilol, and
amlodipine. Patient's BP meds were spaced out as to prevent
troughs and peaks in blood pressure. Patient was previously on
furosemide pre-hospitalization (unclear for what indication -
possible cirrhosis related volume overload). This was held
during hospitalization, and not restarted at time of discharge.
# Bipolar/depression: Patient was continued on home lithium,
sertraline 100mg daily, aripiprazole 30mg. Home clonazepam 1mg
BID was restarted. Oxycodone was titrated off Prior d/c summary
indicates recommendation to wean/stop this medication as it
likely contributed to recent (___) hospitalization requiring
intubation for acute hypoxic respiratory failure secondary to
presume overdose
# BPH: Continued on home tamsulosin
# Hypothyroidism: Continued on home levothyroxine
# Opioid dependence h/o heroin abuse: Called ___
clinic who confirmed that he had been compliant with treatment
prior to hospitalization. Patient's oxycodone was managed to be
titrated off prior to discharge.
TRANSITIONAL ISSUES:
- Pt to complete 5 day course of ciprofloxacin PO 500mg BID s/p
ERCP with sphincterotomy (day 5 = ___
- No aspirin, clopidogrel, NSAIDS, Coumadin until follow-up with
neurosurgery
- Patient's blood pressure was very labile while hospitalized.
Significant changes were made to his blood pressure regimen: no
on amlodipine, lisinopril (BID) and carvedilol. Please stager
these medications as this improved patient's blood pressure and
prevented large swings. Please titrate as needed in the
outpatient setting.
- Outpatient neurosurgery CT scan and appointment on ___
- Consider outpatient optometry examination for blurred vision
if not continuing to improve
- Patient was previously on furosemide pre-hospitalization
(unclear for what indication - possibly cirrhosis related volume
overload). This was held during hospitalization, and not
restarted at time of discharge. Please assess volume status at
___ clinic appointments and at rehab, and re-introduce as
needed.
- Outpatient GI follow-up for HCV cirrhosis
- Recommend slow taper of clonazepam from 1mg BID with intention
to discontinue as tolerated
- Patient was started on lactulose TID-QID for hepatic
encephalopathy. Please titrate as needed to mental acuity and
___ bowel movements per day.
- Patient with consistent hypercalcemia while hospitalized,
likely hypocalciuric hypercalcemia.
- Code: Full
- HCP ___, friend, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry eye
2. Docusate Sodium 200 mg PO QHS:PRN constipation
3. Multivitamins 1 TAB PO DAILY
4. Methadone (Oral Solution) 2 mg/1 mL 70 mg PO DAILY
5. Nitroglycerin Patch 0.4 mg/hr TD Q24H
6. Allopurinol ___ mg PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN pain
8. Nicotine Patch 14 mg TD DAILY
9. CarBAMazepine 600 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Sertraline 100 mg PO DAILY
12. ARIPiprazole 30 mg PO DAILY
13. Lithium Carbonate CR (Eskalith) 450 mg PO QHS
14. Lisinopril 40 mg PO DAILY
15. Gabapentin 300 mg PO TID
16. Doxycycline Hyclate 100 mg PO Q12H
17. Amlodipine 10 mg PO DAILY
18. CloniDINE 0.3 mg PO BID
19. Levothyroxine Sodium 225 mcg PO DAILY
20. Furosemide 40 mg PO DAILY
21. HydrALAZINE 25 mg PO BID
22. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. ARIPiprazole 30 mg PO DAILY
5. CarBAMazepine 600 mg PO DAILY
6. Docusate Sodium 200 mg PO QHS:PRN constipation
7. Gabapentin 400 mg PO TID
8. Lisinopril 20 mg PO BID
9. Lithium Carbonate CR (Eskalith) 450 mg PO QHS
Eskalith CR
10. Methadone (Oral Solution) 2 mg/1 mL 70 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Nicotine Patch 14 mg TD DAILY
13. Omeprazole 20 mg PO DAILY
14. Sertraline 100 mg PO DAILY
15. Carvedilol 6.25 mg PO BID
16. Ciprofloxacin HCl 500 mg PO Q12H Duration: 8 Days
Last dose ___ ___
17. ClonazePAM 1 mg PO BID:PRN Anxiety
18. Tamsulosin 0.8 mg PO DAILY
19. Lactulose 30 mL PO QID
20. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eye
21. Levothyroxine Sodium 225 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
subdural hematoma
hepatitis C cirrhosis
rib fractures
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were admitted to ___ after you had fallen. You were found
to have a bleed in your brain called a subdural hematoma
("SDH"). You were evaluated by the surgical team, the
neurosurgical team, the neurology team and the medical service.
You were found to still be confused and to have some trouble
performing your daily activities afterwards. We also saw that
some of the duct systems in your liver were dilated and
obstructed, so you underwent a procedure called an EUS/ERCP to
relieve the obstruction. You will be discharged to rehab where
you can continue to work on your daily activities before you can
safely go home.
It was a pleasure taking care of you,
The ___ Service
SURGICAL SERVICE PATIENT DISCHARGE INSTRUCTIONS:
Rib Fractures:
* Your injury caused 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 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Do NOT smoke
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10279832-DS-7 | 10,279,832 | 23,999,083 | DS | 7 | 2184-10-11 00:00:00 | 2184-10-11 15:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Alcohol withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of alcohol use disorder admitted to MICU for
management of severe alcohol withdrawal.
In the past month, multiple alcohol binges over the past month
with admissions for alcohol withdrawal, most recently 5d prior
to this admission. She presented to the ED today endorsing a
desire to stop drinking, with last drink 2 hours prior to
arrival. No cough, ST, rhinorrhea, abd pain, naus, vom,
diarrhea, dysuria, frequency, CP, SOB, or leg swelling. No
fevers or chills. No visual changes, blurry vision, or headache.
He denies ever having EtOH withdrawal seizures in the past or
hallucinations although on chart review evidently has had this
before.
In the ED, he reported feeling very tremulous and not
intoxicated.
- initial VS 97.7 138 148/99 18 96% RA
- labs notable for hgb 7.8, ETOH 250, lactate 3.8->2.8->2.5.
chemistry is normal.
- imaging: none
- interventions: diazepam 10, 20, 40, 40, 40. phenobarb loading
and rescue doses. IVFs. thiamine, MVI, folate.
- consults: none
- transfer VS: ___ 24 96% RA
Admitted to MICU for management of severe alcohol withdrawal.
In the ICU, patient is intoxicated. Can state that he does not
have pain. Did not have URI symptoms prior to admission.
Past Medical History:
- Appendectomy
- Alcohol use disorder
Social History:
___
Family History:
Deferred due to intoxication
Physical Exam:
Vital signs: 98.1 139 / 96 88 95 Ra
GEN: Comfortable appearing, pleasant, conversant
HEENT: NCAT, anicteric sclera
CV: Tachycardic. Normal S1, S2, no murmurs
RESP: Good air entry, no rales or wheezes
GI: Normal bowel sounds, soft, no RUQ tenderness or
hepatomegaly,
spleen is not palpable
EXTR: No edema. Intact pulses.
DERM: No rash.
NEURO: Face symmetric, speech fluent, non-focal
PSYCH: Calm, cooperative
Pertinent Results:
Admission labs:
===============
___ 12:32PM BLOOD WBC-7.9 RBC-5.84 Hgb-17.8* Hct-49.9
MCV-85 MCH-30.5 MCHC-35.7 RDW-12.9 RDWSD-39.9 Plt ___
___ 12:32PM BLOOD Neuts-69.0 ___ Monos-8.8 Eos-0.0*
Baso-0.6 Im ___ AbsNeut-5.47 AbsLymp-1.67 AbsMono-0.70
AbsEos-0.00* AbsBaso-0.05
___ 12:32PM BLOOD Plt ___
___ 12:32PM BLOOD Glucose-108* UreaN-19 Creat-0.8 Na-138
K-3.8 Cl-96 HCO3-24 AnGap-22*
___ 12:32PM BLOOD ALT-824* AST-871* AlkPhos-52 TotBili-0.2
___ 12:32PM BLOOD Calcium-8.7 Phos-4.2 Mg-2.2
___ 12:39PM BLOOD Lactate-3.8*
___ 06:03PM BLOOD Lactate-2.8*
Microbiology:
=============
___ 3:04 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
Imaging:
========
RUQUS ___:
Normal right upper quadrant abdominal ultrasound.
CHEST X-RAY ___:
Lung volumes are low with mild bronchovascular crowding. No
focal
consolidation.
CT HEAD ___:
No acute intracranial abnormality on CT examination.
Brief Hospital Course:
___ with history of alcohol use disorder admitted to ___ for
management of severe alcohol withdrawal.
# Alcohol use disorder with severe withdrawal, anxiety,
insomnia: Patient presented with severe alcohol withdrawal, last
drink on ___. He required escalating doses of diazepam in
the ED and was eventually loaded with Phenobarb IV (day 1 =
___ and transferred to the FICU. In the FICU, he was started
on thiamine, folate, and MVI and continued on phenobarbital
protocol. Withdrawal symptoms resolved and he was discharged on
day 5 of the phenobarbital taper. He was also treated
supportively with trazodone and clonidine for alcohol-related
anxiety, insomnia
Social work consultation was greatly appreciated and helped the
patient to secure an appointment with a ___
addiction specialist on ___. He was also referred to the
___ for an intake and consideration of
initiating naltrexone.
Patient was counseled on the importance of a multi-modal
approach to relapse prevention. Pharmacotherapy is an important
adjunct to maintaining sobriety, but at this time, it is not
safe to start naltrexone or disulfiram because of significant
alcohol-induced hepatotoxicity.
# Anion gap metabolic acidosis:
# Elevated lactate:
AGMA + borderline metabolic alkalosis. Toxic alcohol ingestion
could explain anion-gap metabolic acidosis and elevated lactate.
He was given IVF boluses with good response.
# Fever:
# Transaminitis / alcohol-induced liver injury:
LFTs 800s in the setting of heavy alcohol use. Normal Tbili, no
evidence of synthetic dysfunction or encephalopathy. RUQ
ultrasound and hepatitis serologies were negative. Febrile on
admission and had low grade fevers for ___ days without other
localizing signs/symptoms of infection.
Transitional Issues:
- Trend liver function tests
- Strongly consider starting pharmacotherapy (i.e. naltrexone)
for relapse prevention when LFTs normalize
> 30 minutes on discharge activities including counseling and
coordination of care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol use disorder
Alcohol withdrawal
Alcoholic hepatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were treated in the hospital for alcohol use disorder.
Alcohol withdrawal symptoms were treated with IV fluids and
phenobarbital. You were provided with resources from social
work to assist you in maintaining sobriety.
You developed acute alcoholic hepatitis (liver injury due to
excessive alcohol consumption), which was fortunately improving
upon discharge.
Please note that there are several medications that can be very
helpful in maintaining sobriety. However, these medications
cannot be started until your liver injury has resolved. Social
work has also provided you with the information for the clinic
at ___, where they can prescribe such
medications to support you.
Followup Instructions:
___
|
10279898-DS-11 | 10,279,898 | 27,011,718 | DS | 11 | 2135-02-18 00:00:00 | 2135-02-18 16:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ___
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ yo man with metastatic castrate resistant
prostate cancer now on docetaxel (C1D1 ___, recent washout
for right hip septic arthritis, presenting with fever and
worsening right hip pain.
Mr ___ was recently admitted to ___
___ for 1 week of worsening right hip swelling and pain. His
workup there included 1 set ___ bottles) of admission blood
cultures which grew strep agalactiae (R only to tetracycline).
CT of his R hip showed a large joint effusion c/f septic
arthritis in s/o strep bacteremia. TTE was negative for
endocarditis. He underwent ___ guided joint aspiration on ___,
which returned 1 cc cloudy white fluid that is NGTD.
Given clinical concern for septic arthritis, he then underwent
I&D with orthopedics on ___ (cultures are NGTD as of ___. He
was recommended by ID to receive 6 weeks of 2 gm ceftriaxone
daily. Throughout his hospitalization, he had ongoing low grade
temperatures to the 100s.
He was discharged home and reported he initially felt he was
improving. However, this morning, he suddenly developed ___
right hip pain. On weight bearing, he felt his pain was
excruciating, like the "bone would break". He presented to ___
for evaluation.
On ROS, Mr ___ reports 2 weeks of ongoing poor intake since
the onset of his right hip pain. He had some lightheadedness on
sitting up this morning, but no further episodes of LH or
dizziness. He has had a scant cough that is intermittently
productive of white sputum, but no SOB, chest pain,
palpitations, known sick contacts. He reports at least 2 weeks
of watery diarrhea-- up to 3 times a day, which has been
unchanged (C diff at ___ was negative). No abdominal pain, N/V,
dysuria, bleeding, HA, numbness/tingling, choking/aspirating
events. No new rashes. He denies fevers and was surprised to
hear that his sister reported low grade temps in the hospital up
to 100.7F. No chills.
In the ED: Afebrile (Tmax 98.4F) | HR 85 | 122/71 | 100% RA. He
received 2 L NS, vanc/zosyn. Labs notable for a lactate of 5.4
(down to 2.6 after 1L NS). Hip X ray, CXR, and RLE Doppler US
showed no acute changes.
Orthopedics was consulted and noted full ROM about the right hip
with minimal tenderness. Incision was well healing. Recurrent
septic arthritis was deemed less likely in this context, so they
recommended trending inflammatory markers, obtaining outside
hospital records, and admission to oncology service.
His records were obtained in the ED and are in his paper chart
on arrival to floor.
When seen on arrival, Mr ___ reports he feels the best he has
felt over the last 2 weeks. He reports his pain is currently a
___ (evaluated 2 hrs after taking home 5 mg oxycodone).
All other review of systems are negative unless stated otherwise
Past Medical History:
ONCOLOGIC AND TREATMENT HISTORY:
___ - low back pain, normal XR spine
___ - LHG ED with MRI lumbar spine revealing diffuse
metastatic disease and pathological vertebral fracture at L5
with
probably epidural tumor
___ - Kyphoplasty at the L5 vertebral body with a biopsy.
Biopsy revealed prostate cancer.
___ to ___ - Med onc at ___ recommended Lupron, Xgeva,
and radiation to 3 symptomatic bone lesions. PSA decreased
initially but in the ___ began to rise again
___ - CT TORSO showed bone metastasis without any
additional sites of disease however the PSA continued to rise
and
it was thus recommended at the patient be started on Zytiga +
prednisone. Noted to have new left hip pain and a proximal left
femur lesion on bone scan was identified a single fraction of
palliative course of radiation therapy was performed at the
site.
> Patient and family requested second opinion at ___ and was thus referred here to Dr.
___. Screen failed for ___ due to drop in PSA on two
checks, no bone progression on scans. Iniatiated radium 223
___
Continued radium 223 with PSA rise in ___ to 116 from ___
___ Genetic testing negative but notable for VUS BRCA. PSA
rose to 139, stopped following with Dr. ___ as plan was to go
back on abiraterone and continue following with community
oncology
___ Restarted abiraterone, prednisone, and continued
denosumab/leuprolide
___ Interval PSA rise (154->208) without additional interval
e/o clinical worsening; continued abiraterone/pred and lupron
___: Bone scan with areas of progression corresponding to
new sites of pain (eg: L frontal calvarium, R distal femur,
ribs)
___ Iso PSA rise, new symptomatic bone lesions ->
transitioned from abiraterone to enzalutimide.
___: Initiated Q12-week Lupron, Q12 week denosumab
injections at ___ continued enzalutamide with PSA falling
389-301. Shoulder pain that flared, but improved before
scheduled for palliative radiation presumably due to treatment
effect.
___: PSA 340, continued current therapy
___: PSA 437, continue Lupron/denosumab (stopped enza).
___: Started C1D1 docetaxel
Social History:
___
Family History:
Reviewed and not relevant to reason for admission.
Physical Exam:
Admission:
=========
___ 0141 Temp: 98.7 PO BP: 131/70 HR: 70 RR: 18 O2
sat: 98% O2 delivery: Ra
___: Pleasant elderly Caucasian man resting in bed in no
acute distress, conversant.
Neuro: AO x 3 Place- ___ Day- ___.
Able to recite months of year backward. PERRL, palate elevates
symmetrically, tongue midline
HEENT: Oropharynx clear, MMM, no lesions
Cardiovascular: Regular rate and rhythm, occasional ectopic
beats. No murmurs
Chest/Pulmonary: Clear to auscultation bilaterally. Scant dry
cough heard in room
Abdomen: Soft, nontender, nondistended. lovenox injection
ecchymosis over lower abdomen
Pelvis/GU: Condom catheter in place draining clear yellow urine
Extr/MSK:
- 2+ Soft pitting edema over the right lower extremity to the
knee. 1+ soft pitting edema to the knee on the left.
- Full active and passive ROM of left hip. Nontender to
palpation, nontender to movement. Able to lift left leg out of
bed
- Full passive ROM of right hip. Unable to actively lift leg out
of bed due to pain. Unable to keep leg elevated after examiner
lifts leg out of bed due to pain. Knee flexion/extension full.
Plantar/dorsiflexion full.
- No notable joint effusions over lower extremities
- Right hip I&D site dressed with bandage, nontender to
palpation, no surrounding erythema
Skin: No acute rashes
Access: RUE PICC, c/d/i
Discharge:
=========
Vital signs reviewed, afebrile, BP 115/67, heart rate 79,
respirations 18, satting 97% on room air. Inputs and outputs
reviewed, no diarrhea today. Middle-aged man lying in bed,
alert, cooperative, NAD. Anicteric, MMM. Equal chest rise,
CTAB anteriorly, no WOB or cough. Heart regular. Abdomen soft,
NT ND. Extremities warm and well perfused, he has Steri-Strips
over a well opposed, and well healing right anterior hip
surgical wound. He has no significant pitting edema.
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
===========================
___ 03:17PM BLOOD WBC-9.9 RBC-3.46* Hgb-10.2* Hct-34.6*
MCV-100* MCH-29.5 MCHC-29.5* RDW-19.8* RDWSD-69.4* Plt ___
___ 03:17PM BLOOD Glucose-115* UreaN-7 Creat-0.7 Na-141
K-5.1 Cl-109* HCO3-14* AnGap-18
___ 03:17PM BLOOD ALT-24 AST-48* AlkPhos-103 TotBili-0.6
___ 05:30AM BLOOD PSA-610*
___ 03:17PM BLOOD CRP-78.1*
___ 06:40AM BLOOD CRP-46.1*
___ 06:30AM BLOOD CRP-19.2*
MICRO:
=====
___ STAIN-FINAL; RESPIRATORY CULTURE-FINAL
___. difficile PCR-FINAL
___ CULTURE-FINAL
___ Culture, Routine-FINAL
___ Culture, Routine-FINAL
IMAGING/OTHER STUDIES:
====================
Hip Plain film ___. Redemonstration of diffuse sclerotic changes throughout the
pelvis and
bilateral proximal femurs consistent with known metastatic
disease.
2. Lucency along the right inferior pubic ramus is likely
related to prior
pathological fracture as seen on prior CT. No acute displaced
fractures are
demonstrated.
___ RLE Doppler -- IMPRESSION: No evidence of deep venous
thrombosis in the right lower extremity veins.
___ CXR -- IMPRESSION: Similar appearance of diffuse osseous
sclerosis consistent with known metastatic disease. Additional
apparent opacities projecting over the lungs are likely related
to superimposed partially calcified pleural plaques. A new
underlying parenchymal opacity would be difficult to entirely
exclude in this patient.
LABS AT DISCHARGE:
=================
___ 05:30AM BLOOD WBC-5.7 RBC-3.00* Hgb-8.9* Hct-27.9*
MCV-93 MCH-29.7 MCHC-31.9* RDW-19.2* RDWSD-62.4* Plt ___
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD Glucose-88 UreaN-5* Creat-0.6 Na-145
K-4.0 Cl-111* HCO3-23 AnGap-11
___ 06:40AM BLOOD ALT-18 AST-25 AlkPhos-87 TotBili-0.5
___ 05:30AM BLOOD Calcium-7.2* Phos-3.1 Mg-2.2
___ 05:30AM BLOOD PSA-610*
___ 06:30AM BLOOD CRP-19.2*
Brief Hospital Course:
___ with metastatic castrate resistant prostate cancer now on
docetaxel (C1D1 ___, recent washout for right hip septic
arthritis, presenting with right hip pain and reported low grade
fever.
Ultimately he was treated conservatively for this pain, required
no further procedures or sampling, and he was continued on his
ceftriaxone that had begun on ___. With a change in pain
medication to oxycodone, his pain was better controlled, and he
will be going to rehabilitation for ongoing physical therapy.
On the day of discharge he felt well and was just frustrated
that he taken so long to get him to rehab. He had no questions
or concerns and was looking forward to leaving.
#Right hip pain
#Reported low grade fever prior to admission
Recent hospitalization at ___ where he
presented with strep agalactiae bacteremia, found to have a new
severe R hip effusion c/f septic arthritis. He underwent joint
aspiration at ___ on ___, then incision and
drainage and washout by Orthopedic surgery there on ___ and
was placed on IV ceftriaxone with a plan for a total 6-week
course from ___, and he was discharged. He then presented
here with severe right hip pain. His overall exam and clinical
picture was reassuring and did not suggest a recurrent or new
septic arthritis. He had no documented fever this admission and
there was no concern for worsening septic arthritis of the hip.
Additionally, inflammatory markers continued to downtrend with
ongoing antibiotic therapy. Per discussion with Oncology team
(given his metastatic prostate cancer, see below), there was no
role for additional XRT and his hip pain was attributed to
resolving septic arthritis. He will continue a total of six
weeks with ceftriaxone 2gm q24h as previously planned, following
up in ___. For pain control, his PRN oxycodone was increased
and given prior to working with physical therapy. He was
recommended for discharge to rehab.
#Moderate protein-calorie malnutrition:
#Orthostasis
Reported 2 weeks of poor PO intake and episode of
lightheadedness. Received fluid resuscitation and electrolyte
repletion. He was followed closely by our nutrition team and
will need to continue to reinforce important of nutrition should
he desire to continue chemotherapy.
#Diarrhea, resolved
C. diff negative, so thought likely secondary to recent
docetaxel and antibiotics. Provided loperamide PRN, which he was
not requiring for several days prior to discharge.
#Metastatic prostate cancer (liver, bone)
#Cancer associated pain
Dx ___ after presenting with compression fracture of ___ s/p
kyphoplasty. Treated with leuprolide, radium 223, abiraterone.
Transitioned to enzalutamide/Lupron in ___ due to PSA
rise and bone pain w/ progressive osseous metastases. PSA
continued to rise so on ___, he was switched to pred/docetaxel
q3 weeks. Missed planned dose ___ due to septic arthritis.
Completed ___ cGy in 5 fractions to right tibia ___. Has
previously had RT to L hip and L ___ femur CXR and hip Xray in
ED redemonstrating diffuse osseous mets. He was continued on
home prednisone and oxycodone increased as above. His
oncologist was aware of this admission and he has follow-up
scheduled with him.
[x] The patient is safe to discharge today, and I spent [ ]
<30min; [x] >30min in discharge day management services.
___, MD
___
Pager ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
3. PredniSONE 5 mg PO BID
4. Morphine Sulfate ___ 15 mg PO BID:PRN Pain - Severe
5. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
6. Aspirin 81 mg PO DAILY
7. CefTRIAXone 2 gm IV Q24H
8. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H:PRN Disp #*40
Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. CefTRIAXone 2 gm IV Q24H
Started ___, plan 6 week course (which would mean anticipated
stop date of ___
7. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
8. PredniSONE 5 mg PO BID
9. Tamsulosin 0.4 mg PO QHS
10.Outpatient Lab Work
ICD-10-CM Diagnosis Code MOO.20 Please obtain CBC, Chem 10,
LFTs, CRP every 7 days, starting ___, and fax results to:
Attn: ___ (at Dr. ___ office), ___
Building, Phone: ___, Fax: ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#Hip pain, secondary to
#Resolving septic arthritis
#Prostate cancer with osseous metastasis
#Severe protein-calorie malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for worsening hip pain that was attributed to
resolving infection. You had your pain medication adjusted and
will need to continue IV antibiotics for the next several weeks.
While you were here, you were noted to be dehydrated and
malnourished. It is very important that you maintain your
hydration and nutrition in order to safely continue receiving
treatment for your cancer. You are being discharged to rehab in
order to regain your strength.
Followup Instructions:
___
|
10279906-DS-3 | 10,279,906 | 21,028,302 | DS | 3 | 2171-02-11 00:00:00 | 2171-02-11 17:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Actonel / Calcium / Zithromax / Boniva / Remeron
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
___ 06:02PM BLOOD WBC-4.8 RBC-3.93 Hgb-10.9* Hct-39.8
MCV-101* MCH-27.7 MCHC-27.4* RDW-14.0 RDWSD-52.5* Plt ___
___ 06:02PM BLOOD Neuts-72.4* Lymphs-10.2* Monos-16.6*
Eos-0.0* Baso-0.4 Im ___ AbsNeut-3.48 AbsLymp-0.49*
AbsMono-0.80 AbsEos-0.00* AbsBaso-0.02
___ 06:02PM BLOOD ___ PTT-30.6 ___
___ 06:02PM BLOOD Glucose-92 UreaN-31* Creat-0.8 Na-140
K-5.6* Cl-99 HCO3-33* AnGap-8*
___ 06:02PM BLOOD ALT-17 AST-16 AlkPhos-97 TotBili-0.2
___ 06:02PM BLOOD Lipase-12
___ 06:02PM BLOOD cTropnT-<0.01
___ 09:57PM BLOOD cTropnT-<0.01
___ 06:02PM BLOOD proBNP-1505*
___ 06:02PM BLOOD Albumin-3.7 Calcium-9.8 Phos-5.0* Mg-2.2
Cholest-167
___ 06:02PM BLOOD VitB12-250 Folate->20
___ 06:09PM BLOOD %HbA1c-5.8 eAG-120
___ 06:02PM BLOOD Triglyc-74 HDL-88 CHOL/HD-1.9 LDLcalc-64
___ 06:02PM BLOOD TSH-0.39
___ 06:02PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 07:50PM BLOOD Lactate-0.5 K-5.2
IMPORTANT INTERVAL RESULTS:
___ 10:05AM BLOOD ___ pO2-69* pCO2-82* pH-7.33*
calTCO2-45* Base XS-13 Comment-GREENTOP
___ 05:16PM BLOOD ___ pO2-189* pCO2-82* pH-7.35
calTCO2-47* Base XS-15 Comment-GREEN TOP
MICRO:
___ 4:40 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 6:20 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by ___ (___) ON
___ AT
19:07.
Repeat blood cultures from ___ and ___ NGTD
DISCHARGE LABS:
___ 06:07AM BLOOD WBC-6.9 RBC-3.98 Hgb-11.0* Hct-38.5
MCV-97 MCH-27.6 MCHC-28.6* RDW-13.9 RDWSD-49.1* Plt ___
___ 06:07AM BLOOD Glucose-97 UreaN-25* Creat-0.5 Na-146
K-4.5 Cl-97 HCO3-37* AnGap-12
IMAGING:
CXR
IMPRESSION:
Blunted left costophrenic angle may be due to small pleural
effusion and atelectasis, but consolidation is not excluded in
the appropriate clinical setting. If/when patient able,
dedicated PA and lateral views would be helpful for further
evaluation.
Trace right pleural effusion difficult to exclude. Possible
minimal interstitial edema.
CT CHEST/ABD/PELVIS
IMPRESSION:
1. Moderate dependent atelectasis in the bilateral lower lobes
and small
dependent bilateral pleural effusions.
2. Mild pulmonary edema.
3. No acute findings in the abdomen or pelvis.
CT C-SPINE
1. No acute fracture of the cervical spine.
2. Grade 1 retrolisthesis C3 over C4. Grade 1 anterolisthesis
C4 over C5, C5 over C6 and C6 over C7. This is likely
degenerative in nature, although no prior currently available
for comparison. If clinical concern for ligamentous injury, MRI
is more sensitive..
3. 2-3 mm right apical pulmonary nodule.
For incidentally detected nodules smaller than 6mm in the
setting of an
incomplete chest CT, no CT follow-up is recommended.
See the ___ ___ Guidelines for the Management
of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
4. Enlarged, heterogeneous, multinodular thyroid gland.
5. Very partially imaged upper lung apices demonstrate either
mild pleural
thickening or trace pleural effusions.
CT HEAD
1. No evidence of acute intracranial abnormality.
2. Extensive periventricular subcortical white matter
hypodensities, overall unchanged compared to prior, most likely
related to small vessel ischemic changes.
___ VEIN STUDY
1. No evidence of deep venous thrombosis in the left lower
extremity veins.
2. Small left ___ cyst.
3. Patient refused imaging of the right lower extremity.
TTE
Mild symmetric left ventricular hypertrophy with preserved
global biventricular systolic function. Mild aortic and mitral
regurgitation. Mild to moderate tricsupid regurgitation. Mild
pulmonary hypertension.
Brief Hospital Course:
Ms. ___ is a ___ y/o F with PMHx HTN, depression, RBBB who
presented from ___ with lethargy and confusion.
# Acute hypoxic respiratory failure:
# (Likely chronic) compensated hypercarbic respiratory failure:
# Acute metabolic alkalosis:
# Chronic diastolic CHF, ?acute on chronic:
TTE with normal biventricular function, and mild symmetric LVH.
Legs still appear slightly edematous, but with significant skin
wrinkling implying improvement from admission. Tmax 99.1 during
admission which supports likely infectious process. Chest CT
without consolidations/pneumonia. VBG with significant
hypercarbia to 82 and stable on repeat, but relatively preserved
pH of 7.33 and elevated bicarb. Unclear exactly why she is
hypercapnic, but suspect given bicarb trend on labs has been
going on for at least the past week iso her known URI. No known
hx of COPD or asthma (patient is also a never smoker). Patient
given duonebs q6 hours, which we recommend continuing upon
discharge. Lasix discontinued after a couple of IV doses (of
20mg each) given progressing bicarb elevation, and would
recommend monitoring patient's weight closely and deciding on
oral Lasix in future if has worsening edema or suddenly
increasing weight. On discharge patient between room air and 2L
nasal cannula O2 with sats in low ___.
# Toxic metabolic encephalopathy:
Waxing and waning mental status. CT head negative. Geriatrics
team evaluated patient, and trazodone held in setting of
intermittent sedation. Large component of confusion likely
secondary to metabolic changes as described above. Could
consider outpatient MRI if persisting and within goals of care
of patient/family.
# Coag negative staph in blood culture:
Gram stain of aerobic bottle from blood culture on ___ w/ GPCs
in pairs and clusters, with culture eventually growing coagulase
negative staph. Was started on empiric IV vancomycin pending
culture results. High likelihood that this is a contaminant
given lack of fever/leukocytosis, no further positive cultures
and particular organism, therefore vancomycin was discontinued
once this resulted on ___.
# Goals of care:
Patient has DNAR/DNI MOLST on file. However, there is some
discrepancy between a MOLST that we have and another (possibly
more current) MOLST that ___ has stating that she would
or wouldn't want to be transferred to the hospital. (The one we
have on file says she is ok to transfer). I clarified this point
with her healthcare proxy ___, who reports that he did endorse
her transfer to the hospital on this occasion. Would recommend
ongoing discussions between PCP and HCP, and consideration of
filling out an updated MOLST should preferences change.
# Depression/Anxiety:
Patient's nephew reports that she is extremely anxious. There
was some discrepancy between med recs, but after reconciling
further, to clarify, she is NOT on Seroquel. She is on trazodone
and mirtazapine.
# Concern for aspiration:
Did reasonably well with bedside speech/swallow evaluation here.
Diet recommendation is regular solids and thin liquids.
Recommend ongoing evaluation with speech/swallow at ___ if
further concerns for aspiration.
# HTN:
Continued amlodipine 2.5.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraZODone 12.5 mg PO QHS
2. Mirtazapine 30 mg PO QHS
3. amLODIPine 2.5 mg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY
5. Calcium Carbonate 500 mg PO DAILY
6. Famotidine 20 mg PO QHS:PRN GERD
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
8. Ibuprofen 400 mg PO Q6H:PRN Pain - Mild
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
10. TraZODone 12.5 mg PO BID:PRN anxiety
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. amLODIPine 2.5 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Famotidine 20 mg PO QHS:PRN GERD
5. Ibuprofen 400 mg PO Q6H:PRN Pain - Mild
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
7. Mirtazapine 30 mg PO QHS
8. Polyethylene Glycol 17 g PO DAILY
9. HELD- TraZODone 12.5 mg PO QHS This medication was held. Do
not restart TraZODone until discuss with PCP
10. HELD- TraZODone 12.5 mg PO BID:PRN anxiety This medication
was held. Do not restart TraZODone until discuss with PCP
11. HELD- TraZODone 12.5 mg PO BID:PRN anxiety This medication
was held. Do not restart TraZODone until discuss with PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Toxic metabolic encephalopathy
Subacute hypoxic and hypercarbic respiratory failure
URI
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:
___,
You were admitted to the hospital for difficulty breathing and
confusion. One abnormality that we found on your labs was that
you were retaining carbon dioxide. Your medications were
adjusted slightly as well.
You will continue to be treated for these things upon return to
___.
It was a pleasure taking care of you!
Sincerely, your ___ Team
Followup Instructions:
___
|
10280054-DS-10 | 10,280,054 | 20,177,063 | DS | 10 | 2143-05-22 00:00:00 | 2143-05-23 06:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trauma: MVC:
Bilateral pulmonary contusions
right rib fracture
G1 liver laceration
Right temporal bone fracture, to sphenoid
punctate IPH c/w ___
L5 transverse process fracture
S1-S2 fracture
Major Surgical or Invasive Procedure:
___: PEG- PEG removed ___ because pt is eating.
History of Present Illness:
This patient is a ___ year old male who complains of MVC.
The patient was brought ___ by EMS, status post MVC. Per
report the patient was unrestrained driver who struck a
tree. There is significant intrusion into the car, and the
driver side windshield was starred. He was called ___ as a
trauma stat as EMS reported altered mental status, despite
administration of Narcan. The patient was unable to provide
any history.
Past Medical History:
unknown
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
HR: 106 BP: 130/p O(2)Sat: 98% Normal
Constitutional: Obtunded
HEENT: Blood coming from the right ear canal, obvious head
trauma
Collared
Chest: Bilateral breath sounds symmetric
Cardiovascular: Pulses intact throughout
Abdominal: Soft nondistended
Pelvic: Pelvis is stable
Extr/Back: No step-offs the TLS spine no obvious
deformities of any of his extremities, full range of motion
of all joints
Skin: Multiple abrasions over the extremities
Neuro: GCS 7, moves all extremities to painful stimuli,
normal rectal tone
Physical examination upon discharge: ___:
vital signs: t= 98.6, bp= 107/63, hr=65, rr=18, oxygen sat=100%
HEENT: sclera anicteric
CV: ns1,s2,-s3, -s4
LUNGS: clear
ABDOMEN: firm, non-tender, localized erythematous areas
NEURO: alert and oriented x 3, follows commands, muscle
strenght upper ext. +4/+5, lower ext. +5/+5
SKIN: scattered macular lesions with white center, abraded area
coccyx
Pertinent Results:
___ 11:20AM BLOOD WBC-8.2 RBC-4.75 Hgb-14.4 Hct-43.6 MCV-92
MCH-30.2 MCHC-32.9 RDW-13.4 Plt ___
___ 04:35AM BLOOD WBC-11.3* RBC-4.52* Hgb-13.3* Hct-42.4
MCV-94 MCH-29.4 MCHC-31.3 RDW-13.6 Plt ___
___ 04:20AM BLOOD WBC-12.3* RBC-4.58* Hgb-13.1* Hct-42.4
MCV-93 MCH-28.7 MCHC-31.0 RDW-13.6 Plt ___
___ 11:40AM BLOOD WBC-10.0 RBC-4.42* Hgb-13.3* Hct-40.3
MCV-91 MCH-30.1 MCHC-32.9 RDW-12.5 Plt ___
___ 04:10AM BLOOD Neuts-83.0* Lymphs-8.7* Monos-7.5 Eos-0.7
Baso-0.1
___ 11:20AM BLOOD Plt ___
___ 10:58AM BLOOD ___ PTT-34.6 ___
___ 11:40AM BLOOD ___ PTT-35.6 ___
___ 11:40AM BLOOD ___ 11:20AM BLOOD Glucose-78 UreaN-14 Creat-0.7 Na-140
K-4.0 Cl-96 HCO3-33* AnGap-15
___ 04:35AM BLOOD Glucose-86 UreaN-24* Creat-1.0 Na-143
K-5.1 Cl-99 HCO3-30 AnGap-19
___ 04:20AM BLOOD Glucose-105* UreaN-28* Creat-1.0 Na-141
K-4.5 Cl-101 HCO3-27 AnGap-18
___ 10:58AM BLOOD ALT-40 AST-45* LD(LDH)-262* AlkPhos-75
TotBili-0.5
___ 11:26PM BLOOD CK-MB-5 cTropnT-<0.01
___ 05:10PM BLOOD CK-MB-9 cTropnT-<0.01
___ 11:20AM BLOOD Calcium-10.0 Phos-3.6 Mg-1.8
___ 06:03AM BLOOD Vanco-9.3*
___ 02:23PM BLOOD freeCa-1.16
___: chest x-ray:
Right mid to lower lung consolidation is worrisome for contusion
___ this
patient with history of trauma and right 6th rib fracture.
Aspiration may also be present.
___: Head CT scan:
1. Multifocal punctate parenchymal hemorrhages ___ distribution
that is very concerning for diffuse axonal ("shear") injury, ___
this context.
2. Extensive right skull base fracture, as outlined above, with
possible
involvement of the right orbital roof.
___: CT c-spine:
No acute cervical spine fracture or abnormality of alignment.
The known right basilar skull fracture is described on report of
concurrent
head CT.
___: CT chest:
IMPRESSION:
1. Right lateral sixth rib fracture with underlying pulmonary
contusion,
mostly involving the right middle lobe. There is a tiny right
pneumothorax.
2. Bilateral lower lobe consolidations concerning for
aspiration.
3. Small, grade 1 hepatic laceration at the inferior aspect of
the right lobe with a small amount of blood surrounding.
4. Posterosuperior S1 fracture with displacement into the
neural foramen as well as bilateral lateral mass fractures of
S1.
5. Displaced anterior cortical fracture of S2.
6. Fracture of the right transverse process of L5.
7. Hematoma ___ the left piriformis muscle.
___: CTA of the neck:
Dissection with pseudoaneurysm formation of the right internal
carotid artery just proximal to where it enters the carotid
canal, without significant stenosis
___: MRI/MRA head:
Multiple hemorrhagic contusions. Numerous deep white matter,
corpus callosum, and dorsal midbrain hemorrhages ___ a
distribution typical of diffuse axonal injury
___: US of upper ext:
IMPRESSION:
1. No evidence of a right upper extremity deep vein thrombosis.
Note, the cephalic vein was not definitely visualized.
2. Moderate soft tissue edema.
___: CT head:
1. Interval increase ___ multiple sites of intraparenchymal
hemorrhage with distribution again concerning for diffuse axonal
injury.
2. Extensive skull base fracture as detailed above.
___ CT head:
IMPRESSION:
No significant interval change of hemorrhage. No new areas of
hemorrhage.
___: chest x-ray:
Increased right base consolidation and pleural effusion is
suspicious for pneumonia. Mild vascular congestion is new. ET
and NG tube have been removed.
___: chest x-ray:
As compared to the previous radiograph, the opacity at the right
lung base has substantially increased. No opacities have
newlyappeared.
Unchanged minimal retrocardiac atelectasis. Borderline size of
the cardiac silhouette. The monitoring and support devices have
been removed ___ the interval.
___: GI/GJ tube check:
Oral contrast has been injected into the patient's PEG, with
oral
contrast opacifying the stomach.
___: chest x-ray:
Heart size, mediastinal and hilar contours are normal. Lungs
are
clear except for minimal atelectasis ___ the left retrocardiac
region which has improved ___ extent since the prior study.
___ 12:33 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ CLUSTERS.
2+ ___ per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
STAPH AUREUS COAG +. MODERATE 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----------<=0.12 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ 12:43 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
~6OOO/ML Commensal Respiratory Flora.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
ENTEROBACTER AEROGENES. ~3000/ML.
WORK-UP PER ___ ___ (___).
Isolates are considered potential pathogens ___ amounts
>=10,000
cfu/ml.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROBACTER AEROGENES
|
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
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our ___
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
FUNGAL CULTURE (Preliminary):
YEAST.
Brief Hospital Course:
The patient was an unrestrained driver who hit a tree. The
patient was intubated at the scene and transported to the ___
___ for further management. Upon
admission, the patient was given intravenous fluids and
underwent imaging of his head, neck, chest, and abdomen. He was
transported to the intensive care unit for monitoring. After
review of the imaging. the patient was reported to have
sustained a right 5th rib fracture, bilateral pulmonary
contusions, grade 1 liver laceration, S1-2 fracture, L5
transverse process fracture, right mastoid/sphenoid fracgture,
diffuse intraparenchymal hemorrhage, and right carotid
dissection. Because of the extent of his injuries, the patient
was evaluated by neurosurgery, ortho-spine, and neurology.
The patient was found on head cat scan to have multiple punctate
hemorrhages ___ the left frontal, left cerebellar and left and
right temporal lobes. On CTA, he was noted to have a possible
dissection of the right internal carotid artery Neurosurgery was
consulted and gave recommendations including initiating Mannitol
but no surgical intervention was needed. Daily doses of aspirin
were ordered for management of his right carotid dissection.
Because of his head injury the patient had bouts of agitation
controlled with Ativan. There was concern for alcohol
withdrawal and and the psychiatric service was consulted. The
patient was started on clonidine, methadone, Ativan and Haldol.
The patient self-extubated on HD #3 and required re-intubation
within 24 hours for respiratory failure. After aggressive
pulmonary toilet, the patient was extubated on HD #6. The
patient was bronched and was reported to be growing staph aureus
coag. + was started on a 7 day course of naficillin. ___ order to
provide nutrition to the patient, a Dobhoff feeding tube was
placed and later changed to a PEG for long term nutritional
support. Tube feedings were initiated. The patient continued to
experience bouts of agitations and the Psychiatry service was
again consulted. After evaluating the patient, they recommended
a weaning regimen for the Ativan, Haldol, and methadone.
Monitoring of the QTC interval was ordered and measured prior to
dosing of medications. After completing his 7 day course of
nafcillin, the patient completed a 5 day course of levaquin for
persistent pneumonia. Psychiatry reevaluated the patient and
switched his medication regiemen to Ativan, Seroquel, and a
standing dose of methadone.
During his hospital course, the patient was seen by the Spine
service because of his transverse process and sacral fracture.
No surgical intervention was indicated and no weight bearing
restrictions were implemented. He was reevaluated by the Ortho
Trauma service and they recommended 50% weight bearing on the
left side and WBAT on the right however they commented it is
unlikley he would be able to comply. The patient was evaluated
by physical therapy and a plan for discharge was developed. A
mild increase ___ his white blood cell count was noted on HD #10
and the patient's foley catheter and central venous line were
removed and sent for culture. No The patient underwent a chest
x-ray which showed a right lung opacity and the patient was
started on a week course of levofloxacin. He remained afebrile
and his white blood cell count gradually normalized. The patient
also had his feeding tube pulled before discharge as he was
taking adequate food and nutrition.
The patient's mental status has been variable with periods of
confusion and lucidity. The psychiatric service has been
evaluating him and adjusting his anti-psychotic medications.
Over the last few days, he has become oriented to time, person,
and place and has been cooperative with activities. He still
requires assistance with toileting and reminders of daily
activity. Over the last 24 hours he was noted to have a rash on
his lower back. He also reported intense muscle spasms ___ lower
extremities which were relieved with ambulation. His
electrolytes were monitored and within normal limits. The
patient's vital signs have been stable and he has been afebrile.
He has been tolerating a regular diet with 1:1 superivsion and
voiding without difficulty. He has been maintained ___ a Veille
bed because of his episodes of compulsiveness and to reduce the
risk of falls. On HD #26, he was discharged ___ stable condition
to the ___ facility. Follow-up appointments were
scheduled for him, including 2 ENT appointments with
Ortho-spine, Neurosurgery, and the acute care service.
Medications on Admission:
suboxone
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing, SOB
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QWED
5. Docusate Sodium 100 mg PO BID
6. Heparin 5000 UNIT SC TID
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing, SOB
8. Multivitamins 1 TAB PO DAILY
9. Methadone 35 mg PO DAILY
10. Metoprolol Tartrate 25 mg PO BID
11. QUEtiapine Fumarate 50 mg PO QID
hold if patient sleeping
12. QUEtiapine Fumarate 50 mg PO BID:PRN agitation
13. Acetaminophen 325-650 mg PO Q6H:PRN pain
14. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain
15. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Trauma:
Bilateral pulmonary contusions
right rib fracture
G1 liver laceration
Right temporal bone fracture, to sphenoid
punctate IPH c/w diffuse anoxal injury
L5 transverse process fracture
S1-S2 fracture
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:
You were admitted to the hospital after you were involved ___ a
motor vehicle accident. You sustained injuries to your head,
face, back, and abdomen. You were monitored ___ the intensive
care unit until your stable and then transported to the surgical
floor. You have slowly improved from your injuries but will need
a ___ facility to assisst you. Your vital signs
have been stable and your neurological status is improving. You
are now preparing for discharge to a ___ facility.
Followup Instructions:
___
|
10280283-DS-7 | 10,280,283 | 26,244,329 | DS | 7 | 2178-12-08 00:00:00 | 2178-12-08 13:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Crestor / Penicillins / Vytorin ___
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with HTN, dyslipidemia, AF, presents with chest pressure
beginning at 2am this morning. ___ intensity, radiates down
left arm. Not pleuritic, positional. Also unrelated to exertion.
Lasted 1 hour them remitted, but recurred several times
throughout the day so came in to be evaluated.
Of note, normal ETT in ___, clean cath in ___
In the ED intial vitals were: pain 6 97.8 74 149/92 16 100%.
- CBC and Chem 7 were unremarkable. Troponin x 1 was <0.01 and
lactate was 1.2.
- ECG showed STE in lead II so code STEMI was called, but cards
felt this was not likely acute STEMI
- Patient was given: ASA 325, nitroglycerin x 1
Vitals on transfer pain 0 98.1 82 143/81 15 100% RA
On the floor the patient reports feeling well and has had no
chest pain since 6pm. He reports feeling well and would like to
be discharged tomorrow AM. He is already planning to get a
stress test next ___ as part of Tinsel Study with Dr. ___.
ROS: On review of systems, s/he denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. S/he denies recent
fevers, chills or rigors. S/he denies exertional buttock or calf
pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
- Dyslipidemia
- Paroxysmal atrial fibrillation
- Hypertension
- Hyperthyroidism
- Tachycardia-induced cardiomyopathy from thyrotoxacosis
Social History:
___
Family History:
- Brother with MI at age ___
No family history of early arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION
VS: T 98 HR 76 BP 138/85 RR 20 SaO2 99% on RA
General: Well appearing man in NAD
HEENT: EOMI, MMM
Neck: JVP ~8cmH2O
CV: RRR, no m/r/g.
Lungs: CTAB
Abdomen: Soft, nontender
GU: No foley
Ext: Nonedematous
Neuro: A&Ox3. Nonfocal.
Skin: No rash
PULSES: 2+ DPs
DISCHARGE:
VS: T 98 HR 76 BP 138/85 RR 20 SaO2 99% on RA
General: Well appearing man in NAD
HEENT: MMM, OP non-erythematous
Neck: No JVD
CV: RRR, no m/r/g.
Lungs: CTAB
Abdomen: Soft, nontender, normoactive BS
Ext: warm, no edema.
Neuro: A&Ox3. Nonfocal.
Skin: No rash
PULSES: 2+ DPs
Pertinent Results:
ADMISSION LABS
___ 05:30PM BLOOD WBC-10.5 RBC-4.68 Hgb-14.4 Hct-42.7
MCV-91 MCH-30.8 MCHC-33.8 RDW-12.2 Plt ___
___ 05:30PM BLOOD Neuts-79.8* Lymphs-10.8* Monos-7.9
Eos-0.9 Baso-0.5
___ 05:30PM BLOOD ___ PTT-45.3* ___
___ 05:30PM BLOOD Glucose-92 UreaN-17 Creat-1.1 Na-143
K-4.0 Cl-104 HCO3-29 AnGap-14
___ 05:30PM BLOOD Calcium-9.5 Phos-2.8 Mg-2.2
___ 05:30PM BLOOD cTropnT-<0.01
___ 01:22AM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:44PM BLOOD Lactate-1.2
___ CXR
FINDINGS: PA and lateral views of the chest were provided
demonstrating no focal consolidation, effusion or pneumothorax.
The cardiomediastinal
silhouette is normal. Bony structures are intact. There is no
free air below the right hemidiaphragm.
IMPRESSION: No acute intrathoracic process.
EKG: normal sinus rhythm. normal axis. subtle global PR
depression and ST elevation, most prominent in lead II.
DISCHARGE LABS
___ 08:20AM BLOOD WBC-9.9 RBC-5.01 Hgb-15.2 Hct-45.5 MCV-91
MCH-30.3 MCHC-33.4 RDW-12.6 Plt ___
___ 08:20AM BLOOD Glucose-105* UreaN-12 Creat-0.9 Na-141
K-4.0 Cl-102 HCO3-28 AnGap-15
___ 08:20AM BLOOD Calcium-9.4 Phos-2.6* Mg-2.1
___ 08:20AM BLOOD ___ PTT-40.2* ___
Brief Hospital Course:
___ M with HTN, Afib on coumadin, hyperthyroidism presents with
crescendo chest pain x 1 day.
# CHEST PAIN: atypical angina, given non exertional, not
relieved by nitroglycerin, episodes lasting >1 hour. Troponin
negative x 2. EKG without ischemic changes; slight ST elevation
in lead II was present on old EKG. Concern for unstable angina;
pt was loaded with clopidogrel but not placed on heparin given
therapeutic INR. Pt's chest pain resolved completely upon
admission. Given resolution of chest pain, negative trop and
EKG, the patient was indicated for non-urgent stress testing. Pt
was instructed to attend his already-scheduled outpatient stress
on next ___ as part of a clinical study. Pt reports he can
tell when he is in Afib and when he is in sinus, and denied
being in Afib during episodes of chest pain. Upon further
review, EKG notable for subtle global PR depression. Pt reported
non-productive cough and URI sx for the 3 days prior to
admission. Early pericarditis was considered, however given pt
did not report pleuritic or positional nature to his chest pain,
and chest pain had resolved, pt was not discharged on treatment
for pericarditis. He was instructed to follow up with his
cardiologist Dr. ___ his pain recurred.
# ATRIAL FIBRILLATION: Rate well controlled. Pt was maintained
on metoprolol. Warfarin was held ___ for possibility of
catheterization. INR remained therapeutic at 2.3 on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. coenzyme Q10 10 mg oral qd
4. Fish Oil (Omega 3) 1000 mg PO BID
5. Cyanocobalamin 1000 mcg PO DAILY
6. Warfarin 5 mg PO 4X/WEEK (___)
7. Warfarin 7.5 mg PO 3X/WEEK (___)
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Pravastatin 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO BID
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. coenzyme Q10 10 mg oral qd
8. Pravastatin 20 mg PO DAILY
9. Warfarin 5 mg PO 4X/WEEK (___)
10. Warfarin 7.5 mg PO 3X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
chest pain, non-anginal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to take care of your during your stay at
___. You came in with chest pain concerning for coronary
artery disease. However, your cardiac enzymes remained negative.
Your EKG was not consistent with coronary artery disease, but
suggested the possibility of inflammation of the sac around the
heart, called pericarditis. Since you pain resolved in less than
24 hours, we will take a strategy of watchful waiting, to see if
your chest pain recurs. You should follow up with your
cardiologist Dr. ___ 2 weeks.
Followup Instructions:
___
|
10281078-DS-17 | 10,281,078 | 21,564,186 | DS | 17 | 2143-05-02 00:00:00 | 2143-05-02 09:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
headache, wound drainage
Major Surgical or Invasive Procedure:
None this admission
History of Present Illness:
Ms. ___ is a ___ female status
post craniotomy for colloid cyst resection. She did initially
well postoperatively, but now has been sick and feeling ill,
shaky, cold for the last week.
There is a question of drainage from the incision, but it has
not
drained the last two days.
I proceeded today with doing a lumbar puncture to rule out
meningitis and also measuring an opening pressure. Results of
that will be dictated in a different note.
We sent the CSF for stat Gram-stain cultures, cell count,
protein
and glucose and we will inform the patient of the results today.
If nothing new comes from this lumbar puncture and CSF studies,
we will see the patient back in one week for wound check.
Past Medical History:
HTN
NIDDM
Hypercholesterol
Arthritis
Diverticulitis
Social History:
___
Family History:
Father deceased from MI vs. aneurysm. Mother deceased, ___
bladder cancer & dementia at advanced age. No family history of
early onset dementia.
Physical Exam:
Upon discharge:
previous inc cdi, well healed
neuro intact with no deficits
Pertinent Results:
___ CSF CULTURE: No growth
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Test performed by Lateral Flow Assay.
Results should be evaluated in light of culture results
and clinical
presentation.
Brief Hospital Course:
Ms. ___ is a ___ year old female who was admitted on ___ for
a concern for possible meningitis. CSF was obtained by lumbar
puncture and studies were sent. She as started on empiric
treatment with vancomycin and cefipime.
On ___, ID was consulted. She was given a one time dose of
decadron.
On ___, she remained hemodynamically and neurologically stable
on antibiotics and waiting for cultures to grow.
On ___, She was consented for PICC line.
On ___, the final cultures were negative will go home tomorrow
with Vanco 1gram bid and Cipro 500m po bid for a total of 14
days. She will follow up with her PCP with lab results ___ she
lives in ___. Her PICC line was placed on the left arm.
___: dc home w/ ___ services for IV abx
Medications on Admission:
keppra, metformin, simvastatin, valsartan, tylenol
Discharge Medications:
1. Vancomycin 1000 mg IV Q 12H
Continue for a total of 14 days. Stop ___
RX *vancomycin 500 mg 2 vials twice a day Disp #*40 Vial
Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days
Continue for a total of 14 days (switched to cipro from
Cefepime). Stop ___
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*20 Tablet Refills:*0
3. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
RX *sodium chloride 0.9 % [Normal Saline Flush] 0.9 % 1 inj
Daily Disp #*20 Syringe Refills:*0
4. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL
2 ML Daily Disp #*10 Syringe Refills:*0
5. LeVETiracetam 750 mg PO BID
6. Valsartan 320 mg PO DAILY
7. Simvastatin 40 mg PO QPM
8. Bisacodyl 10 mg PO DAILY:PRN constipation
9. Docusate Sodium 100 mg PO BID
10. Acetaminophen 325-650 mg PO Q6H:PRN pain
Do not exceed more than 4 grams in 24hrs.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Meningitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a concern of possible meningitis
Discharge Instructions
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
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.
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.
Followup Instructions:
___
|
10281385-DS-16 | 10,281,385 | 28,192,801 | DS | 16 | 2197-12-19 00:00:00 | 2197-12-19 17:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
CODE STROKE for left hemiparesis
Major Surgical or Invasive Procedure:
-Right MCA clot retrieval with ___ and Solitaire devices
History of Present Illness:
Ms. ___ is a ___ year old right handed woman who presented
with an acute onset left face and hemibody paresis with a
background
history of HTN and DM2. She had just attended her brother's wake
and was accompanied by her daughter. Her daughter brought her
home where they arrived at ___. They walked together from the
car and up the pathway to the apartment when she suddenly
dropped
her cane from her left hand. Her head seemed to tilt
down/forwards. Her daughter realized something was wrong and
called EMS. She thought she was hypoglycemic so the daughter
gave
her some orange juice which the patient attempted to swallow and
then quickly spat out. Here, she was noted initially to have an
NIHSS of 17 (performed by the ED, confirmed by my examination as
18) and was brought to the CT scanner for CT, CTA, and CTP which
revealed no hemorrhage but evidence of a R M2 superior division
cutoff and considerable increased MTT without decreased CBV. She
was given IV tPA at 80 minutes after LSW time with minimal
improvement in her deficits, so she is being brought to the
Neurointerventional suite for IA therapy.
This clinical history is mostly provided by her daughter at the
bedside who is translating for the patient who only speaks
___.
These symptoms are completely new to her. She has no history of
GI bleed, stroke, cerebral hemorrhage, head injury, surgery to
the ___ or spine (except one spine surgery at least ___ years
ago), or known vascular malformations.
The review of systems is limited due to the patient's critical
status, but the daughter thinks that she may have lost weight
(up
to ___ lbs over the past few months).
Past Medical History:
[] Cardiovascular - HTN
[] Endocrine - Diabetes mellitus type 2
[] MSK - Bilateral knee replacement and b/l redo ___ ago),
Spinal stenosis (1 surgery ___ ago)
[] Urologic - Recurrent UTIs (with retention, self
catheterization daily)
Social History:
___
Family History:
CAD (brother, MI x 2). ___ disease (brother). ___
aneurysm (first cousin). Mother died young of uncertain causes.
No known stroke or seizures.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS T: 97.3 HR:75 BP:166/67 RR:17 SaO2: 98%RA
General: NAD, lying in bed, head turned to right, elderly woman.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, some resistance to leftward rotation, otherwise no
nuchal rigidity, no cervical artery bruits
Cardiovascular: RRR, soft aortic systolic murmur
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 [18]
1a. Level of Consciousness - 0
1b. LOC Questions - 0
1c. LOC Commands - 1
2. Best Gaze - 2
3. Visual Fields - 2
4. Facial Palsy - 3
5a. Motor arm, left - 4
5b. Motor arm, right - 0
6a. Motor leg, left - 1
6b. Motor leg, right - 0
7. Limb Ataxia - 1
8. Sensory - 2
9. Language - 0
10. Dysarthria - 1
11. Extinction and Neglect - 1
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, age and
month. Attention to examiner easily attained and maintained.
Responds to simple commands in ___ and ___ initially does
not close eyes to command, but later is able to. 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. Moderate dysarthria. Identifies her
left hand as belonging to the examiner.
- Cranial Nerves - PERRL 3->2 brisk. VF diminished to blink to
threat in the left upper and left lower quadrants. Unable to
gaze
left past midline, but otherwise EOMI with no nystagmus. V1-V3
without deficits to light touch bilaterally. Pronounced L lower
face weakness at rest and with volitional smile, flat nasolabial
fold. Hearing grossly intact. Palate elevation symmetric. No
trapezius movement on the left; head deviated to the right.
Tongue midline.
- Motor - Normal bulk. No pronation, no drift on RUE. On LUE, no
movement. No tremor or asterixis.
[ Direct Confrontational Strength Testing ]
Arm
Deltoids [C5] [R 5] [L 0]
Biceps [C5] [R 5] [L 0]
Triceps [C6/7] [R 5] [L 0]
Flexor Digitorum [C8] [R 5] [L 0]
Leg
Iliopsoas [L1/2] [R 5] [L 4+]
Quadriceps [L3/4] [R 5] [L 5]
Hamstrings [L5/S1] [R 5] [L 4+]
Tibialis Anterior [L4] [R 5] [L 5-]
Gastrocnemius [S1] [R 5] [L 5]
- Sensory - No deficits to light touch on R. No withdrawal to
pain on LUE. Responds to pain and light touch on LLE.
- Reflexes
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 0 0 0 1 1
R 2 2 2 2 1
Plantar response extensor on left, flexor on right.
- Coordination - FTN intact on right arm, HKS intact on right
leg. HKS clumsy with left leg.
- Gait - deferred.
DISCHARGE PHYSICAL EXAM:
- Vitals: Tc/Tm 99.6 BP 120-140/50-70 P ___ RR 18 97% RA FSBS
170-200
- Neuro: eyes open spontaneously. Responds to questions with
one-word answers. Comprehension appears intact (primarily ___
speaking). Rightward head deviation. Right gaze deviation (can
cross midline). Right facial droop. Left arm fully plegic,
triple flexion of left leg. Right side full strength. Toes
briskly upgoing on left, upgoing on right.
Pertinent Results:
ADMISSION LABS:
___ 08:45PM BLOOD WBC-8.0 RBC-4.19* Hgb-12.9 Hct-38.1
MCV-91 MCH-30.9 MCHC-34.0 RDW-12.2 Plt ___
___ 08:45PM BLOOD ___ PTT-28.2 ___
___ 08:45PM BLOOD UreaN-28*
___ 04:06AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.7 Cholest-155
___ 08:54PM BLOOD Glucose-148* Na-142 K-3.7 Cl-106
calHCO3-21
PERTINENT LABS:
- %HbA1c-6.2* eAG-131*
- Triglyc-104 HDL-58 CHOL/HD-2.7 LDLcalc-76
- TSH-2.3
DISCHARGE LABS:
___ 09:15AM BLOOD WBC-9.0 RBC-3.3* Hgb-10.6* Hct-29.8*
MCV-91 MCH-32.4* MCHC-33.6 RDW-12.7 Plt ___
___ 09:15AM BLOOD Glucose-210* UreaN-22* Creat-0.6 Na-136
K-4.2 Cl-103 HCO3-22 AnGap-15
NCHCT/CTA HEAD AND NECK (___):
1. Right middle cerebral artery superior division occlusion.
There is
prolonged mean transit time with decreased cerebral blood flow,
but preserved cerebral blood volume suggesting ischemia without
large core infarct. Patchy hypodensities in the right MCA
distribution in the centrum semiovale and the corona radiata
may reflect areas of infarct or small vessel disease. There is
no other intracranial vascular occlusion.
2. Area of hypodensity in the right cerebellar hemisphere,
likely representing a chronic infarct given subsequent MRI
findings.
3. No hemodynamically significant stenosis, dissection, or
occlusion in the neck vasculature.
TTE (___):
The left atrium is normal in size. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. Mild (1+) aortic regurgitation is
seen. 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. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
EKG (___): Sinus tachycardia. Non-specific ST-T wave
changes. Compared to the previous tracing of ___ the rate is
faster and ST-T wave changes are more prominent.
NCHCT (___): In comparison to ___, there is
significant interval progression of right hemispheric edema.
Additionally, hyperdensity in the right basal ganglia likely
reflects hemorrhagic transformation of patient's known right MCA
infarct, contrast enhancement due to compromised blood ___
barrier, or both. MRI will be helpful for further
characterization.
MRI HEAD (___): Right MCA infarct, predominantly involving
its superior division. Areas of hemorrhage within infarcted
parenchyma, compatible with hemorrhagic transformation. Right
hemispheric edema has significantly progressed since ___
exam, and is unchanged since study obtained earlier today.
NCHCT (___): Stable right MCA infarction with foci of
hemorrhage stable from most recent NECT of the head.
CTA CHEST (___):
1. Dilatation of the ascending aorta to 4.0 x 3.9 cm. No
evidence of
atheroma within the thoracic aorta.
2. Mild cardiomegaly.
3. Secretions within the trachea without evidence for
parenchymal aspiration.
4. Fatty liver.
Brief Hospital Course:
___ yo RH ___ woman with h/o HTN and DM2 who presented with
acute left facial, arm and leg paresis, found to have acute
stroke in right M2 superior division.
# NEURO: Patient received IV tPA in the ED. When her exam did
not show significant improvement, she underwent surgical clot
retrieval with ___ and Solitaire devices with successful
restoration of flow to superior division of right MCA. She was
then admitted to the ICU for monitoring. Repeat imaging showed
significant edema and some hemorrhagic conversion in the MCA
territory. Fortunately, repeat non-contrast head CTs showed no
expansion of the hemorrhage. On HD #5 she was transferred from
the ICU to the floor where her she remained stable.
Embolic source for stroke was suspected given M2 cut-off on CTA,
so extensive workup was pursued. Ultimately there was no embolic
source found: TTE appeared normal, no e/o PFO/ASD or thrombi and
LVEF>55%. She was monitored on telemetry throughout
hospitalization and had no episodes of AFib. No source of
artery-to-artery emboli on CTA. A1C 6.2%, LDL 76. Aortic arch
atheroma was also ruled out via CTA chest. Of note, CTA chest
incidentally showed 4cm thoracic aortic aneurysm.
Given that there was no clear embolic source for her stroke, as
well as presence of aortic aneurysm, it was decided not to start
Coumadin. Patient was instead started on ASA 81mg daily two days
after receiving IV tPA and clot retrieval.
Clinically, patient had some small improvement in her neurologic
exam during hospitalization. By HD #3 her dense eye-opening
apraxia had resolved and right gaze deviation improved (able to
cross midline). On discharge she had fully plegic left arm,
triple flexion of left leg, rightward head and gaze deviation
and minimal speech output. She will be discharged to acute
rehab.
Of note, patient developed torticollis ___ rightward head
deviation ___ stroke. This was treated supportively with soft
cervical collar and massage. On HD #11 tizanidine 2mg BID was
started for muscle spasm.
# GI: Patient failed video swallow eval so Dobhoff tube was
placed in the ICU. She again failed a repeat video swallow and
a percutaneous gastrostomy tube was placed on HD #10. Tube feeds
were started 24 hours afterward and advanced to goal 40cc/hr.
# CV:
(1) HTN: Treated with IV hydralazine + labetalol while NPO. Once
Dobhoff tube placed, restarted home HCTZ 25mg daily + lisinopril
40mg daily. Also started atenolol 12.5mg daily to reduce aortic
wall stress in setting of incidentally detected aortic aneurysm
(see below).
(2) Ascending aortic aneurysm: 4cm in diameter, incidentally
found on CTA chest. Started atenolol 12.5mg daily for treatment.
She will need repeat CTA in 6 months and ___ year for
surveillance, to be followed up by PCP.
# ID: Patient febrile with leukocytosis in ICU, found to have
pan-sensitive E. coli UTI (has h/o chronic urinary retention and
has frequent UTIs at baseline). Initially treated with
Vanc/Cefepime, then narrowed to Ceftiaxone when cultures
returned. She will complete 10 day course, last day = ___.
# ENDO: Has h/o NIDDM. Home oral glycemics (metformin 500mg BID
+ glyburide 5mg TID) were held during hospitalization and
replaced with sliding scale insulin. Her blood sugars were
labile secondary to tube feeds so she was started on glargine
6mg HS as well. At rehab her insulin should be discontinued and
she should be restarted on metformin and glyburide.
# CHRONIC MEDICAL PROBLEMS:
(1) Recurrent UTIs: Has h/o urinary RETENTION, self catheterizes
daily at home. Foley in place during hospitalization, should be
discontinued at rehab and straight cath restarted.
(2) GERD: continued home omeprazole 20mg daily.
(4) MSK pain: held home tramadol during hospitalization.
==========================================
TRANSITIONS OF CARE:
- 4cm thoracic aortic aneurysm incidentally found on CTA chest.
Should have repeat CTA in 6 months for follow up.
- Home metformin + glyburide held during hospitalization. Should
D/C insulin and restart these meds at rehab.
- Please D/C Foley and resume intermittent straight
catheterization at rehab.
Medications on Admission:
glyburide 5mg TID
hydrochlorothiazide 25mg daily
lisinopril 40mg daily
metformin 500mg BID
methenamine hippurate 1g BID with 500mg Vitamin C
Omeprazole 20mg daily
tramadol 50mg ___ tablets every ___ as needed for pain
Discharge Medications:
1. methenamine hippurate *NF* 1 gram Oral BID
2. Ascorbic Acid ___ mg PO BID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 20 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atenolol 12.5 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. CeftriaXONE 1 gm IV Q24H Duration: 1 Days
First day = ___
Last day = ___
9. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
10. Glargine 6 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
11. Nystatin Oral Suspension 5 mL PO QID
12. Tizanidine 2 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ACUTE ISSUES:
1. Right MCA acute ischemic stroke s/p tPA + surgical clot
retrieval
CHRONIC ISSUES:
1. Thoracic Aortic Aneurysm (4.0x3.9cm)
2. Hypertension
3. DMII
4. Recurrent UTIs (h/o urinary retention)
5. GERD
6. MSK pain
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 ___,
___ was a pleasure taking care of you during your hospitalization
at ___. You were admitted
because of acute onset left face and left body paralysis caused
by an acute ischemic stroke in your ___. You were treated with
a medication to destroy any clots in addition to surgical
removal of the clot. You tolerated these treatments well. You
had difficulty swallowing after the stroke and a tube was placed
through your nose into your stomach to deliver nutrition. A
feeding tube was then surgically placed in your stomach for
longer-term nutrition while your ability to swallow recovers.
.
The reason for the clot formation and subsequent stroke remains
unclear. We found no evidence that the stroke occurred because
of heart disease. In addition, your diabetes and cholesterol are
under good control.
.
In addition, your images revealed a dilation of one of the large
blood vessels from the heart, called a thoracic aortic aneurysm.
To prevent a potential rupture of this vessel, we have started
you on a heart medication (Carvedilol) that reduces your heart
rate. It is also important that you monitor the size of this
dilation. You should have repeat imaging of your chest and heart
in 6 months (see below for information about scheduling this).
.
We have made the following changes to your medications:
1. STARTED aspirin 81mg daily (to prevent strokes in the future)
2. STARTED atenolol 12.5mg daily
3. CHANGED lisinopril from 40mg daily to 20mg twice daily
3. HELD your oral diabetes meds (metformin 500mg twice daily and
glyburide 5mg three times daily) --> can be restarted in rehab
as tolerated
4. STARTED insulin (glargine 6 units before bedtime + sliding
scale) to treat your diabetes
6. STARTED ceftriaxone 1gram daily for 10 days to treat your
urinary tract infection (last day = ___
7. STARTED nystatin oral solution 5mg three times daily to treat
oral thrush
8. STARTED tizanidine 2mg by mouth twice daily to treat the
muscle spasms in your neck
Followup Instructions:
___
|
10281385-DS-17 | 10,281,385 | 27,441,232 | DS | 17 | 2198-02-25 00:00:00 | 2198-02-25 14:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
___ PEG-GJ tube exchange (___)
History of Present Illness:
___ year old female with a history of R MCA stroke with residual
left sided weakness and dysphagia (s/p J tube) who presents with
respiratory distress.
Mrs. ___ was in her usual state of health until last ___
when a leak developed in her J tube. She had been on 50% PO
diet and 50% J tube calories due to residual oropharyngeal motor
deficits following her stroke in ___. However, after her J
tube began leaking, the speech pathology team at her rehab
facility felt that she could be trialed on a 100% PO diet. She
was trialed on a 7 day 100% PO diet which went well up until
last night, when per report she suffered chocking following
eating some yogurt. She subsequently developed respiratory
distress, so she presented to the ED. Prior to this, she denies
having dyspnea, fevers, chills, cough at home.
In the ED, vitals were 105 158/75 30 100% on 100%
non-Rebreather. RT suctioned the patient with return of
frothy/milky thin secretions. Patient was with "abundant rales"
on right. She improved on nebulizers and SpO2 was 98% prior to
getting to the floor.
Overnight she triggered for sinus tachycardia to 130s which
improved with metoprolol.
This AM, she reports feeling well and denies cough, chest pain,
dyspnea, abdominal pain, dysuria.
Past Medical History:
- Right MCA stroke s/p clot retrieval on ___
- Dysphagia ___ stroke with frank aspiration on video swallow
___
- Hypertension
- Diabetes mellitus, type 2
- Bilateral knee replacements
- Spinal stenosis s/p surgery ___
- Urinary retention requiring self catheterizations pre stroke
- Spinal stenosis
- Anxiety
- GERD
Social History:
___
Family History:
- Brother: CAD (MI x 2), ___ disease
- Cousin: ___ aneurysm
- Mother: Died young of unknown causes
- No history of stroke or seizures.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T 98.0 BP 126/55 HR 112 RR 20 SaO2 100% on 3L
General: Alert, oriented. ___ and ___ speaking. Daughter
___ present at bedside and translating
HEENT: Left sided facial droop. MMM. Grossly intact swallowing
mechanism on palpation of neck.
Neck: No JVD
Lungs: CTAB without wheezing, rales
CV: RRR, no m/r/g. Not tachycardic currently.
Abdomen: Soft, nontender. Ecchymosis on mid-abdomen. J tube site
without erythema, discharge, leaking. Site is nontender.
Ext: WWP, nonedematous
Neuro: A&Ox3. Left arm weakness. Wiggles toes. Sensation
intact
DISCHARGE PHYSICAL EXAM:
Vitals: T 97.3 BP 131/57 HR 69 RR 18 SaO2 99% on RA
General: Alert, oriented x 3. ___ and ___ speaking.
HEENT: Left sided facial droop. MMM.
Neck: No JVD
Lungs: CTAB without wheezing, rales
CV: RRR, no m/r/g.
Abdomen: Soft, nontender. Ecchymosis on mid-abdomen is improved.
New J-tube in place without erythema, leaking, discharge. Site
is nontender.
Ext: WWP, nonedematous
Neuro: A&Ox3. Left arm weakness. Wiggles toes. Sensation
intact.
Pertinent Results:
___ 12:00AM BLOOD WBC-7.7 RBC-4.51# Hgb-13.1 Hct-41.4#
MCV-92 MCH-29.1# MCHC-31.8 RDW-13.8 Plt ___
___ 05:21AM BLOOD WBC-11.6*# RBC-3.97* Hgb-11.4* Hct-36.4
MCV-92 MCH-28.6 MCHC-31.2 RDW-13.7 Plt ___
___ 05:38AM BLOOD WBC-4.7# RBC-3.57* Hgb-10.5* Hct-33.3*
MCV-93 MCH-29.5 MCHC-31.6 RDW-13.4 Plt ___
CHEST X-RAY (___)
Heart size and mediastinum are stable. Lungs are clear with no
evidence of aspiration. There is potential subluxation of the
left shoulder. No evidence of pneumothorax or pleural effusion
is seen.
SWALLOW EVALUATION:
EVALUATION:
An oral and pharyngeal swallowing videofluoroscopy was performed
today in collaboration with Radiology. Honey-thick liquid and
pureed consistency barium were administered. Results follow:
ORAL PHASE: Bolus formation was moderately impaired. Bolus
control was moderately impaired without anterior spill. A-P
tongue movement was moderately impaired and characterized by
lingual weakness and tongue pumping when attempting to initiate
a
dry swallow. Lingual weakness resulted in a moderate amount of
oral cavity residue. Oral transit time was moderately impaired.
Pt with premature spill over to the level of the valleculae with
honey thick liquids.
PHARYNGEAL PHASE:Swallow initiation was mildly delayed.
Laryngeal elevation was mildly reduced. Laryngeal valve closure
was moderately reduced. There was a trace to mild amount of
residue in the valleculae, the pyriform sinuses, and along the
aryepiglottic folds after the swallow with honey thick liquids.
Velar elevation, epiglottic deflection, bolus propulsion, and
pharyngoesophageal sphincter relaxation were all WNL.
ANTERIOR TO POSTERIOR POSITION: N/A
ASPIRATION/PENETRATION:There was mild aspiration before the
swallow with tsp honey thick liquids due to premature spillover,
swallow delay, and reduced laryngeal valve closure. There was
also a mild amount of aspiration after the swallow with tsps
honey thick liquids due to pharyngeal residue. Pt was not
sensate
to aspiration events during today's evaluation and cued cough
and
throat clear were only mildly beneficial at clearing aspirated
material form the laryngeal vestibule.
TREATMENT TECHNIQUES:Pt benefitted form taking repeat dry
swallows to decrease oral and pharyngeal residue. Cued cough
was
only mildly beneficial at decreasing amount of residue remaining
in the laryngeal vestibule after an aspiration event.
SUMMARY:Pt presented with moderate oral and pharyngeal dysphagia
characterized by lingual weakness, poor bolus control, premature
spill over, oral cavity reissue, swallow delay, and reduced
laryngeal valve closure. These deficits resulted in mild
aspiration of tsps honey thick liquids before and after the
swallow. Aspiration was silent and cued cough was only mildly
beneficial at clearing the laryngeal vestibule. Based on the
results of the current evaluation, it is recommended that the Pt
remain NPO with all nutrition, hydration, and medication via
alternate means. Given that Pt has long standing history of
dysphagia and current swallow function not likely to improve in
the short term, support replacing PEG for longer term
alternative
means of nutrition. Based on observations made today, Pt likely
safe to initiate supervised trials of honey thick liquids and
pureed solids with SLP, once her current acute medical issues
have resolved. Given that aspiration was silent today, Pt's
diet
should not be advanced without repeat videoswallow study at
rehab.
RECOMMENDATIONS:
1. NPO with all nutrition, hydration, and medication via
alternative means
2. as Pt has long standing history of dysphagia and current
swallow function not likely to improve in the short term,
support
replacing PEG for linger term alternative means of nutrition
3. Q4 oral care
4. once Pt's overall medical status has improved, Pt felt to be
safe to initiate supervised trials of pureed solids and honey
thick liquids with SLP
5. as Pt's aspiration was silent during today evaluation,
recommend repeat video swallow study at rehab prior to diet
advancement
Brief Hospital Course:
___ F with recent R MCA stroke and residual left-sided weakness,
impaired swallow, who presents with aspiration event.
#) ASPIRATION/Severe dysphagia: Frankly aspirating per video
report and may have been silently aspirating during PO trial
this week PTA. Supporting this is the milky fluid which was
suctioned in the ED. Reassuringly, serial CXRs without evidence
of PNA/pneumonitis. Patient leukocytosis on admission resolved
on HD#2 suggesting it likely represented transient pneumonitis.
Patient weaned from supplemental O2 successfully. J-tube was
replaced in ___ on ___ without complication. Tube feeds
restarted on ___ ___ and advanced to goal without incident. PO
meds which had previously been held were restarted through her
GJ tube.
Per speech and swallow evaluation, she is frankly aspirating.
They recommended that she remain NPO including meds, Q4H oral
care, and repeating video swallow study prior to advancing diet.
If repeat video swallow is acceptable, she could try a
supervised trial of pureed solids, honey thickened liquids with
speech language pathologist.
#) STROKE: Recent R MCA ischemic stroke ___ s/p TPA & clot
retrieval.
- Continue ASA rectally when NPO and via GJ tube when possible.
#) Hypertension: stable
#) DM2 controlled: stable on insulin
TRANSITIONAL ISSUES
-------------------
[] Will need speech and swallow evaluation PRIOR to resuming any
further POs
[] Follow-up on pending blood cultures
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
2. BusPIRone 5 mg PO DAILY
3. Glargine 34 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Lisinopril 5 mg PO DAILY
hold for sBP<100
5. Metoprolol Tartrate 12.5 mg PO BID
hold for HR<60
6. Mirtazapine 30 mg PO HS
7. Simvastatin 20 mg PO DAILY
8. Tizanidine 2 mg PO BID
9. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. Aspirin 325 mg PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Enoxaparin Sodium 40 mg SC DAILY
14. Lidocaine 5% Patch 1 PTCH TD DAILY
15. Ascorbic Acid (Liquid) 500 mg PO DAILY
16. Gabapentin 100 mg PO TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
3. Aspirin 325 mg PO DAILY
4. BusPIRone 5 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Glargine 34 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Lidocaine 5% Patch 1 PTCH TD DAILY
8. Lisinopril 5 mg PO DAILY
9. Metoprolol Tartrate 12.5 mg PO BID
10. Tizanidine 2 mg PO BID
11. Ascorbic Acid (Liquid) 500 mg PO DAILY
12. Enoxaparin Sodium 40 mg SC DAILY
13. Gabapentin 100 mg PO TID
14. Mirtazapine 30 mg PO HS
15. Simvastatin 20 mg PO DAILY
16. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
17. Docusate Sodium (Liquid) 100 mg PO BID
Hold for diarrhea.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Aspiration
History of CVA
Anxiety
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at ___
___. You were admitted after an aspiration event and
after a speech and swallow evaluation, you were found to have
impaired swallowing mechanisms. We replaced your J-tube on
without complications and restarted your home tube feeds. You
will need to have a repeat swallow study prior to resuming an
oral diet.
Followup Instructions:
___
|
10281517-DS-14 | 10,281,517 | 27,141,403 | DS | 14 | 2175-12-19 00:00:00 | 2175-12-21 19:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
prednisone / aspirin / quetiapine
Attending: ___
Chief Complaint:
Chief Complaint: AMS/Rigidity
Reason for MICU transfer: Q2h Neuro Checks
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
___ year old woman with PMHx of atrial fib on xarelto, DVT in
___, left foot drop of unclear etiology, COPD, and HTN who
intially presented to the ED s/p mechanical fall, found to have
b/l mandibular fxs and was admitted to ACS. ACS/OMFS determined
that there was no indication for surgical intervention. Her
hospital stay was c/b delirium and as a result, decision was
made to transfer to medicine. AAOx3 on admission per RN and on
the night of admission she was agiatated and delirious.
Pt recieved 25mg Seroquel today at 1030AM prior to the medicine
team eval, she was responsive to commands from the family. She
has been on her home Venlafaxine, recently weaned off Trazadone.
Per medicine team, she was AAOx2 at 1pm (knew where she was and
who she was). Approximately 2 hrs later she was found to be
rigid on exam and subsequently became diaphotetic (but remained
aferbile), hypertensive (170s), tachycardic (100s). At that
time, she was not responding to questions. Seen by Psych/Neuro
who thought that the pt was suffering from an NMS-like condition
(no fevers) or Serotonin Syndrome. Pt responded to 0.5mg Ativan
but has subsequently worsened. Dantrolene was not given due to
interaction with Verapamil and Bromocriptine could not be given
that the medication is PO and pt is unable to take PO or have
NGT placed (mandibular fxs). Benadryl IV was attempted at 830pm
but pt did not respond. Of note, CK 266 -> 399 -> 266. Given
decreasing UOP, pt has also been bolused 2L of IVF with
resulting increase in UOP. After speaking with Psychiatry and
nursing, it was determined that pt would best be ___ in the
ICU with q2h neuo checks.
Review of systems:
Unable to obtain
Past Medical History:
PAST MEDICAL HISTORY:
- Atrial fibrillation on Xerelto
- GERD
- L foot drop of unclear etiology
- Umbilical hernia
- Osteoporosis
- R DVT ___
- Asthma/COPD
- Arthritis
- Macular Degeneration
- Glaucoma
- Cataracts
Social History:
___
Family History:
Non contributory to critical illness.
Physical Exam:
ADMISSION EXAM
===============
Vitals: 97.6 160/92 97 16 100%RA
GENERAL: Oriented to hsopital, name, not year; flat affect,
dystonic, very still
HEENT: Sclera anicteric, dry MM, oropharynx clear, ecchymoses on
chin
NECK: supple, JVP not elevated, no LAD
LUNGS: CTAB anteriorly
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No rash
NEURO: Orientation as above, unable to complete full neuro exam
given inability to participate; notable for muscle rigidity in
lower extremities > upper extremities, mild clonus at the ankle,
neg babinski b/l, 1+ symmetrical DTRs throughout, ___
DISCHARGE EXAM
===============
Pertinent Results:
ADMISSION LABS
===============
___ 09:40AM BLOOD WBC-8.3 RBC-4.17* Hgb-11.2* Hct-35.7*
MCV-86 MCH-26.8* MCHC-31.3 RDW-15.6* Plt ___
___ 09:40AM BLOOD Neuts-72.4* ___ Monos-6.9 Eos-1.0
Baso-0.6
___ 09:40AM BLOOD ___ PTT-28.9 ___
___ 09:40AM BLOOD Glucose-96 UreaN-24* Creat-0.8 Na-140
K-3.8 Cl-104 HCO3-28 AnGap-12
___ 07:10AM BLOOD CK(CPK)-266*
___ 07:15PM BLOOD ALT-20 AST-28 LD(LDH)-245 CK(CPK)-266*
AlkPhos-94 TotBili-0.3
___ 07:10AM BLOOD CK-MB-9
___ 06:19PM BLOOD CK-MB-9 cTropnT-<0.01
___ 07:30AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.4
___ 06:19PM BLOOD calTIBC-458 Ferritn-15 TRF-352
___ 06:19PM BLOOD TSH-0.49
___ 06:35AM BLOOD VitB12-GREATER TH (___)
DISCHARGE LABS
===============
___ 06:55AM BLOOD WBC-7.1 RBC-3.91* Hgb-10.6* Hct-32.7*
MCV-84 MCH-27.0 MCHC-32.3 RDW-16.3* Plt ___
___ 06:55AM BLOOD Neuts-78.4* Lymphs-11.3* Monos-9.7
Eos-0.2 Baso-0.3
___ 06:55AM BLOOD Glucose-106* UreaN-21* Creat-0.5 Na-147*
K-3.0* Cl-107 HCO3-29 AnGap-14
___ 06:55AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.2
MICROBIOLOGY
==============
Blood cx x2 NGTD
Urine Cx NGTD
IMAGING STUDIES
================
CXR on admission
IMPRESSION: Calcified pleural plaques, usually associated with
prior asbestos exposure. No evidence of acute cardiopulmonary
disease
CT Face on admission
IMPRESSION:
Bilateral mandibular condylar fractures
CT Head and cervical spine at ___ negative
CT Head ___ No acute intracranial injury. Bilateral
mandibular condyle fractures are again noted. If clinical
suspicion for an acute infraction is high, MRI is the more
sensitive study.
Brief Hospital Course:
IMPRESSION: ___ with afib, HTN presented after fall, found to
have b/l mandibular fxs, but subsequenly found to have serotonin
syndrome secondary to Seroquel.
# Reaction to Seroquel: Pt with AMS, tachycardia, hypertension,
diaphoresis, muscle rigidity, and clonus. Occurred in the
setting of Seroquel and Venlafaxine. Given exam and medication
as precipitant, most likely a reaction to medication. Given no
fever and normal CK, less likely NMS and more likely
parkinsonian-like reaction to Seroquel. Responded to lorazepam,
a muscle relaxant. CK trend was reassuring. Fevers abated.
Mental status slowly improved. Rigidity improved. Once her
symptoms improved she was still found to be slightly agitated
and had a baseline left foot drop. She was transferred to the
neurology service for further evaluation. We attempted to get a
MRI but the patient was very agitated, and at the request of the
family, the decision was made to defer it until later as an
outpatient. We restarted her effexor on ___ but she had
worsening rigidity so we discontinued it. She had improvement in
her rigidity and mental status. We did a repeat head CT on ___
that was stable. We were able to send a vitamin b12 but the rest
of the work up was deferred as the patient has severe anxiety at
being in the hospital.
# AMS: Most likely 2/t Seroquel reaction as described above.
Given recent fall, IC bleed was ruled out with head CT. Also
could be hypoactive delirium, but given exam, will want to treat
as above first. No clear infectious concerns. Minimized tethers
and avoid delirogenic meds. Was still agitated but has known
anxiety ___ being in hospital. We believe that her symptoms will
improve at home.
# Depression: Initially held Venlafaxine given above. Restarted
on ___ due to concern for withdrawal. She, however, had
worsening of her symptoms so we held the venlafaxine.
# Mandibular fracture: She was initially seen by OMFS who did
not think she required surgery. They recommend a full liquid
diet for 4 weeks until they follow up with her. She was also
seen by ENT who recommended a 10 day course of ciprodex ear
drops and an audiogram in 4 weeks.
# HTN: Held Verapamil given interacion with Dantrolene, resumed
in AM ___. Had improved blood pressure control but still
elevated, likely ___ anxiety from being in hospital. Verapamil
was restarted once it was determined dantrolene would not be
needed.
# Afib: CHADS2 of 2, NSR on admission, on Xeralto. Continued
home rivaroxaban, rate appeared controlled.
# Dispo: To rehab
TRANSITIONAL ISSUES
# HTN: Blood pressures were often elevated during this
admission, despite restarting her home medications. She should
be seen soon by her PCP to measure her BP, ensuring it is coming
down, as well as adjust medications as necessary.
# Effexor: It is being held due to her rigidity that developed
after starting it
# Sleep: Please set up a sleep study to evaluate for obstructive
sleep apnea.
# Dehydrated: Patient demonstrated some hemoconcentration during
last day of admision, including a mild azotemia. Please
encourage patient to take adequate POs. Consider monitoring
these labs and hydration status.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. etodolac 500 mg oral BID
2. Rivaroxaban Dose is Unknown PO DAILY
3. Venlafaxine XR 150 mg PO DAILY
4. Venlafaxine XR 75 mg PO HS
5. Atorvastatin 20 mg PO HS
6. Verapamil 120 mg PO Q12H
7. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
8. Pantoprazole 40 mg PO Q24H
9. Senna 8.6 mg PO BID:PRN contipation
10. Montelukast 10 mg PO DAILY
11. TraZODone 200 mg PO HS:PRN insomnia
12. ValACYclovir 1000 mg PO Q12H
Discharge Medications:
1. Atorvastatin 20 mg PO HS
2. Pantoprazole 40 mg PO Q24H
3. Rivaroxaban 20 mg PO DINNER
4. Senna 8.6 mg PO BID:PRN contipation
5. Verapamil 120 mg PO Q12H
6. Ciprofloxacin 0.3% Ophth Soln 4 DROP LEFT EAR TID Duration: 6
Days
RX *ciprofloxacin 0.2 % 4 drops ear three times a day Disp #*1
Bottle Refills:*0
7. Montelukast 10 mg PO DAILY
8. ValACYclovir 1000 mg PO Q12H
9. etodolac 500 mg ORAL BID
10. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
11. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Mandibular Fracture
Reaction to Seroquel
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted after falling and sustaining
fractures in your jaw. The surgeons did not feel that this
needed to be operated on and transferred you to the medicine
service. You had to your medications, specifically the
combination of Effexor and seroquel, and we would recommend
avoiding both in the future. You went to the ICU for this
reaction but were sent back to the floor in 1 day after
resolution of most of your symptoms. When we attempted to
restart your Effexor this reaction recurred, which we think is
attributable to the Effexor itself. You were transferred to the
neurology service for evaluation of your foot drop. A vitamin
b12 level was sent which is still pending. We recommended a MRI
of the brain but you were very anxious so this was deferred
until the outpatient visit. We did a repeat head CT on ___
that was stable. You should follow up with neurology and the
surgeons as listed below. Due to your reaction to Seroquel and
Effexor, the Effexor was stopped.
The following medication changes were made:
Start:
Ciprodex ear drops for 6 more days for the left ear (recommended
by the Ear, Nose, and Throat physicians)
Metoprolol Succinate 25 mg each day (for blood pressure)
Stop:
Effexor
Xanax
We recommended along with Physical Therapy that you should go to
an ___ rehabilitation facility prior to going home, but
your family insisted on bringing you home and that they could
provide 24 hour care.
Followup Instructions:
___
|
10281589-DS-8 | 10,281,589 | 27,261,649 | DS | 8 | 2171-12-25 00:00:00 | 2171-12-26 21:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
jaundice and fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PCP: ___ MD
CC: jaundice
HPI:
Ms. ___ is a ___ y/o woman with hx of EtOH/HCV cirrhosis
complicated by esophageal varices, ascites, portal hypertensive
gastropathy with recent hospitalization ___ for alcoholic
hepatitis and UGI bleeding from ___ ulcers and gastropathy
who now presents from liver clinic for worsening jaundice. She
says that after her last admission she remained compliant with
her discharge medications and had been abstaining from alcohol.
However about 2 weeks ago her boyfriend broke up with her, and
she started drinking 1 pint of vodka daily. Around that time she
also started to develop some associated fatigue and skin
yellowing. Over the past few days she has also had nausea with
non-bloody vomiting. Normal BMs, formed and brown, as recently
as today. She presented to liver clinic and due to her degree of
jaundice was referred to the ED.
She denies any associated fevers, chills, HA, chest pain,
palpitations, SOB, cough, abdominal discomfort, diarrhea,
dysuria, or any other complaints.
ED Course:
- Initial Vitals/Trigger: 98.9 80 98/68 18 100%
Exam showed jaundice, scleral ictereus, spiders
No abd tenderness
Brown stool guiac negative
Sacral ecchymosis
No asterixis, fully oriented
- Labs revealed leukocytosis to 12.9k, thrombocytopenia to 41k,
INR 1.9, albumin 3.1, bilirubin 23.1, AST 250 ALT 58,
hyponatremia 123, hypomagnesemia 0.9, hypokalemia 3.0. EtOH
level 84. Lactate 3.1.
- Pyuria with 147 WBCs, 4 RBCs.
- CXR without acute abnormality.
- RUQ u/s with patent portal flow (though reversed), patent
hepatic veins, no ascites
She was admitted to Medicine for further evaluation and
management of alcoholic hepatitis.
In the ED, initial vitals: 98.9 80 98/68 18 100%
Vitals prior to transfer: 99.8 61 101/61 16 100% RA
Currently, 99.4 104/64 86 18 99%RA.
She was lying comfortably in bed in NAD.
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 diarrhea or constipation. No dysuria or
hematuria. No hematochezia, no melena. No numbness or weakness,
no focal deficits.
Past Medical History:
EtOH/HCV cirrhosis complicated by esophageal varices, ascites,
portal hypertensive gastropathy
h/o traumatic SDH (___)
depression
PAST SURGICAL HISTORY: tubal ligation (___)
Social History:
___
Family History:
significant for alcoholism
Physical Exam:
ADMISSION:
VS: 99.4 104/64 86 18 99%RA.
GENERAL: adult female profoundly jaundiced, lying comfortably in
bed in NAD. alert, oriented
HEENT: + scleral, buccal, and diffuse skin icterus/jaundice,
MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
RESP: CTAB no wheezes, rales, rhonchi
CV: normal rate, regular rhythm, Nl S1, S2, No MRG
ABD: Soft, NT/ND bowel sounds present, no rebound tenderness or
guarding. significant hepatomegaly 4-5cm below R costal margin,
no significant tenderness
GU: no foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis,
trace ___ edema
NEURO: CNs2-12 intact, motor function grossly normal. no
asterixis.
SKIN: multiple scattered spider angiomata, palmar erythema
DISCHARGE:
Pertinent Results:
=======================
ADMISSION:
=======================
___ 02:25PM BLOOD WBC-12.9* RBC-2.41* Hgb-8.8* Hct-25.8*
MCV-107* MCH-36.5* MCHC-34.0 RDW-19.2* Plt Ct-41*#
___ 02:25PM BLOOD Neuts-75.5* Lymphs-13.4* Monos-9.5
Eos-1.5 Baso-0.3
___ 03:26AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Target-OCCASIONAL
___ 03:00PM BLOOD ___ PTT-38.4* ___
___ 03:26AM BLOOD Ret Aut-5.5*
___ 02:25PM BLOOD Glucose-89 UreaN-20 Creat-1.1 Na-123*
K-3.0* Cl-79* HCO3-26
___ 02:25PM BLOOD ALT-58* AST-250* AlkPhos-275*
TotBili-23.1*
___ 02:25PM BLOOD Albumin-3.1* Calcium-8.0* Phos-3.2
Mg-0.9*
___ 03:26AM BLOOD Hapto-53
___ 02:25PM BLOOD Osmolal-286
___ 02:25PM BLOOD ASA-NEG Ethanol-84* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:51PM BLOOD ___ pO2-27* pCO2-40 pH-7.48*
calTCO2-31* Base XS-4
___ 04:51PM BLOOD Lactate-3.1*
___ 03:34AM BLOOD freeCa-0.93*
URINE:
___ 05:20PM URINE Color-DkAmb Appear-Hazy Sp ___
___ 05:20PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-LG Urobiln-8* pH-6.0 Leuks-LG
___ 05:20PM URINE RBC-4* WBC-147* Bacteri-MOD Yeast-NONE
Epi-1
___ 05:20PM URINE Hours-RANDOM UreaN-461 Creat-158 Na-<10
K-31 Cl-<10
___ 05:20PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
___ 5:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
=======================
DISCHARGE:
=======================
=======================
IMAGING:
=======================
___ RUQ U/S:
IMPRESSION:
1. Coarsened echogenic liver, compatible with the history of
cirrhosis. No
focal mass.
2. Patent portal veins. The right portal vein and main portal
vein
demonstrate reversal of flow. There is a patent paraumbilical
vein.
3. No ascites.
4. Gallbladder sludge. No specific evidence of cholecystitis.
5. Minimal borderline dilation of the common bile duct,
measuring 6-7 mm.
___ CXR:
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are
normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural
effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with hx of EtOH/HCV cirrhosis
complicated by esophageal varices, ascites, portal hypertensive
with recent hospitalization for alcoholic hepatitis and
non-variceal UGI bleed now admitted for profound jaundice with
severe alcoholic hepatitis.
# Alcoholic hepatitis: Severe based on very high initial DF of
62, MELD 26. Alcoholic hepatitis evidenced by recent heavy EtOH
use with AST>>ALT and hepatomegaly along with hyperbilirubinemia
and coagulopathy. No biliary obstruction on imaging. She was
managed with IV fluids, electrolyte repletion, and treatment of
infection. Her bilirubin steadily trended downward, but on ___
began uptrending again. Repeat infectious work-up including
BCx, UCx, liver u/s, CXR was unrevealing. She was discharged
with instructions to repeat outpatient lab work on the week of
discharge. SW was involved and gave the patient materials to
aid in EtOH cessation.
# Hypothyroidism: Work-up of hyponatremia revealed elevated TSH
and low T4 and T3. Started on levothyroxine. TPO antibodies
were negative. ___ should be repeated as an outpatient.
# UTI: Due to pansensitive Klebsiella. Received 1 week of
ciprofloxacin completing ___ with resolution of urinary
symptoms.
# Severe hypomagenesemia and hypokalemia: Most likely due to
chronically depleted stores from EtOH abuse and malnutrition.
EKG revealed normal QTc, and she was without any events on
telemetry monitoring. She was treated with aggressive
electrolyte repletion.
# Hyponatremia: Remained asymptomatic. Etiology of hyponatremia
most likely due to intravascular volume depletion as evidenced
by ___ with BUN/Cr significantly above her baseline in setting
of poor po intake with nausea/vomiting. ___ be exacerbated by
beer-potomania given poor solute intake as well. This improved
with IV fluids.
# Acute kidney injury: BUN/Cr ___, significantly above
baseline ___. This improved with IV fluids and holding her
home furosemide/spironolactone.
# EtOH abuse: She was monitored on CIWA protocol with diazepam
prn and remained hemodynamically stable without seizures or DTs.
Social work was consulted. Abstinence will be critical for her
health going forward.
# Depression: Continued home sertraline.
# Esophageal ulcers: Continued pantoprazole BID.
# CONTACT: sister ___
TRANSITIONAL ISSUES:
- maximize resources for alcohol abstinence given high mortality
risk amidst her 2 recent alcoholic hepatitis episodes
- needs a f/u appt with Dr. ___
- repeat ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Thiamine 100 mg PO DAILY
3. Nadolol 40 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Furosemide 40 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Sertraline 75 mg PO DAILY
8. Spironolactone 50 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Pantoprazole 40 mg PO Q12H
3. Sertraline 75 mg PO DAILY
4. Thiamine 100 mg PO DAILY
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Nadolol 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Alcoholic hepatitis, severe
- Urinary tract infection
- Acute kidney injury
- severe electrolyte abnormalities
Secondary Diagnosis:
- EtOH withdrawal
- Proptosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your hospitalization.
You were admitted on ___ after developing worsening jaundice and
fatigue. You underwent an extensive work-up including physical
exams, blood tests, and imaging tests. Based on these results,
you were found to have very severe alcoholic hepatitis -
swelling and damage to the liver from alcohol use. Based on how
severe this damage was, you face a very high risk of becoming
very sick again, especially if you use any alcohol. Further
alcohol use will threaten not just your health but your life as
well. It is extremely important that you refrain from drinking
any alcohol.
You were treated with IV fluids and electrolytes, and you were
also given antibiotics for a urinary tract infection.
Fortunately you improved with this treatment.
Please be sure to take your medications as prescribed and to
follow-up at the appointments below.
Regards,
Your ___ Team
Followup Instructions:
___
|
10281634-DS-8 | 10,281,634 | 26,131,119 | DS | 8 | 2141-12-22 00:00:00 | 2141-12-23 12:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
codeine
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
IUD removal ___
Physical Exam:
Discharge physical exam
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, minimally TTP, no rebound/guarding
Ext: mild b/l calf TTP. no palpable cords, erythema, or edema
Pertinent Results:
LABS
==================
___ 02:50PM BLOOD WBC-9.4 RBC-3.55* Hgb-10.3* Hct-31.7*
MCV-89 MCH-29.0 MCHC-32.5 RDW-12.8 RDWSD-42.4 Plt ___
___ 06:08PM BLOOD WBC-11.0* RBC-4.13 Hgb-12.3 Hct-37.3
MCV-90 MCH-29.8 MCHC-33.0 RDW-13.2 RDWSD-43.2 Plt ___
___ 02:50PM BLOOD Neuts-73.8* Lymphs-14.6* Monos-10.7
Eos-0.0* Baso-0.3 Im ___ AbsNeut-6.91* AbsLymp-1.37
AbsMono-1.00* AbsEos-0.00* AbsBaso-0.03
___ 06:08PM BLOOD Neuts-83.3* Lymphs-10.3* Monos-5.3
Eos-0.4* Baso-0.2 Im ___ AbsNeut-9.18* AbsLymp-1.13*
AbsMono-0.58 AbsEos-0.04 AbsBaso-0.02
___ 06:08PM BLOOD Glucose-95 UreaN-9 Creat-0.6 Na-134 K-4.7
Cl-97 HCO3-26 AnGap-16
___ 06:08PM BLOOD ALT-13 AST-20 AlkPhos-85 TotBili-0.4
___ 06:08PM BLOOD Lipase-25
___ 02:50PM BLOOD HBsAg-Negative
___ 02:50PM BLOOD HIV Ab-Negative
___ 02:50PM BLOOD HCV Ab-Negative
___ 08:21PM BLOOD Lactate-1.0
___ 09:27PM URINE Color-Straw Appear-Clear Sp ___
___ 06:05PM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:27PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:05PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 09:27PM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-1
___ 06:05PM URINE RBC-2 WBC-2 Bacteri-NONE Yeast-NONE
Epi-12
___ 03:00AM URINE CT-NEG NG-NEG
MICROBIOLOGY
==================
___ 6:05 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
BETA STREPTOCOCCUS GROUP B. >100,000 CFU/mL.
___ 8:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 8:20 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Time Taken Not Noted Log-In Date/Time: ___ 9:27 pm
URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 2:50 pm SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
IMAGING
==================
___ CT Scan
Final Report
INDICATION: ___ with LLQ abdominal pain, feverNO_PO contrast//
evaluate for
diverticulitis or other intra-abdominal proces
TECHNIQUE: Single phase split bolus contrast: MDCT axial images
were acquired
through the abdomen and pelvis following intravenous contrast
administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on
PACS.
DOSE: Total DLP (Body) = 1,046 mGy-cm.
COMPARISON: None.
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. The gallbladder is
surgically absent.
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: There is a small hiatal hernia. The stomach
is otherwise
unremarkable. Small bowel loops demonstrate normal caliber,
wall thickness,
and enhancement throughout. Scattered diverticular noted in the
colon,
particularly the sigmoid without evidence of acute
diverticulitis. The
appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is
trace free fluid in the pelvis.
REPRODUCTIVE ORGANS: IUD is identified within the uterus. The
right adnexae is unremarkable. There is an oblong cystic
structure in the left adnexum measuring 5.6 by 2.9 by 3.4 cm.
Given oblong configuration, this may represent a hydrosalpinx.
The left adnexae is otherwise unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture. Sclerosis surrounding the SI joints, more
exuberant on the iliac side bilaterally. Moderate degenerative
changes seen at the hips bilaterally.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Oblong cystic structure in the left adnexa which given
configuration may represent a hydrosalpinx. Consider dedicated
exam with pelvic ultrasound, the acuity of which can be
determined clinically.
2. Diverticulosis without diverticulitis.
3. Sclerosis abutting the SI joints bilaterally which may
represent
sacroiliitis of versus osteitis condensans ilii.
___ Pelvic US
Final Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ year old woman with abdominal pain, fevers//
evaluate oblong
structure seen on CT a/p, ?evidence of PID
Has a Mirena IUD, distant LMP
TECHNIQUE: Grayscale ultrasound images of the pelvis were
obtained with
transabdominal approach followed by transvaginal approach for
further
delineation of uterine and ovarian anatomy.
COMPARISON: CT of the abdomen and pelvis from ___ at
20:55
FINDINGS:
The uterus is anteverted and measures 7.8 x 3.9 x 5.5 cm. The
endometrium is
homogenous and measures 4 mm. The IUD was demonstrated within
the endometrial
cavity. The IUD appears satisfactorily placed.
The left ovary measures 5.3 x 3.2 x 3.0 cm. In the left adnexa,
two cysts
which measure 3.3 x 2.6 x 2.6 cm and 2.0 x 1.7 x 1.8 cm are not
seen to
definitely communicate, one of which may contain some debris and
a represent a
hemorrhagic cyst.
The right ovary measures 3.0 x 1.9 x 1.5 cm an appears normal.
There is a
trace amount of free fluid.
IMPRESSION:
Left ovary containing physiologic cysts, one containing
debris/hemorrhage..
___ LENIS
Final Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ G1P1 who presented with worsening abdominal
pain, N/V/D,
fevers, admitted for tx of presumed left pyosalpinx, now w/ calf
pain// eval
for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation
was performed
on the bilateral lower extremity veins.
COMPARISON: None
FINDINGS:
There is normal compressibility, flow, and augmentation of the
bilateral
common femoral, femoral, and popliteal veins. Normal color flow
and
compressibility are demonstrated in the tibial veins.
Evaluation of the
peroneal veins bilaterally was limited.
There is normal respiratory variation in the common femoral
veins bilaterally.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Brief Hospital Course:
Ms. ___ is a ___ yo G2P1 who presented with 3 days of
abdominal pain, pelvic cramping,
nausea/vomiting/diarrhea/fevers, and was found to have a left
adnexal dilated structure on CT scan, with adnexal tenderness on
CMT. She was admitted for treatment of a presumed left
pyosalpinx.
*) Left pyosalpinx: Pt defervesced after her initial
presentation, with first afebrile time 18:20 on ___. She was
started on IV Gentamicin/Clindamycin (___). Her WBC
downtrended from 11 (___) to 9.4 (___). Given that pt remained
afebrile and her pain improved, she was transitioned to PO
Levofloxacin/Flagyl on ___. Her STI panel was negative for HIV,
RPR, Hepatitis B, Hepatitis C, gonorrhea, and chlamydia.
*) Bilateral lower extremity tenderness: On ___, pt reported
bilateral calf tenderness. She underwent lower extremity venous
ultrasounds which did not demonstrate any evidence of DVT.
*) GBS UTI: Pt's urine culture grew group B strep. She was
started on a 3-day course of amoxicillin (___-) to treat her
UTI.
*) Contraception: Pt underwent removal of her IUD at the
bedside. She elected to use the patch for contraception. Pt was
made aware of decreased efficacy of the patch for contraception
in the setting of obesity. She remained interested in the patch
as she uses this method primarily for cycle control. She is not
currently sexually active.
By hospital day #3, Ms. ___ was afebrile, her
abdominal pain was minimal, she was tolerating a regular diet
without nausea/vomiting, and she was ambulating independently.
She was discharged home in stable condition with outpatient
follow-up scheduled.
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
do not exceed 4000mg in 24 hours
RX *acetaminophen 500 mg 1 tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*1
2. Amoxicillin 500 mg PO Q12H
RX *amoxicillin 500 mg 1 tablet(s) by mouth twice daily Disp #*5
Tablet Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
take with food
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*1
4. Levofloxacin 500 mg PO Q24H
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth daily
Disp #*14 Tablet Refills:*0
5. MetroNIDAZOLE 500 mg PO BID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth twice
daily Disp #*28 Tablet Refills:*0
6. Xulane (norelgestromin-ethin.estradiol) 150-35 mcg/24 hr
transdermal 1X/WEEK
RX *norelgestromin-ethin.estradiol [___] 150 mcg-35 ___ on the skin once a week Disp #*4 Patch Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Pyosalpinx
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the Gynecology Service with abdominal pain
and fevers. You were treated for a pyosalpinx (infection of the
fallopian tubes) with IV antibiotics, and have been transitioned
to oral antibiotics. Your IUD was removed.
You were found to have a urinary tract infection. Please take
the amoxicillin as prescribed to treat this infection.
You have overall recovered well and are ready for discharge.
Please follow the instructions below.
General instructions:
* Take your medications as prescribed.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina (no tampons, no douching, no sex) for 2
weeks.
* You may eat a regular diet.
* You may walk up and down stairs.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
Contraception:
* You elected to start the patch for birth control and are
provided a prescription. Please change the patch once a week.
* You may use the patch for three weeks in a row and then take
one week off for a period, or you may elect to continuously use
the patch.
* You are eligible for another IUD should you choose one in 3
months.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
10281780-DS-8 | 10,281,780 | 21,923,139 | DS | 8 | 2141-08-30 00:00:00 | 2141-08-30 17:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Keflex
Attending: ___.
Chief Complaint:
cellulitis, hyperkalemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ h/o DM, HTN, CKD Stage I (baseline Cr 0.8) who
presented to the ED at the advice of her PCP for hyperkalemia.
Patient was recently seen at the ___ ED on ___ for left
chest/breast cellulitis. She was noted to have a small abscess
but no purulent drainage on I&D. She left AMA as she did not
want admission for IV abx, and was given a prescription for
Bactrim DS and Keflex x10 days. She had follow-up with her PCP
___ ___, at which time labs were drawn and showed elevated K to
7.2 and ___ with Cr 1.4. She was sent to the ___ ED for
further evaluation. in the ED, patient reported improvement in
her cellulitis pain and warmth, as well as decrease in the
abscess site. She denied fevers, headaches, dysuria, bleeding
anywhere.
Past Medical History:
-DM, HTN, Stage I CKD, HLD
-Breast cellulitis, Anemia
Radial fx ___ s/p L ORIF
s/p cesarean x1
Tooth extractions w/o bleeding complications
Social History:
___
Family History:
No significant cardiac, renal illnesses in family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98 PO 116/73 L Lying 81 18 98%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, periorbital swelling
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
CHEST: elongated discolored lesion on L breast with mild area of
induration but no surrounding erythema. nontender to palpation.
no open lesions
ABDOMEN: nondistended, nontender in all quadrants,
norebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, strength
intact
SKIN: warm and well perfused, no excoriations or lesions,
petechiae over shoulders, back and chest
DISCHARGE PHYSICAL EXAM:
Vitals: 97.7 PO 131 / 78 57 18 98 RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, abrasion on hard palate stable.
Wet purpuric lesion on right buccal mucosa faint and smaller.
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
CHEST: stable, elongated discolored lesion on L breast with mild
area of induration but no surrounding erythema. Non-tender to
palpation.
No open lesions, though some desquamation. Outer part of lesion
outlined.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: stable, scattered petechiae on chest, shoulders and back.
Stable petechiae around left IV antecubital site.
Neuro: CNs2-12 grossly intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
___ 01:53PM PLT COUNT-336
___ 01:53PM NEUTS-62.8 LYMPHS-16.3* MONOS-16.2* EOS-2.4
BASOS-0.8 IM ___ AbsNeut-4.51# AbsLymp-1.17* AbsMono-1.16*
AbsEos-0.17 AbsBaso-0.06
___ 01:53PM WBC-7.2# RBC-3.67* HGB-10.7* HCT-33.3* MCV-91
MCH-29.2 MCHC-32.1 RDW-14.0 RDWSD-46.5*
___ 01:53PM CALCIUM-9.8
___ 01:53PM estGFR-Using this
___ 01:53PM UREA N-33* CREAT-1.4* SODIUM-131*
POTASSIUM-7.2*
___ 01:53PM GLUCOSE-135*
___ 04:20PM PLT SMR-RARE* PLT COUNT-<5*
___ 04:20PM NEUTS-64.8 ___ MONOS-11.6 EOS-2.1
BASOS-0.3 IM ___ AbsNeut-4.64 AbsLymp-1.42 AbsMono-0.83*
AbsEos-0.15 AbsBaso-0.02
___ 04:20PM WBC-7.2 RBC-3.54* HGB-10.1* HCT-32.0* MCV-90
MCH-28.5 MCHC-31.6* RDW-13.9 RDWSD-46.0
___ 04:20PM LACTATE-1.1 K+-6.2*
___ 04:20PM GLUCOSE-112* UREA N-40* CREAT-2.5*#
SODIUM-134* POTASSIUM-6.5* CHLORIDE-98 TOTAL CO2-20* ANION
GAP-16
___ 06:39PM PLT COUNT-<5*
___ 06:39PM WBC-7.7 RBC-3.53* HGB-10.2* HCT-32.4* MCV-92
MCH-28.9 MCHC-31.5* RDW-14.2 RDWSD-47.9*
___ 06:55PM K+-5.3*
___ 07:25PM K+-5.0
___ 07:45PM URINE MUCOUS-RARE*
___ 07:45PM URINE HYALINE-28*
___ 07:45PM URINE RBC-5* WBC-5 BACTERIA-FEW* YEAST-NONE
EPI-1
___ 07:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-SM*
___ 07:45PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 07:45PM URINE UHOLD-HOLD
___ 07:45PM URINE HOURS-RANDOM
___ 08:45PM PLT COUNT-<5*
___ 08:45PM GLUCOSE-78 UREA N-36* CREAT-2.0* SODIUM-134*
POTASSIUM-5.1 CHLORIDE-99 TOTAL CO2-18* ANION GAP-17
PERTINENT/INTERVAL LABS:
==========================
___ 04:20PM BLOOD WBC-7.2 RBC-3.54* Hgb-10.1* Hct-32.0*
MCV-90 MCH-28.5 MCHC-31.6* RDW-13.9 RDWSD-46.0 Plt Ct-<5*
___ 06:39PM BLOOD WBC-7.7 RBC-3.53* Hgb-10.2* Hct-32.4*
MCV-92 MCH-28.9 MCHC-31.5* RDW-14.2 RDWSD-47.9* Plt Ct-<5*
___ 03:07AM BLOOD WBC-9.4 RBC-3.29* Hgb-9.6* Hct-29.8*
MCV-91 MCH-29.2 MCHC-32.2 RDW-14.0 RDWSD-46.2 Plt Ct-<5*
___ 10:45AM BLOOD WBC-6.2 RBC-3.12* Hgb-9.0* Hct-28.6*
MCV-92 MCH-28.8 MCHC-31.5* RDW-14.2 RDWSD-47.4* Plt Ct-<5*
___ 07:05AM BLOOD WBC-4.8 RBC-3.49* Hgb-10.0* Hct-31.4*
MCV-90 MCH-28.7 MCHC-31.8* RDW-13.5 RDWSD-44.6 Plt Ct-<5*
___ 06:36AM BLOOD WBC-11.1*# RBC-3.03* Hgb-8.8* Hct-27.0*
MCV-89 MCH-29.0 MCHC-32.6 RDW-13.4 RDWSD-43.8 Plt Ct-19*#
___ 03:07AM BLOOD ___ PTT-28.2 ___
___ 07:05AM BLOOD ___ PTT-28.8 ___
___ 06:36AM BLOOD ___ PTT-25.0 ___
___ 10:45AM BLOOD G6PD-PND
___ 03:07AM BLOOD Ret Aut-1.0 Abs Ret-0.03
___ 04:20PM BLOOD Glucose-112* UreaN-40* Creat-2.5*#
Na-134* K-6.5* Cl-98 HCO3-20* AnGap-16
___ 08:45PM BLOOD Glucose-78 UreaN-36* Creat-2.0* Na-134*
K-5.1 Cl-99 HCO3-18* AnGap-17
___ 03:07AM BLOOD Glucose-93 UreaN-32* Creat-1.6* Na-134*
K-6.0* Cl-100 HCO3-20* AnGap-14
___ 10:45AM BLOOD Glucose-125* UreaN-28* Creat-1.2* Na-142
K-5.1 Cl-107 HCO3-21* AnGap-14
___ 07:05AM BLOOD Glucose-223* UreaN-22* Creat-0.9 Na-141
K-4.4 Cl-106 HCO3-19* AnGap-16
___ 06:36AM BLOOD Glucose-141* UreaN-23* Creat-0.7 Na-143
K-3.5 Cl-107 HCO3-21* AnGap-15
___ 06:55PM BLOOD K-5.3*
___ 07:25PM BLOOD K-5.0
___ 03:07AM BLOOD ALT-20 AST-15 LD(LDH)-284* AlkPhos-55
TotBili-0.4
___ 03:07AM BLOOD Hapto-368*
___ 10:45AM BLOOD HBsAg-NEG HBsAb-Borderline HBcAb-NEG
___ 06:36AM BLOOD HIV Ab-NEG
___ 04:20PM BLOOD Lactate-1.1 K-6.2*
IMAGING
___ UNILAT BREAST US LIMITE IMPRESSION: In the
lateral left breast at 3 o'clock in the area of concern as
indicated by the patient, there is skin thickening with
underlying soft tissue edema, but no drainable fluid collection.
RECOMMENDATION(S): Follow-up in the Breast Care Center is
recommended. In the left breast at 3 o'clock in the area of
concern as indicated by the patient, there is skin thickening
with underlying soft tissue edema, but no drainable fluid
collection. Follow-up in the Breast Care Center is recommended.
___ RENAL U.S. IMPRESSION: Normal renal ultrasound.
No hydronephrosis.
DISCHARGE LABS:
___ 07:10AM BLOOD WBC-14.6* RBC-3.23* Hgb-9.6* Hct-29.0*
MCV-90 MCH-29.7 MCHC-33.1 RDW-13.5 RDWSD-44.6 Plt Ct-67*#
___ 07:10AM BLOOD ___ PTT-25.3 ___
___ 07:10AM BLOOD Glucose-147* UreaN-28* Creat-0.7 Na-142
K-3.8 Cl-104 HCO3-22 AnGap-16
___ 07:10AM BLOOD Calcium-9.2 Phos-2.7 Mg-1.7
Brief Hospital Course:
Ms ___ is a ___ year old woman with a history of DM, HTN, CKD
Stage I (baseline Cr 0.8), who presented to the ED at the advice
of her PCP for hyperkalemia and was found to have severe
thrombocytopenia (plts <5) and ___, in the setting of Bactrim
and Keflex treatment for chest/breast cellulitis.
ACUTE ISSUES:
=============
# Thrombocytopenia
On admission, the patient was found to be acutely and severely
thrombocytopenic (plts <5) with petechiae on exam, in the
setting of a 10 day course of Bactrim and Keflex treatment for
cellulitis. She received 2 platelet transfusions (___)
with no response in the platelet count. Hematology was consulted
regarding the etiology and management of her thrombocytopenia,
which was thought to be most consistent with drug induced
(immune mediated) thrombocytopenia in the setting of Bactrim and
Keflex use. These antibiotics were discontinued on admission and
added to her allergy list. There was low concern for thrombotic
microangiopathy given no evidence of hemolysis on labs or smear.
Moreover, the peripheral smear did not reveal any evidence of an
underlying infiltrative or other acute process. HBsAb titer was
borderline likely due to vaccination, but hep B and C serologies
were otherwise negative. HIV screen was also negative. As such,
the patient's immune thrombocytopenia was unlikely to be viral
related. On the night of ___, she developed new wet purpura on
the right buccal mucosa, a finding that was concerning for
increased risk of intracranial bleed. As such, IV 40mg
dexamethasone was given on ___. Since ___, the patient
received 3 doses of IV 40 mg dexamethasone daily in addition to
aminocaproic Acid 2 g PO Q8H. The patient's platelets remained
<5 on ___, but increased to 19 on ___, after which
aminocaproic acid was discontinued. On ___, her platelet level
was 67. During the hospitalization, she had no active signs of
bleeding. On discharge, the wet purpura on her buccal mucosa was
improved and the abrasion on her hard palate was stable. She was
to take a final dose of 40mg PO dexamethasone on ___.
#Hyperkalemia:
The patient had a K of 7.2 at follow up appointment with her PCP
___ ___. When she presented to the ___ ___, her K was 6.2 on
whole blood. She was given calcium gluconate and temporized with
10u regular insulin/25gm dextrose. The patient's hyperkalemia
likely occurred in the setting of acute on chronic kidney
disease and resolved with Kayexalate and improvement of her ___
(as described below). K was 3.8 on discharge.
# ___: Cr was 2.5 on admission from baseline 0.8. Her Cr
robustly down-trended with IVF, returning to baseline values (Cr
0.9 on ___, suggested a prerenal process. Acute interstitial
nephritis from Bactrim was also considered, but felt to be less
likely given improvement with IVF. Renal US was normal. The
patient's Cr on discharge was 0.7. Her antihypertensives
valsartan and chlorthalidone were held at discharge in the
setting of normotension on amlodipine and previous
prerenal-appearing ___ these can be considered for resumption
after meeting with PCP and following blood pressures.
# Breast/Chest cellulitis:
The patient previously presented to the ___ ED on ___ for
left chest/breast cellulitis, where she was noted to have a
small abscess but no purulent drainage on I&D. She left AMA as
she did not want admission for IV antibiotics and was given a
prescription for Bactrim DS and Keflex x10 days. Upon
presentation for this admission (___), the area of cellulitis
was non-tender and showed mild induration and discoloration over
left lateral breast status post a 9 day course of Bactrim and
Keflex. Bedside US showed no localized area of fluid collection.
As Bactrim and Keflex were held on the night of admission, she
received one dose of doxycycline and IV vancomycin. She was
afebrile with no leukocytosis. Overall, her cellulitis was felt
to be resolved status post an adequate course of antibiotics. As
such, all antibiotics were held to ensure no other offending
drugs would exacerbate her drug-induced thrombocytopenia.
CHRONIC ISSUES:
===============
# HTN : continued amlodipine, held valsartan and chlorthalidone
iso renal failure
# DM: HISS, held home metformin and glyburide; aspirin was held
in setting of thrombocytopenia
# HLD: continued statin, fish oil
Transitional Issues:
================
#CODE: Full (presumed)
#CONTACT: Brother ___ ___
Held medications at discharge: Should not be restarted until
discussion with PCP.
-ASA 81 due to thrombocytopenia
-Valsartan due to prerenal ___ + normotension on amlodipine
-Chlorthalidone due to prerenal ___ + normotension on amlodipine
Changed medications at discharge: none
New medications at discharge: 1 dose of 40 mg dexamethasone po
to be taken on ___.
- Please follow up on the patients platelet levels as she
presented with severe thrombocytopenia. We recommend checking
them on ___ or ___.
- Please add Bactrim and Keflex to the list of her allergies as
they most likely caused her thrombocytopenia
- Please follow up on the patient's creatinine and electrolytes
as she presented with acute kidney injury (Cr. 2.5) and
hyperkalemia to 6.2. These can also be checked on ___ or ___.
- Please follow up on the status of patient's left breast
cellulitis, which was felt to have resolved following a 9 day
course of Bactrim and Keflex prior to admission
- Breast US on admission showed now drainable fluid collection
over the area of her cellulitis; however, it was recommended
that she follow up at the ___ Breast Care Center
___ please see that the patient does so.
>30 minutes spent on discharge planning
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 10 mg PO DAILY
2. Chlorthalidone 25 mg PO DAILY
3. GlyBURIDE 2.5 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Pravastatin 20 mg PO QPM
6. Valsartan 320 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Vitamin D Dose is Unknown PO DAILY
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Medications:
1. Dexamethasone 40 mg PO ONCE Drug induced thrombocytopenia
Duration: 1 Dose. Please take a single dose on ___.
RX *dexamethasone 4 mg 10 tablet(s) by mouth Once Disp #*10
Tablet Refills:*0
2. Vitamin D 400 UNIT PO DAILY
3. amLODIPine 10 mg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Fish Oil (Omega 3) 1000 mg PO BID
6. GlyBURIDE 2.5 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Pravastatin 20 mg PO QPM
9. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until you speak with your primary care
physician
10.Outpatient Lab Work
E87.5: Hyperkalemia; and D69.6: Thrombocytopenia
Please check CBC and chem-10 on ___ or ___. Please fax
results to patient's PCP, ___ NP
(___).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hyperkalemia, Thrombocytopenia, Acute Kidney Injury,
Chronic Kidney Disease, Cellulitis
Secondary: Hypertension, Diabetes Mellitus, Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WAS I ADMITTED?
-You were admitted for a high potassium level in your blood and
found to have a very low platelet level as well as abnormal
kidney function tests
WHAT WAS DONE FOR ME WHILE I WAS IN THE HOSPITAL?
- Your low platelet level was most likely due to an immune
system response caused by the antibiotics Bactrim and Keflex, so
we discontinued these medications and also gave you steroids,
which helped to improve the platelet level.
- For your decreased kidney function, we gave you intravenous
fluids, after which your kidney function tests returned to
baseline levels. We paused some of your blood pressure
medicines; you can discuss starting them back up with your
primary care doctor when you see him next.
- For your high potassium levels, we gave you a medication to
help you excrete potassium. After receiving this medication and
as your kidney function returned to baseline, your potassium
levels also returned to normal.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- Please call your primary care physician to schedule ___ follow
up appointment within the next ___ days. Your platelet measured
should be measured by your primary care physician ___ ___ or
___.
- Please take all of your medications as prescribed.
- Please take your steroid (dexamethasone) medication tomorrow
on ___.
- Please avoid taking the antibiotics Bactrim and Keflex again.
- If you haven any fever, chills, nausea, vomiting, weight gain,
increased swelling, or shortness of breath please call your PCP
or come to the emergency department.
It was a pleasure caring for you at ___.
Best Wishes,
your ___ team
Followup Instructions:
___
|
10281856-DS-4 | 10,281,856 | 26,892,588 | DS | 4 | 2151-06-03 00:00:00 | 2151-06-03 17:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with a history of suicide
attempt who presents following an acetaminophen overdose.
The patient reports having intermittent aches/pains, most
recently abdominal pain, for which she takes NSAIDS and
acetaminophen. She took ___ tablets of acetaminophen a week
ago
for a headache. Then, two days prior to arrival, she took a
"handful" (amount unknown, though she suspects ~20 tablets) for
abdominal pain. She is not able to quantify the strength of
pills
or the exact number of pills that she took, and notes that it
was
an accidental overdose without any intension to harm herself.
The
following morning, she developed worsening abdominal pain,
nausea, and ~10 episodes of non-bloody, non-bilious vomiting
within a five hour period.
She initially presented to ___ yesterday evening,
were work up was notable for significant transaminitis (AST
1259,
ALT 1056, Alk phos 72, Tbili 3.1), negative urine tox screen,
negative serum alcohol, and undetectable acetaminophen level.
She
was started on acetylcysteine infusion and transferred to ___
for further management.
In the ED,
- Initial Vitals: T 100.8, HR 105, BP 127/91, RR 24, SpO2 95% RA
-Exam:
-No scleral or sub lingual jaundice
-Patient does appear slightly confused
- Labs:
Chem: Na 143, Cl 113, HCO3 16, BUN 4, Cr 0.5
CBC: WBC 12.3, Hgb 13.6, Plt 164
Coags: INR 3.5
LFTs: ALT 3683, AST 4331, Tbili 2.3
VBG: ___
Lactate: 1.8
Serum tox: acetaminophen negative
UA: RBC 80, WBC 1, few bact
- Imaging:
RUQUS: Normal liver ultrasound without evidence of biliary
dilatation. Patent hepatic vasculature.
CT head: No acute intracranial findings. No substantial
intracranial edema.
- Consults:
Hepatology: timing consistent with stage II (___) of
acetaminophen overdose. Plan for broad workup and transplant
evaluation. Continue NAC.
Transplant surgery: will follow
- Interventions: NAC gtt
The patient was placed on ___ given concern for SI
attempt.
Upon arrival to ___, she reports feeling well overall. Notes
her
abdominal pain, nausea and vomiting from yesterday have
resolved.
Denies chest pain, shortness of breath, cough, fever, chills or
other systemic symptoms. Denies any history of liver issues.
Family history of SLE in her mother; no known personal
autoimmune
disease. She denies drinking alcohol or eating mushrooms; drinks
herbal tea on occasion. No recent illness. She notes a history
of
depression (unclear if formally diagnosed), though has never
taken any anti-depressants regularly. Reports a prior
psychiatric
admission ___ years ago for wrist slitting. Denies any prior SI
attempts, recent worsening depression or anxiety.
ROS otherwise as above, or negative.
Past Medical History:
Psychiatric admission for SI (___)
?Depression (per patient)
Social History:
___
Family History:
Mother with SLE. Father with "liver issues", alcohol use
disorder, possible hepatitis.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: Temp 98.6F BP 123/89 HR 71 RR 23 100% on RA
GENERAL: WDWN female in NAD. Lying comfortably in bed.
HEENT: NCAT. Pupils equal. Sclera anicteric and without
injection. MMM.
NECK: Supple.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Normal respiratory effort. CTAB without wheezes, rales or
rhonchi.
ABDOMEN: Normal bowels sounds, non distended, mild to deep
palpation in the RUQ. No rebound, guarding or organomegaly.
EXTREMITIES: Warm, well perfused. No ___ edema or erythema.
SKIN: Warm, dry. No rashes.
NEUROLOGIC: A&Ox3. CN2-12 grossly intact. Moves all extremities.
DISCHARGE PHYSICAL EXAM
========================
24 HR Data (last updated ___ @ 608)
Temp: 98.1 (Tm 98.5), BP: 101/66 (96-110/62-75), HR: 73
(72-91), RR: 18, O2 sat: 97% (97-98), O2 delivery: Ra
GENERAL: WDWN female in NAD. Sitting up comfortably in bed.
Oriented x 3.
HEENT: NCAT. Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Normal respiratory effort. CTAB without wheezes, rales or
rhonchi.
ABDOMEN: Normal bowels sounds, non distended, non tender. No
rebound, guarding or organomegaly.
EXTREMITIES: Warm, well perfused. No ___ edema or erythema.
SKIN: Warm, dry. No rashes.
NEUROLOGIC: A&Ox3, no asterixis.
PSYCH: Flat affect, speaks in low volume.
Pertinent Results:
Admission Labs:
___ 05:26AM BLOOD WBC-12.3* RBC-4.62 Hgb-13.6 Hct-39.4
MCV-85 MCH-29.4 MCHC-34.5 RDW-12.5 RDWSD-38.6 Plt ___
___ 05:26AM BLOOD ___ PTT-31.8 ___
___ 05:26AM BLOOD Glucose-135* UreaN-4* Creat-0.5 Na-143
K-4.1 Cl-113* HCO3-16* AnGap-14
___ 05:26AM BLOOD ALT-3683* AST-4331* AlkPhos-46
TotBili-2.3*
___ 01:45PM BLOOD Calcium-7.8* Phos-2.2* Mg-1.7
Pertinent Interval Labs:
___ 08:30AM BLOOD Iron-219*
___ 08:30AM BLOOD calTIBC-220* ___ TRF-169*
___ 03:52AM BLOOD IgM HAV-NEG
___ 08:30AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-POS*
___ 08:30AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 08:30AM BLOOD ___
___ 08:30AM BLOOD IgG-892 IgM-93
___ 08:30AM BLOOD MUM IgG-POS*
___ 08:30AM BLOOD CMV IgG-POS* CMV IgM-NEG CMVI-Generally
EBV IgG-POS* EBNA-POS* EBV IgM-NEG EBVI-Results in TOX IgG-NEG
TOXI-If acute i VZV IgG-Equivocal*
___ 08:30AM BLOOD HIV Ab-NEG
___ 05:26AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 11:44AM BLOOD Glucose-134* Lactate-3.1*
Discharge Labs:
___ 07:09AM BLOOD WBC-5.9 RBC-4.02 Hgb-11.8 Hct-34.6 MCV-86
MCH-29.4 MCHC-34.1 RDW-13.2 RDWSD-41.3 Plt ___
___ 07:09AM BLOOD Neuts-37.8 ___ Monos-9.2
Eos-14.6* Baso-1.0 Im ___ AbsNeut-2.22 AbsLymp-2.13
AbsMono-0.54 AbsEos-0.86* AbsBaso-0.06
___ 05:10PM BLOOD ___ PTT-29.7 ___ 07:18AM BLOOD ___ PTT-32.0 ___
___ 07:18AM BLOOD Glucose-86 UreaN-4* Creat-0.4 Na-139
K-3.7 Cl-106 HCO3-20* AnGap-13
___ 07:18AM BLOOD ALT-1700* AST-134* LD(LDH)-157 AlkPhos-67
TotBili-1.1
___ 07:18AM BLOOD Albumin-3.4* Calcium-8.6 Phos-4.3 Mg-1.8
Studies:
RUQUS ___
Normal liver ultrasound without evidence of biliary dilatation.
Patent
hepatic vasculature.
CXR ___
No acute cardiopulmonary process.
ECHO ___
Suboptimal image quality. Normal biventricular cavity sizes and
regional/global
biventricular systolic function. Mild tricuspid regurgitation.
Normal estimated pulmonary artery
systolic pressure. Resting tachycardia
CT ___. Edematous changes involving the liver and porta hepatis with
free-fluid, secondary to acute liver failure.
Brief Hospital Course:
SUMMARY
=========
Ms. ___ is a ___ female with a history of suicide
attempt ___ years ago who presents following an intentional
acetaminophen overdose without suicidal attempt, admitted to the
FICU for acute liver failure now being called out to the
medicine floor with down-trending LFTs.
ACUTE ISSUES:
=============
#Acute liver failure
#Significant transaminitis
Presenting after taking ~half a bottle of acetaminophen two days
prior to arrival. Significantly elevated LFTs, INR >1.5, and
initial AMS consistent with acute liver failure. Acute liver
failure likely ___ acetaminophen toxicity (stage II per
hepatology). Leukopenia/thrombocytopenia also consistent with
liver injury. Her MELD peaked at 25 and was 10 upon discharge.
She was started on NAC which was continued during her stay until
discharge on ___. She was followed by hepatology, transplant,
and toxicology. Other infectious and autoimmune etiologies were
excluded. Low suspicion for shock liver. Her LFTs continued to
improve while on NAC. No need for transplant according to the
The Liver Transplant Multidisciplinary Committee due to her
improving clinical status. Labs on discharge: ALT 1700, AST 134,
INR 1.2, T. bili 1.1. As her INR was <1.5 and LFTs continued to
downtrend with resolution in her clinical symptoms and ability
to tolerate PO, hepatology felt that NAC was no longer necessary
and that she no longer required inpatient workup. She received
the first dose of the Hepatitis B vaccine series.
#Hypokalemia, borderline hypomagnesemia, resolved
Acute acetaminophen overdose is associated with dose-dependent
hypokalaemia (Waring et al, ___. Hypomagnesemia was likely ___
to poor nutrition due to her persistent nausea with eating
leading to poor PO intake. Resolved after repletion.
#Acetaminophen overdose
Describes taking a "handful" of acetaminophen for pain. Has
reported 10 pills to some providers, 20 pills to others. She
denied any intentional overdose, recent worsening depression,
current SI/HI, or hallucinations. In addition, the patient is a
___ and conceivably understands the risks of
acetaminophen overdose. Of note, the patient had a psychiatric
hospitalization ___ years ago for wrist slitting with suicidal
intent. Placed on ___ in the ED and had a 1:1 sitter in
the ICU which has been discontinued since the patient denies
suicide attempt. Patient was educated on safe use of Tylenol.
#AVNRT
During ambulation, patient reportedly tachycardic to 110s-150s
that resolved spontaneously. She was sinus tachy on EKG without
any documented episodes of her SVT. Pulse has been in low 100s
this admission, most recently ___ in the past 24h. Transient
fevers, but resolved and no infectious symptoms. No history of
tachycardia.
#Metabolic acidosis
Mild non gap metabolic acidosis that has improved since
admission possible iso liver injury and resolving emesis.
#Encephalopathy, resolved
Noted to have confusion in the ED. CT head negative for
intracranial etiology. Suspect ___ ALF/lab abnormalities as
described above. A&Ox3 now. No asterixis.
#Leukocytosis, resolved
Likely stress response ___ liver failure. CXR and Ucx normal. No
infectious sxs. No longer febrile. Likely from liver
inflammation.
CORE MEASURES
==============
#CODE STATUS: Full (confirmed)
#CONTACT: ___ (boyfriend) - ___ Mother -
___
TRANSITIONAL ISSUES
====================
[ ] Please recheck LFTs 1 week post-discharge per hepatology
___'s. No need for hepatology follow-up unless her LFTs worsen.
[ ] Continue to educate patient on appropriate Tylenol usage.
[ ] Discuss with patient about her migraines, as this is why she
supposedly took the Tylenol.
[ ] Continue to monitor patient for signs of suicidal ideation.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Acute liver failure
SECONDARY DIAGNOSIS
====================
Acetaminophen overdose
Atrioventricular nodal re-entrant tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you here at ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted because you had severe abdominal pain,
nausea, and vomiting. It was found that you had acute liver
failure.
WHAT WAS DONE WHILE I WAS HERE?
- You were admitted to the ICU for your acute liver failure.
- An extensive workup was done to look for the cause of your
acute liver failure. We believe it was most likely due to the
amount of Tylenol you took that put you into acute liver
failure.
- You were given medications to help treat your acute liver
failure.
- You were monitored very closely.
- Our hepatology team, transplant team, toxicology team, and
psychiatry team were involved.
WHAT DO I NEED TO DO ONCE I LEAVE?
- Please keep all of your follow-up appointments. It is very
important for you to keep your appointment next week with Dr.
___ to ensure that your liver function has normalized.
- If you have any recurrence of abdominal pain, nausea, or
vomiting, or if you notice your hands shaking, some confusion,
or yellowing of your skin, you should go back to the Emergency
Room immediately.
- Avoid drinking alcohol, taking Tylenol or any over the counter
supplements. Most drugs are cleared through the liver and can
cause further injury to your liver which can be fatal. Please
discuss with your new PCP before taking anything.
Be well,
Your ___ Care Team
Followup Instructions:
___
|
10282002-DS-24 | 10,282,002 | 24,626,113 | DS | 24 | 2187-01-05 00:00:00 | 2187-01-06 05:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Iodine-Iodine
Containing / iron / shrimp
Attending: ___.
Chief Complaint:
Hypertensive emergency
Major Surgical or Invasive Procedure:
Coronary Angiography on ___
History of Present Illness:
Ms. ___ is a ___ woman with a history of PVD c/b
mesenteric ischemia, stage I adenocarcinoma of the lungs (in
remission s/p CyberKnife ___, PMR (on prednisone),
poorly-controlled hypertension (outpatient BP SBP 170s-190s),
and CAD who presented to the ___ ED after a syncopal episode
and admitted to the CCU with concern for hypertensive emergency.
The patient was in her usual state of health until approximately
one week prior to presentation when the patient began to
experience increasing fatigue and lightheadedness. She went to
her PCP on ___ in the setting of her new symptoms and, per
the patient, some of her blood pressure medications were changed
due to her lightheadedness. On ___, the morning of hospital
admission, the patient was experiencing her typical anginal
chest pain and took two nitroglycerin with relief. She ate with
her friends but was still feeling quite lightheaded while
sitting at the table. She then syncopized while sitting at the
table for approximately 1 minute according to witnesses. There
was no head strike, fall, or tonic-clonic motions. She did
experience a preceding R-sided headache. She had no post-ictal
confusion. No bowel/bladder incontinence. She was taken by
ambulance to the ___ ED for further workup.
Of note, the patient reports that she has been experiencing
increasing frequency and severity of chest pain over the past
several weeks. She typically experiences intermittent chest pain
at most once per day that was relieved with rest and
nitroglycerin. However, over the past multiple weeks she has
been experiencing her usual chest pain multiple times per day
and is now sometimes requiring up to two nitroglycerin tablets
to relieve the pain. According to the patient, she is scheduled
for outpatient stress test on ___.
In the ED, the patient's initial vitals were:
98.1 54 120/76 18 97% RA
EKG showed a RBBB with anterolateral ST depressions and T-wave
inversions in lateral leads
Labs were notable for:
Normal CBC
Bicarb - 33, BUN 56,
Cr 2.0 @ 1100 --> Cr 1.5 @ 1700 (baseline 1.3 - 1.5)
pro-BNP - 3375
Trop-T 0.02 --> Trop-T 0.01
CXR was benign
CT Head was negative
The patient was given IVF.
At two hours after ED presentation the patient developed
systolic blood pressures to the 230s systolic.
Nicardipine drip was started and patient's systolic pressures
returned to the 150s. She was then admitted to the CCU with
concern for hypertensive emergency given the elevated
creatinine, headache, and troponin leak.
Vitals on transfer: 97.6, 155/52, 73, 20, 96% RA
On arrival to the CCU: The patient reports that she feels well.
She denies chest pain or dyspnea. Her headache has resolved. She
denies dizziness but endorses some lightheadedness. She denies
any recent weight loss, illnesses, dysuria, increased frequency,
diarrhea, or constipation.
REVIEW OF SYSTEMS:
Positive per HPI.
All of the other review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes
+ Hypertension
- Dyslipidemia
2.OTHER PAST MEDICAL HISTORY
h/o H. pylori
carotid stenosis
GERD
Mesenteric Ischemia
PMR on 20mg pred daily
Basleine R sided Bell's Palsy
Stage I adenocarcinoma of the lung involving the right middle
lobe for which she is status post CyberKnife stereotactic body
radiotherapy completing on ___.
VASCULAR HISTORY:
1. ___ Stenting of common origin of celiac and superior
mesenteric in the setting of diffuse abdominal pain and 13 lb
weight loss.
2. ___ Treatment of a left SMA/celiac in-stent stenosis with
a 7 x 18 mm articulating stent.
Social History:
___
Family History:
Mother had an myocardial infarction in the ___. Dad had CVA in
the ___. One brother with coronary artery bypass graft, greater
than ___ years, one half brother with heart condition, not
specified.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
VS: 97.6, 155/52, 73, 20, 96% RA
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP not elevated.
CARDIAC: Regular rate and rhythm. Normal S1, S2. S3 palpable.
systolic murmur heard best at apex. no rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
NEURO: CN II-XII intact. Strength ___ in all extremities.
Cerebellum intact.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
PHYSICAL EXAM ON DISCHARGE:
===========================
VS: Afebrile 101-191/49-61 60-70s18 94-98% RA
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP not elevated.
CARDIAC: Regular rate and rhythm. Normal S1, S2. S3 palpable.
systolic murmur heard best at apex. no rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: R fem access w/o erythema, swelling, or tenderness.
Warm, well perfused. No clubbing, cyanosis, or peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
LABS ON ADMISSION:
==================
___ 11:10AM BLOOD Lactate-1.2
___ 11:01AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.4
___ 11:01AM BLOOD CK-MB-3 proBNP-___*
___ 11:01AM BLOOD cTropnT-0.02*
___ 05:51PM BLOOD ALT-18 AST-31 LD(LDH)-422* CK(CPK)-127
AlkPhos-72 TotBili-1.1
___ 11:01AM BLOOD Glucose-80 UreaN-56* Creat-2.0* Na-139
K-4.1 Cl-97 HCO3-33* AnGap-13
___ 11:01AM BLOOD ___ PTT-25.4 ___
___ 11:01AM BLOOD WBC-9.7 RBC-4.07 Hgb-12.4 Hct-38.1 MCV-94
MCH-30.5 MCHC-32.5 RDW-13.9 RDWSD-47.8* Plt ___
___ 11:01AM BLOOD Neuts-69.7 Lymphs-18.4* Monos-7.1 Eos-3.1
Baso-0.5 Im ___ AbsNeut-6.76* AbsLymp-1.79 AbsMono-0.69
AbsEos-0.30 AbsBaso-0.05
MICROBIOLOGY:
=============
urine culture ___ negative
IMAGING:
========
CT HEAD ___
No acute intracranial process.
CXR ___
Mild cardiomegaly, no signs of pneumonia or edema.
Renal U/S ___
No evidence of renal artery stenosis on this limited scan. 7 mm
right upper pole renal mass of undetermined nature. This could
represent a small AML but is not classic for by ultrasound
appearance for this. Given the size and patient's age, this
could be followed by repeat ultrasound in ___ months..
Cardiac nuclear study ___. Reversible, medium sized, mild perfusion defect involving the
RCA territory.
2. Normal left ventricular cavity size and systolic function.
Stress test ___
IMPRESSION: No anginal symptoms with ischemic ST segment
changes.
Resting systolic hypertension with an appropriate hemodynamic
response
to the Persantine infusion. Nuclear report sent separately.
Cath ___
left main normal; LAD mild disease; LCX with 40% distal stenosis
(better than prior); RCA 40% mid
LABS ON DISCHARGE:
==================
___ 07:40AM BLOOD WBC-7.5 RBC-3.59* Hgb-11.0* Hct-33.8*
MCV-94 MCH-30.6 MCHC-32.5 RDW-14.0 RDWSD-47.9* Plt ___
___ 07:40AM BLOOD Glucose-78 UreaN-38* Creat-1.6* Na-144
K-3.8 Cl-106 HCO3-23 AnGap-19
___ 07:40AM BLOOD CK-MB-3 cTropnT-0.03*
___ 07:40AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.6
Brief Hospital Course:
Ms. ___ is a ___ woman with a PVD c/b mesenteric
ischemia, stage I adenocarcinoma of the lungs (in remission s/p
CyberKnife ___, PMR (on prednisone), poorly-controlled
hypertension, and CAD who presented to the ___ ED after a
syncopal episode likely vasovagal found to have hypertensive
emergency admitted to the CCU for further management.
#Unstable angina
#Chest pain: Patient with recent worsening of anginal symptoms
over the last few weeks though still responsive to
nitroglycerine. Her hospital course was complicated by frequent
episodes of substernal chest pain radiating to the back. During
several of these episodes, she has ST depressions in V5-V6.
Troponins negative in house. pMIBI notable for moderate
reversible inferior wall perfusion defect. No evidence of high
grade stenosis on cath (LAD mild disease; LCX with 40% distal
stenosis; RCA 40% mid). Continued aspirin, carvedilol titrated
to 25mg BID, rosuvastatin. Added amlodipine 7.5mg to regimen in
addition to isodil 60mg daily as well. Sent home with sublingual
NTG as well. Persistent chest pain could be ___ uncontrolled
hypertension vs vasospasms. Will follow up on outpatient basis.
#Hypertensive emergency: patient presented normotensive but
developed HTN to the 230's associated with a rise in Cr and a
headache. Emergency given concern for end organ damage. Was
initially started on nitroprusside gtt but transitioned to an
oral regimen as such: amlodipine 7.5mg daily, isosorbide
mononitrate 60mg daily, carvedilol 25mg BID, valsartan 160mg
daily, methyldopa 250q12H. Blood pressures were labile
throughout hospital stay but were under better control with
final BP regimen aforementioned above.
#Syncope: episode of syncope prior to admission while sitting at
a table for 1 minute. No headstrike, fall, tonic clonic motions,
post ictal confusion, bowel or bladder incontinence. While in
house, work up was negative aside from mildly positive
orthostatics in the CCU. Leading dx was vasovagal response in
setting of bradycardia from high carvedilol dosing. Did not have
any syncopal episodes while inhouse.
#Vertigo
#Headache: Occurred with movement, does not happen at rest has
been going on for a few weeks. Has nystagmus on exam and sees
double on lateral gaze. Consider MRI as outpatient.
#HFpEF: patient with known disease, appeared
euvolemic/hypovolemic on initial exam. Initially held torsemide
but restarted home regimen upon discharge.
___: Likely in setting of poor PO intake and HTN emergency.
Resolved to baseline (1.3-1.5) with lowered blood pressure.
#PVD: Continued home rosuvastatin
#PMR:Continued prednisone 20mg. Consider PCP ppx as outpatient
#GERD: Patient described heartburn, sourtaste in throat in AM.
Started on ranitidine 150mg BID upon discharge.
TRANSITIONAL ISSUES:
=====================
NEW MEDICATIONS:
-Amlodipine 7.5mg daily
-Imdur 60mg daily
-Ranitidine 150mg BID
CHANGED MEDICATIONS:
-Carvedilol 25mg BID (decreased due to low HR)
-ASA 81mg daily
-Valsartan 160mg daily
STOPPED MEDICATIONS:
-None
OTHER:
-Follow-up blood pressure and adjust anti-hypertensives as
needed
-Patient is on a prednisone taper for PMR
-Noted to have 7mm right upper pole renal mass. Recommend repeat
ultrasound in ___ months
-Repeat BMP within 1 week of discharge to monitor renal function
and electrolytes on new dose of valsartan
-Patient discharged on home torsemide. Monitor weights and
adjust accordingly
-Discussed that the patient should not drive as we adjust her
medications. Will follow-up with primary care physician for
clearance.
-Code: Full
-Contact: ___ ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Valsartan 80 mg PO DAILY
2. Tiotropium Bromide 1 CAP IH DAILY
3. Carvedilol 31.25 mg PO BID
4. Methyldopa 250 mg PO Q12H
5. Rosuvastatin Calcium 10 mg PO QPM
6. Torsemide 20 mg PO 3X/WEEK (___)
7. Potassium Chloride 10 mEq PO DAILY
8. Fluocinonide 0.05% Cream 1 Appl TP BID
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Levothyroxine Sodium 75 mcg PO DAILY
11. Aspirin 81 mg PO Q48H
Discharge Medications:
1. amLODIPine 7.5 mg PO DAILY
RX *amlodipine 2.5 mg 3 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
2. Isosorbide Mononitrate 60 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. Valsartan 160 mg PO DAILY
RX *valsartan 160 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Aspirin 81 mg PO Q48H
7. Fluocinonide 0.05% Cream 1 Appl TP BID
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Methyldopa 250 mg PO Q12H
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. Potassium Chloride 10 mEq PO DAILY
Hold for K >
12. PredniSONE 20 mg PO DAILY
Tapered dose - DOWN
13. Rosuvastatin Calcium 10 mg PO QPM
14. Tiotropium Bromide 1 CAP IH DAILY
15. Torsemide 20 mg PO 3X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Hypertensive Emergency
Secondary: Chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you.
Why you were admitted?
You were admitted because of the fainting episode, chest pain
and high blood pressures you were experiencing
What was done for you while you were in the hospital?
-You were initially admitted to the cardiac critical care unit
for management of your high blood pressure
-Imaging of your head did not show any evidence of bleed or
stroke
-You were started on medications to help control your blood
pressure and your symptoms improved
-During your hospital stay, you had several episodes of chest
pain. You underwent a cardiac catheterization which did not show
any significant blockages of your arteries.
-To help with your chest pain, you will continue your
nitroglycerine and the medications for your blood pressure
What to do when you leave the hospital?
-Please take all of your medications as prescribed
-Please follow-up with your primary care physician ___ 5 days
of your discharge for continued monitoring of your blood
pressure
-Please call your doctor or return to the Emergency Department
if you experience chest pain that does not respond to your
nitroglycerine, lightheadedness, palpitations, shortness of
breath, fevers or chills.
-Please discuss with your primary care physician prior to
driving
We wish you all the best!
Your ___ Team
Followup Instructions:
___
|
10283092-DS-14 | 10,283,092 | 20,133,128 | DS | 14 | 2161-09-16 00:00:00 | 2161-09-18 20:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amlodipine
Attending: ___.
Chief Complaint:
Chest pressure of 3 days duration and near syncopal attack
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M PMHx HTN, HLD, non-ischemic cardiomyopathy presented
with left sided chest pressure of 3 days duration which was
continuous with possible radiation to the left arm (difficult to
distinguish due to cervical radiculopathy)aggravated by activity
(but not impeding it) mild to moderate in severity. Was
associated with SOB but not diaphoresis, nausea or vomiting. He
has been in contact with his outpatinet cardiologists who have
increased his dose of lasix from 80 mg 40 mg to 120 mg 40 mg in
the am and pm respectively due to his symptoms of chest pressure
and SOB. He has not been gaining weight in the past 2 weeks and
has recorded it very diligently at 200 lbs without significant
change. SOB was intermittent and exertional. Patient was still
able to go up stairs and well as carry out his job (___
___). No orthopnea, no PND, no palpitations, no leg or
abdominal swelling, no fatigue
.
He was admitted last ___ with a similar complaint which was more
severe at that time. He was found to have a BNP of 300 and a TTE
showed an LVEF of 20% with an akinetic anterior wall, septum and
apex. A coronary cath showed non-obstructive CAD
.
He was at his cardiologists office earlier today where an NP
reffered him to the ED after finding that his LBBB appeared
worsened and his chest pressure had not resolved. During his EKG
the patient became flushed, diaphoretic and ashen, was
complaining of dizziness and felt as if he would faint.
.
In the ED, initial vitals were 98.1- ___- 18- 99
Labs and imaging significant for old LBBB on EKG
Patient given morphine and nitroglycerine with mild improvement
in his pain. CXR was clear and troponins were negative x1.
.
Vitals on transfer were 98- 121/79- 86- 16- 98% on RA
On arrival to the floor, patient Stable
.
REVIEW OF SYSTEMS:
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Past Medical History:
. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- sCHF ( Cardiomypathy) of uncertain etiology (initially ___
w LVEF 20%, presumed to be non-ischemic, w improvement in EF
back
50-60% over last ___ in setting of medical management
.
Cardiac MR showed The LV cavity size was severely increased with
severe LV systolic dysfunction (LVEF 21%). There was global
hypokinesis with the basal lateral segments contracting best and
the septal segments contracting worst (although this is likely
due to intraventricular conduction delay). There was a focus of
patchy
late gadolinium enhancement at the inferior RV insertion point,
which represents a nonspecific pattern out of proportion to the
degree of LV dysfunction. Corresponding T2 and early
gadolinium enhancement images demonstrated no evidence of an
active inflammatory process. The RV cavity size was normal
with moderate RV systolic dysfunction (RVEF 27%). There was
moderate-to-severe MR and moderate TR. ___ was biatrial
enlargement. There
was a small pericardial effusion.
.
3. OTHER PAST MEDICAL HISTORY:
- Gout on allupurinol ___
- GERD on omeprazole 20 mg
Social History:
___
Family History:
No family h/o heart disease
Physical Exam:
ADMISSION EXAM:
VS: T98 , BP121/79 , HR86, RR16 , SpO2 98 RA, 15 point drop in
systolic blood pressure when standing.
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, Normal S1, Reversed splitting of S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
NEURO: CN II-XII tested and intact, strength ___ throughout,
sensation grossly normal. Gait not tested.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
DISCHARGE EXAM:
VS: T98.5 , BP115/79 , HR86, RR16 , SpO2 98 RA,
110/70 lying
110/70 sitting
105/55 standing
-___ 24hr
92.4kg-->92.5kg
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP of 5 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, Normal S1, Reversed splitting of S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e. No femoral bruits.
Pertinent Results:
ADMISSION LABS:
___ 11:55AM BLOOD WBC-8.0 RBC-4.72 Hgb-14.6 Hct-40.6
MCV-86# MCH-30.9 MCHC-35.9*# RDW-14.0 Plt ___
___ 11:55AM BLOOD Neuts-71.4* ___ Monos-5.3 Eos-2.4
Baso-0.9
___ 11:55AM BLOOD ___ PTT-29.3 ___
___ 11:55AM BLOOD Glucose-109* UreaN-17 Creat-0.9 Na-139
K-3.8 Cl-100 HCO3-27 AnGap-16
___ 05:45PM BLOOD CK(CPK)-69
___ 11:55AM BLOOD proBNP-790*
___ 11:55AM BLOOD cTropnT-<0.01
___ 05:45PM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:45PM BLOOD Calcium-9.3 Phos-4.2 Mg-2.0
DISCHARGE LABS:
___ 06:34AM BLOOD WBC-6.9 RBC-4.16* Hgb-13.0* Hct-36.5*
MCV-88 MCH-31.3 MCHC-35.7* RDW-14.0 Plt ___
___ 06:34AM BLOOD Glucose-111* UreaN-17 Creat-1.1 Na-140
K-3.4 Cl-99 HCO3-34* AnGap-10
EKG:
Normal sinus rhythm with intra-atrial conduction abnormality and
one
ventricular premature complex. Left axis deviation. Left
bundle-branch block.
Compared to the previous tracing of ___ the ventricular
premature complex is
new.
IntervalsAxes
___
___
The cardiac, mediastinal and hilar contours are unchanged, with
the heart size
mildly enlarged. Lungs are clear. No pulmonary vascular
congestion is
present. No pleural effusion or pneumothorax is present. There
are no acute
osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ yo man w/ hx of dialated cardiomyopahty
without evidence of CAD presenting with pre-syncopal episode and
chest pain after having his outpatient lasix regimen increased
in the days prior to admission.
.
PreSyncope: Patient presented from clinic complaining of chest
discomfort as described below and what was determined to be a
___ episode in his ___ clinic characterized
by flushing, light headness, narrowing of his vision and a
sensation as if he were to faint. EKG did not show any acute
ischemic changes and biomarkers were negative x2. CXR did not
show any evidence of pulmonary edema or acute intrathorasic
process. His presenting examination was notable for
orthostasis, lack of peripheral edema and flat neck veins. In
the week prior to admission his outpatient lasix had been
increased from 40 mg Qam and 20 mg QPM to 120 mg QAM and 80 mg
QPM in response to complaints of shortness of breath despite
stable weights. His symptoms were felt to be related to this
high dosing of diuretics, which were held during his admission
and discharged on 80 mg PO lasix QAM and follow up with his
cardiologist. His shortness of breath was felt to be attributed
to his chronic mild elevation in BNP as a result of his chronic
systolic heart failure, but not to volume overload.
.
CHRONIC SYSTOLIC HEART FAILURE: Patient was admitted with a
weight of 92.4kg, no peripherial edema, flat neck veins and a
clear CXR. BNP was mildly elevated as a result of his chronic
systolic heart failure, but not to volume overload. He was
continued on losartan, simvastatin, aspirin and carvediol at
home doses with lasix held initially and discharged on 80 mg QD.
Discharge weight 92.5 kg felt to represent dry weight.
.
CHEST PRESSURE: patient described near constant symptoms for the
past several weeks that did not vary significantly with exercise
or exertion, EKG w/o ischemic changes and no elevation in
cardiac biomarkers. Pain was felt to be non-cardiac in nature
and discharged for outpatient work up.
.
GOUT: stable, continued allopurinol.
TRANSITIONAL ISSUES:
-lasix changed as above
-patient requires work up for likely BiV pacer placement
-patient is not on aldosterone antagonist despite EF of 25%
-patient's dry weight 92.5 kg.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Furosemide 120 mg PO QAM
2. Furosemide 80 mg PO QPM
3. Carvedilol 12.5 mg PO BID
4. Allopurinol ___ mg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Simvastatin 10 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Carvedilol 12.5 mg PO BID
4. Furosemide 80 mg PO DAILY
hold for SBP<100, HR<60
5. Losartan Potassium 100 mg PO DAILY
6. Simvastatin 10 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
-presyncope and orthostasis
-chronic systolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted for evaluation of your shortness of
breath, chest discomfort and fainting episode at your doctors
___. It was determined that your dose of lasix was too high
and you had become dehydrated. The dose of this medication has
been decreased from 120 mg and 80 mg every night to 80 mg daily.
Follow up with your cardiologist has been made, please call his
office to negotiate the exact time.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10283141-DS-15 | 10,283,141 | 26,176,839 | DS | 15 | 2122-08-14 00:00:00 | 2122-08-14 19:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol / Lyrica / Haldol / Reglan / Toradol / morphine /
ketamine / Tessalon Perles
Attending: ___.
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with h/o ___ cell disease who presents to
the ED with complaints of full body pain, fever, and cough. She
was recently diagnosed with influenza B at ___ and
has recently completed a course of Tamiflu (last day on ___.
Despite this, patient has had ongoing fevers with Tmax of
104.9F,
generalized muscle aches, fatigue, and productive cough. She
notes that she is also having all over body pain consistent with
her ___ cell crisis. She presented to the ED for further
evaluation.
In the ED, initial VS were notable for;
Temp 101.3 HR 110 BP 172/81 RR 19 SaO2 96% RA
Examination notable for;
Appears unwell, diaphoretic, tachycardic, clear lungs
bilaterally, soft abdomen which is diffusely tender without
rebound/guarding, and no peripheral edema.
Labs were notable for;
WBC 16.5 Hgb 7.5 Plt 292
Retic 3.2% AbsRC 0.08
Na 141 K 3.8 Cl 109 HCO3 20 BUN 4 Cr 0.8 Gluc 100
ALT 27 AST 57 ALP 76 Tbili 1.6 Alb 3.2
Hapto 123 Trop-T <0.01
WBC 15.4 Hgb 6.1 Plt 232
WBC 15.1 Hgb 8.0 Plt 297
WBC 12.9 Hgb 8.3 Plt 272
Influenza B PCR positive
CXR with multifocal opacities in the right lung likely affecting
all lobes, suspicious for multifocal pneumonia, left lung
grossly
clear.
Hematology were consulted;
Patient was given;
- PO acetaminophen 1000mg x2
- IV hydromorphone 1.5mg x2
- IV hydromorphone 2mg x4
- IV hydromorphone 4mg
- 3L NS
- IV ondansetron 4mg
- IV promethazine 6.25mg
- IV azithromycin 500mg
- IV ceftriaxone 1g
- PO oseltamivir 75mg x2
- IV diphenhydramine 12.5mg
- IV diphenhydramine 25mg
- PO folic acid 1g
- PO metoprolol tartrate 25mg
- PO pantoprazole 40mg
- 2 units pRBCs
Vital signs on transfer notable for;
Temp 100.2 HR 89 BP 153/89 RR 20 SaO2 93% RA
Upon arrival to the floor, patient is very uncomfortable,
complaining of significant full body pain including legs, back,
and chest. Endorsing cough which worsens her pain. Did not find
much pain control from IV dilaudid 2mg in the ED and requesting
higher dose. Endorses some shortness of breath with coughing.
Also endorsing some lower extremity edema which she attributes
to
having to sleep upright over the past couple of days because of
her cough.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
==============================
___ cell anemia - complicated by acute chest syndrome in the
distant past
Depression/anxiety
Victim of domestic violence
GERD
s/p splenectomy at ___
s/p tonsillectomy/adenoidectomy at ___
s/p C-section at ___
s/p cholecystectomy at ___
s/p R breast lumpectomy at ___
Social History:
___
Family History:
FAMILY HISTORY:
===============
Father - DM
Mother - DM, mitral valve prolapse
Cousin - ___ cell disease
Paternal aunt - breast cancer, ovarian cancer
Grandmother - heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VITALS: ___ 2343 Temp: 101.7 PO BP: 166/114 HR: 101 RR: 20
O2 sat: 93% O2 delivery: Ra
GENERAL: Alert and interactive. Moderate distress secondary to
pain.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Flow
murmur heard at ___.
LUNGS: Mildly labored respirations. Crackles at bilateral bases.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM
=======================
Temp: 99.4 (Tm 99.4), BP: 135/79 (109-189/71-123), HR: 69
(52-83), RR: 18, O2 sat: 97% (93-97), O2 delivery: Ra
GENERAL: Laying in bed resting, appears well
HEENT: Sclera anicteric and without injection
NECK: Supple, no JVD
CARDIAC: RRR, S1 + S2 present, flow murmur heard at ___.
LUNGS: CTAB, no adventitious noises
ABDOMEN: SNTND, +BS, no rebound/guarding
EXTREMITIES:Trace ___ edema
SKIN: Warm. No rashes.
NEUROLOGIC: AOx3. Moving all 4 extremities.
Pertinent Results:
ADMISSION LABS
===============
___ 08:55PM BLOOD WBC-16.5* RBC-2.65* Hgb-7.5* Hct-21.6*
MCV-82 MCH-28.3 MCHC-34.7 RDW-16.7* RDWSD-48.8* Plt ___
___ 08:55PM BLOOD Neuts-74.3* Lymphs-18.3* Monos-5.6
Eos-0.0* Baso-0.2 NRBC-1.4* Im ___ AbsNeut-12.23*
AbsLymp-3.02 AbsMono-0.92* AbsEos-0.00* AbsBaso-0.03
___ 01:55AM BLOOD Hb A-1.3 Hb S-50.6* Hb C-43.7* Hb A2-4.4*
Hb F-0
___ 08:55PM BLOOD Plt ___
___ 08:55PM BLOOD Ret Aut-3.2* Abs Ret-0.08
___ 08:55PM BLOOD Glucose-100 UreaN-4* Creat-0.8 Na-141
K-3.8 Cl-109* HCO3-20* AnGap-12
___ 08:38AM BLOOD ALT-27 AST-57* AlkPhos-76 TotBili-1.6*
___ 08:38AM BLOOD cTropnT-<0.01
___ 08:38AM BLOOD Albumin-3.2*
___ 08:55PM BLOOD Hapto-123
INTERVAL LABS
==============
___ 01:55AM BLOOD Hb A-1.3 Hb S-50.6* Hb C-43.7* Hb A2-4.4*
Hb F-0
___ 08:22AM BLOOD ___ PTT-24.6* ___
___ 01:55AM BLOOD ___
___ 05:50AM BLOOD Ret Aut-5.1* Abs Ret-0.15*
___ 10:36AM BLOOD Ret Aut-3.4* Abs Ret-0.10
___ 07:50AM BLOOD ALT-75* AST-65* AlkPhos-106* TotBili-1.0
___ 07:50AM BLOOD cTropnT-<0.01 proBNP-588*
___ 08:38AM BLOOD cTropnT-<0.01
___ 05:11AM BLOOD HAV Ab-NEG
___ 08:55PM BLOOD Hapto-123
___ 07:50AM BLOOD Hapto-___
___ 05:50AM BLOOD Hapto-___
IMAGING
========
CXR (___)
FINDINGS:
Multifocal opacities noted in the right lung likely affecting
all lobes
suspicious for multifocal pneumonia. Left lung is grossly
clear.
Cardiomediastinal silhouette is stable. No acute osseous
abnormalities.
Surgical clips noted in the upper abdomen.
CTA (___)
MPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Diffuse ground-glass opacities in both lungs are compatible
with pneumonia
as seen on prior chest x-ray.
3. Mediastinal and hilar lymph nodes are likely reactive.
MICROBIOLOGY
============
Strep Pneumo Ag - Negative
Legionella Ag - Negative
Sputum Gramstain - Respiratory flora
FLU - B +
Brief Hospital Course:
Ms. ___ is a ___ with h/o ___ cell (HgB SC) disease who
presented to the ED with complaints of full body pain, fever,
and cough and found to have pneumonia and ___ cell pain
crisis consistent with acute chest syndrome. Completed Tamiflu
and Ceftriaxone/Azithromycin for 10 day course (___) for
pneumonia and confirmed influenza B. Pain was controlled with IV
opioids and transitioned to PO opioids on discharge.
TRANSITIONAL ISSUES
====================
PRIMARY CARE
[ ] Pt received pnuemovacc in ___, we administered a
meningococcal vaccine (and ___ given currently living in a
shelter)this hospitalization. She will need continued boosters
and yearly flu vaccines given her asplenia
[ ] Pt given prescription for augmentin (pill in pocket) in the
event of fever
[ ] Started lisinopril, please obtain BMP at follow-up
[ ] Pt on considerable amount of opioid pain medications, would
consider having patient sign pain contract. Her insurance
required PA for opioid pain medications.
[ ] Pt currently living in shelter. Prefers to receive 1 week
prescriptions of pain medications at a time as her medications
have been stolen previously.
HEMATOLOGY
[ ] Pt has follow-up with you prior to her new PCP, pt will get
BMP drawn before appointment on ___, please monitor
electrolytes.
[ ] Consider retrialing hydroxyurea, broached this with the
patient and she was theoretically amenable
[ ] Pt has required ~ 10 transfusions this year, previous b/l
hemoglobin ___
Plan for pain medications
- Pt discharged on
--- Long acting : 36mg BID Oxycodone SR x 7 days -> 18mg QAM,
36mg QPM x 5 days -> 18mg BID
--- Short acting : Oxycodone 30mg Q6H PRN (home dose prior to
admission)
- Future plan for pain crisis: ___ IV hydromorphone boluses
Q1H until pain capture, once achieved, hydromorphone 4mg Q4H
PRN, and begin to space out Q6H -> 2mg hydromorphone Q6H -> Q8H.
Historically, pt does not achieve high enough hydromorphone
levels for pain capture on PCA unless she is on a basal rate.
ACUTE/ACTIVE ISSUES:
====================
___ Cell Pain Crisis
___ Cell Anemia (HgB SC disease)
Pt w/ a history of ___ cell disease (HgB SC), and multiple
recent admissions this year for pain crises who p/w leg, back,
chest pain in the setting of acute chest syndrome as below. The
patient has been on and off opioid pain control from the last
decade including oxycodone (long and short acting formulations)
and methadone, she is intolerant to many adjuvants including
gabapentin, lyrica, ketamine and tordol. This admission she
presented w/ severe generalized pain. She was on PCA with
uncontrolled pain. The pain service was consulted who
recommending contuining with her PCA and uptitrating, however
the pt still had uncontrolled pain w/o a basal rate. We then
switched her to 4mg hydromorphone Q4H PRN which was effective.
After pain capture we were effectively able to reintroduce her
home oral regimen (uptitrated her long acting oxycodone) and
slowly taper her IV to 4mg Q6H -> 2mg hydromorphone Q6H -> Q8H.
We continued her on a bowel regimen and she did not experience
any AMS or over-sedation w/ this regimen. The pt does well when
distinct expectations are set and she is told about medication
changes prior to her occurrence. Over the course of the
admission she received several IVF boluses, her oxygen was
maintained > 94% and she required 4u pRBCs. Her b/l hgb is
___, though even after transfusions this admission she ~
___ at best. She received her meningococcal vaccine + ___
this admission (pneumovax and flu in ___ and was discharged w/
PRN augmentin (pill in pocket) for fevers.
#Cough
#Hypoxia
#Pneumonia
#Acute Chest Syndrome
Completed Tamiflu and Ceftriaxone/Azithromycin for 10 day course
(___) for pneumonia and confirmed influenza B. She did
receive Lasix x2 w/o improvement given concern that she was
volume overloaded in the setting of IVF and blood transfusions.
Overall this improved following prolonged antibiotic course as
above, and her pain prolonged her hospitalization more than her
respiratory issues. She did have a CTA this admission which was
negative for acute PE, and often refused her DVT prophylaxis.
#HTN
Intermittently hypertensive this admission, have previously been
limited by relative hypotension associated w/ tizandidine.
However once stabilized we started lisinopril 5mg.
#Long QTc
Previous QTc > 500, however downtrended to ~430-450.
#Pruritus
Considerable pruritus in the setting secondary to opioid pain
medications. Pt has dye allergy and takes PO Benadryl. She
received considerable amounts of IV Benadryl, during her acute
pain crisis. Started loratadine in this setting and transitioned
her back to her home PO Benadryl.
#Insomnia
Pt w/ considerable insomnia related to pain and anxiety, has had
poor tolerance/reactions to multiple other medications
(trazodone, gabapentin, seroquel, ambien, mirtazapine etc)
CHRONIC ISSUES:
===============
#HISTORY OF DOMESTIC VIOLENCE:
Patient reports history of domestic violence (her father) and is
now living inshelter while awaiting assistance with housing. Pt
was seen by social work and given resources and will return to
her shelter at discharge.
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. OxyCODONE (Immediate Release) 30 mg PO Q6H:PRN Pain -
Moderate
2. Xtampza ER (oxyCODONE myristate) 18 mg oral Q12H
3. Tizanidine 8 mg PO TID
4. Metoprolol Tartrate 25 mg PO DAILY
5. Loryna (28) (drospirenone-ethinyl estradiol) ___ mg oral
DAILY
6. Pantoprazole 40 mg PO Q24H
7. DiphenhydrAMINE 50 mg PO QHS:PRN itching
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO ONCE:PRN fever
Take in case of fever and go to the nearest emergency room
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth
once as needed Disp #*3 Tablet Refills:*1
2. Azithromycin 250 mg PO Q24H Duration: 5 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once daily Disp #*45
Tablet Refills:*0
4. GuaiFENesin ___ mL PO Q6H:PRN cough
RX *guaifenesin [Cough Syrup] 100 mg/5 mL ___ ml by mouth every
six (6) hours Disp ___ Milliliter Milliliter Refills:*0
5. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*45
Tablet Refills:*0
6. Loratadine 10 mg PO DAILY
RX *loratadine 10 mg 1 tablet(s) by mouth once a day Disp #*45
Tablet Refills:*0
7. Senna 8.6 mg PO BID
RX *sennosides 8.6 mg 1 tablet(s) by mouth Twice daily as needed
Disp #*30 Tablet Refills:*0
8. Xtampza ER (oxyCODONE myristate) 36 mg oral BID Duration: 20
Doses
Please take BID for 7 days and then switch to 18mg in the
morning 36 in the evening for 5 days before decreasing to
18mg/18mg
RX *oxycodone myristate [Xtampza ER] 36 mg 1 capsule(s) by mouth
twice a day Disp #*20 Capsule Refills:*0
9. DiphenhydrAMINE 50 mg PO QHS:PRN itching
10. Loryna (28) (drospirenone-ethinyl estradiol) ___ mg oral
DAILY
RX *drospirenone-ethinyl estradiol 0.02 mg-3 mg (24) 1 tab-cap
by mouth as directed Disp #*28 Tablet Refills:*1
11. OxyCODONE (Immediate Release) 30 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 30 mg 1 tablet(s) by mouth Q6H as needed Disp #*28
Tablet Refills:*0
12. Pantoprazole 40 mg PO Q24H
13. Tizanidine 8 mg PO TID
14. Xtampza ER (oxyCODONE myristate) 18 mg oral Q12H
please follow taper on d/c instructions
15.Outpatient Lab Work
___ Cell disease 282.60
___, Fax ___
Chem-10, CBC with differential, reticulocyte count
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Acute Chest Syndrome
SECONDARY DIAGNOSES:
=====================
Community-acquired pneumonia
Influenza
___ Cell Pain Crisis
Insomnia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You had pneumonia after having the flu, and were also having a
___ cell pain crisis.
What did you receive in the hospital?
- You recieved antibiotics and Tamiflu to treat your pneumonia,
and prolonged influenza infection
- You were given IV fluids
- We gave you medications to treat your pain
- You received multiple blood transfusions
- You were seen by the hematology doctors
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- We have set up appointments to help you transition your care
to ___, it will be important that you make these appointments
(ie. hematology and primary care here)
- If you have new shortness of breath, chest pain or fever you
should go to the emergency room
- We gave you an antibiotic to take in the event that you notice
you are getting a fever "pill in pocket", if you have fever you
should take this pill and go to the emergency room
- We discussed you pain medications extensively, it will be
important that you stick to the taper schedule
-Oxycodone SR (Oxycontin) 40 mg twice daily x 7 days -> 18mg in
the morning + 40mg in the evening x 5 days -> 18mg twice daily
-Oxycodone ___ 30mg Every 6 hours as needed for pain
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10283141-DS-16 | 10,283,141 | 23,965,654 | DS | 16 | 2122-08-27 00:00:00 | 2122-08-27 11:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol / Lyrica / Haldol / Reglan / Toradol / morphine /
ketamine / Tessalon Perles / gabapentin
Attending: ___.
Chief Complaint:
Chest pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ with h/o ___ cell (HgB SC) disease, recurrent
hospitalizations, recently admitted ___ with influenza
and pneumonia and resulting acute chest syndrome presenting with
recurrent chest pain. During recent hospitalization, patient was
treated with ceftriaxone/azithromycin for 10-day course
completed
___ hematology service was consulted for management of
___ cell crisis and acute chest syndrome. Decision was made
to proceed with transfusions alone, and not exchange transfuse
given relatively mild acute chest. With respect to pain
management, per discharge summary, PCA was ineffective in
controlling pain. Pain service was consulted and, despite
uptitration of PCA, pain remained poorly controlled. She was
then switched to hydromorphone 4 mg q4h prn with more effective
pain relief. Her home regimen was then reintroduced, with slow
taper of IV hydromorphone from 4 mg q4h to 4 mg q6h to 2 mg q6h
to 2 mg q8h. Per discharge summary, "the patient does well when
distinct expectations are set and she is told about medication
changes prior to" changes being made. Throughout that
hospitalization, she received IV fluids, O2 sat was maintained
over 94%, and she received a total of 4 units packed red blood
cells. Of note, CTA during that admission was negative for
acute
PE.
Patient now returns with reports of recurrent chest pain. She
reports that, on the evening prior to presentation, she ate a
steak bomb and several bites of mozzarella stick, which was not
shared with anyone else. At about 8 ___, she developed nausea
and
nonbloody emesis. Between 12 and 3 AM on the morning of
presentation, she had 3 episodes of nonbloody diarrhea, with
onset of chest pain over the following hours. She describes
chills, diaphoresis, dizziness, mild shortness of breath with
palpitations, and describes pain as sharp, stabbing, associated
with palpitations, ___. She denies dysuria, lower extremity
edema. She denies cough.
In the ___ ED:
VS 97.8->99.2, 94/61, 97% RA
Exam unremarkable
Labs notable for:
WBC 6.3, 10.7, plt 354
BUN 11, Cr 1.0
TnT<0.01
Retic 2.8
Influenza negative
Imaging: CXR, not completed
Consults: None
Received:
IVF
Dilaudid 4 mg IV x3
Benadryl
On arrival to the floor, patient endorses 8 out of 10 chest pain
confirms above history in detail. She states that pain is very
similar to prior episodes of ___ cell crises.
ROS: 10 point review of system reviewed and negative except as
otherwise described in HPI
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
==============================
___ cell anemia - complicated by acute chest syndrome in the
distant past
Depression/anxiety
Victim of domestic violence
GERD
s/p splenectomy at ___
s/p tonsillectomy/adenoidectomy at ___
s/p C-section at ___
s/p cholecystectomy at ___
s/p R breast lumpectomy at ___
Social History:
___
Family History:
FAMILY HISTORY:
===============
Father - DM
Mother - DM, mitral valve prolapse
Cousin - ___ cell disease
Paternal aunt - breast cancer, ovarian cancer
Grandmother - heart disease
Physical Exam:
VS: ___ Dyspnea: 5 RASS: 0 Pain Score: ___
___ Temp: 99.2 PO BP: 162/105 HR: 82 RR: 18 O2 sat:
96%
O2 delivery: RA
___ 2230 Pain Score: ___
GEN: alert and interactive, comfortable, no acute distress,
moving around in bed, stands up, speaking in full sentences,
appropriate laughter intermittently through history
HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without
lesion or exudate, moist mucus membranes, ears without lesions
or
apparent trauma
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Regular rate and rhythm with ___ systolic murmur
throughout precordium, no rubs or gallops
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
GI: soft, nontender, without rebounding or guarding,
nondistended
with normal active bowel sounds, no hepatomegaly
EXTREMITIES: no clubbing, cyanosis, or edema
GU: no foley
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation
NEURO: Alert and interactive, cranial nerves II-XII grossly
intact, strength and sensation grossly intact
PSYCH: normal mood and affect while discussing symptoms, mild
agitation/guardedness when discussing life in shelters
DISCHARGE EXAM:
Gen - comfortably sitting up in bed eating, does not appear to
be in any distress
HEENT - moist mucous membranes, no OP lesions
___ - rrr, s1/2, faint systolic murmur heard best at rusb
Pulm - CTA b/l, no w/r/r
GI - soft NT ND +BS
Ext - no peripheral edema or cyanosis
Skin - warm and dry
Psych - during exam this morning - calm and cooperative.
Pertinent Results:
___ 01:28PM BLOOD WBC-6.3 RBC-3.76* Hgb-10.7* Hct-32.4*
MCV-86 MCH-28.5 MCHC-33.0 RDW-16.7* RDWSD-50.8* Plt ___
___ 01:28PM BLOOD Glucose-81 UreaN-11 Creat-1.0 Na-137
K-7.6* Cl-102 HCO3-21* AnGap-14
___ 08:27AM BLOOD LD(LDH)-262* TotBili-0.9
___ 01:28PM BLOOD cTropnT-<0.01
___ 03:50PM BLOOD cTropnT-<0.01
Blood cultures negative
CXR
There is no definite focal consolidation, pleural effusion or
pneumothorax.
The previously seen ill-defined opacities in the left upper and
right upper
and right lower lung the are less conspicuous than prior. The
size of the
cardiac silhouette is enlarged but unchanged.
Brief Hospital Course:
Assessment/Plan: ___ with h/o ___ cell (HgB SC) disease,
recurrent hospitalizations, recently admitted ___ with
influenza and pneumonia and resulting acute chest syndrome
presenting with recurrent chest pain likely triggered by
foodborne gastroenteritis.
# Chest pain:
# SCD:
Initially felt to have vast-occlusive pain in the setting of
___ cell. However, given persistent pain medication
requirement and difficulty with taper due to continued severe
subjective pain, her pain was more attributed to opiate use
disorder than true crisis. She was started on IV dilaudid in the
hospital with a very difficult weaning process. Ultimately her
discharge regimen for narcotics is her home regimen of xtampza
36 mg BID and oxycodone 30 mg q6h prn. She should see hematology
as an outpatient. Consideration of hydroxyurea might help with
her ___ cell disease.
# Hypertension: Lisinopril started during last admission,
continued
# Bradycardia: had an episode of bradycardia and somnolence
while hospitalized. Somnolence attributed to high narcotic
requirement, bradycardia might be due to concurrent use of
tizanidine. Ultimately she was not amenable to dose reduction of
tizanidine. An echo had no structural abnormalities and EKG did
not have conduction abnormalities.
# Long QTc: >550 on arrival, now ___.
- Avoid QT prolonging medications without same day EKG
# Psychosocial: Pt living in shelter now, awaiting housing. Did
not want to discuss with social work and refused any attempts at
assisting her living situation.
Time spent: 30 minutes including face to face time
OUTSTANDING ISSUES
[ ] Pattern of opioid abuse to be discussed further with PCP.
Should have a care plan when she comes in for SC crises though
she refuses a PCA stating it "almost killed me once"
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Loryna (28) (drospirenone-ethinyl estradiol) ___ mg oral
DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Amoxicillin-Clavulanic Acid ___ mg PO ONCE:PRN fever
4. OxyCODONE (Immediate Release) 30 mg PO Q6H:PRN Pain -
Moderate
5. Tizanidine 8 mg PO TID
6. Senna 8.6 mg PO BID
7. DiphenhydrAMINE 50 mg PO QHS:PRN itching
8. Lisinopril 5 mg PO DAILY
9. Loratadine 10 mg PO DAILY
10. Xtampza ER (oxyCODONE myristate) 36 mg oral BID
11. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
Discharge Disposition:
Home
Discharge Diagnosis:
___ Cell SC crisis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because of severe pain in the
setting of your ___ cell disease. Eventually your pain
medication requirement decreased and you were able to take your
pills again.
We wish you the best.
Sincerely,
Your care team at ___
Followup Instructions:
___
|
10283141-DS-17 | 10,283,141 | 22,665,147 | DS | 17 | 2122-09-13 00:00:00 | 2122-09-13 13:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol / Lyrica / Haldol / Reglan / Toradol / morphine /
ketamine / Tessalon Perles / gabapentin
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ yo currently homeless woman with a PMH notable
for ___ cell (HgbSC) disease requiring multiple
hospitalizations for pain crises and acute chest syndrome,
depression and anxiety a/w a history of domestic violence, and
GERD who presented to the ED this morning with acute chest pain
and new-onset non-bloody diarrhea c/f acute chest syndrome.
She was just discharged on ___. She feels that after discharge
she was withdrawing from opiates as she feels that she was
weaned too quickly on her last admission. She was doing okay
until she had increasing chest pain and yesterday had 4 episodes
of watery diarrhea. Today she states the diarrhea has stopped
but that the pain was worsening which prompted her to come to
the emergency room.
On arrival to the emergency room T-max 97.8, heart rate 81,
blood pressure 131/89, respiratory 18 satting 100% on room air.
While there she was briefly hypertensive to the 190s. EKG was
concerning for Wellens sign and she received a sublingual
nitroglycerin x1. Cardiology was consulted in the emergency room
who felt that her EKG changes were similar to previous
presentations including on ___ and ___. Troponins were checked
and were negative x2. Because of concern of acute chest
hematology was consulted they felt that given her negative
troponins and her negative chest x-ray and her breathing
comfortably on room air that she likely did not meet criteria
for acute chest syndrome. They recommended admission to medicine
for treatment of ___ cell crisis. While in the emergency room
she received Dilaudid x4, Benadryl, her home lisinopril, 2 L of
normal saline, and Tylenol.
On arrival to the floor she discusses that she feels that 4 mg
of IV Dilaudid does not help and that on last admission they
gave her 24 hours of 6 mg of IV Dilaudid and she is hopeful that
she can have this again. She asked that the medications be
pushed that minibag does not seem to work well for her. We
discussed that all pain meds will be minibaged. She states that
recently her OxyContin had been increased to 36 mg twice daily
but that she was supposed to wean down to 18 mg twice daily and
that while she is here she would like to go on OxyContin lower
dose at 20 mg twice daily instead of 40 mg twice daily. She
feels that the chest pain is improved since getting IV fluids
and pain medications. She denies any fevers chills. She does
state on last admission she was supposed to undergo an
ultrasound of her heart and does not know why this was not done.
ROS: 10 point review of system reviewed and negative except as
otherwise described in HPI
Past Medical History:
___ cell anemia - complicated by acute chest syndrome. Not
currently followed by hematologist.
Depression/anxiety
Victim of domestic violence
GERD
s/p splenectomy at ___
s/p tonsillectomy/adenoidectomy at ___
s/p C-section at ___
s/p cholecystectomy at ___
s/p R breast lumpectomy at ___
Social History:
___
Family History:
Father - DM
Mother - DM, mitral valve prolapse
Cousin - ___ cell disease
Paternal aunt - breast cancer, ovarian cancer
Grandmother - heart disease
Physical Exam:
ADMISSION:
=========
VS: 98.7 PO 173/115 81 20 99% RA
___ 2230 Pain Score: ___
GEN: alert and interactive, comfortable, no acute distress,
moving around in bed, stands up, speaking in full sentences,
appropriate laughter intermittently through history
HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without
lesion or exudate, moist mucus membranes, ears without lesions
or
apparent trauma
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Regular rate and rhythm with ___ systolic murmur
throughout precordium, no rubs or gallops
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
GI: soft, nontender, without rebounding or guarding,
nondistended
with normal active bowel sounds, no hepatomegaly
EXTREMITIES: no clubbing, cyanosis, or edema
GU: no foley
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation
NEURO: Alert and interactive, cranial nerves II-XII grossly
intact, strength and sensation grossly intact
PSYCH: normal mood and affect while discussing symptoms
DISCHARGE:
==========
24 HR Data (last updated ___ @ 1225)
Temp: refused vitals (Tm 99.2), BP: 159/96 (126-164/80-107), HR:
110 (69-110), RR: 16 (___), O2 sat: 97% (97-98), O2 delivery:
RA
GEN: lying in bed, appears resting comfortably initially,
becomes angry but cooperative with exam, no acute distress.
HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without
lesion or exudate, moist mucus membranes, ears without lesions
or
apparent trauma
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Regular rate and rhythm with ___ systolic murmur
throughout precordium, no rubs or gallops
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
GI: soft, nontender, without rebounding or guarding,
nondistended
with normal active bowel sounds, no hepatomegaly
EXTREMITIES: no clubbing, cyanosis, or edema
GU: no foley
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation
NEURO: Alert and interactive, cranial nerves II-XII grossly
intact, strength and sensation grossly intact
PSYCH: normal mood and affect while discussing symptoms
Pertinent Results:
ADMISSION:
==========
___ 09:00AM BLOOD WBC-7.3 RBC-3.80* Hgb-10.8* Hct-31.5*
MCV-83 MCH-28.4 MCHC-34.3 RDW-15.4 RDWSD-45.9 Plt ___
___ 10:01AM BLOOD Hypochr-1+* Anisocy-1+* Poiklo-1+*
Microcy-2+* Target-1+* Tear Dr-1+* RBC Mor-SLIDE REVI
___ 09:00AM BLOOD ___ PTT-29.5 ___
___ 09:00AM BLOOD Ret Aut-2.3* Abs Ret-0.09
___ 09:00AM BLOOD Glucose-91 UreaN-8 Creat-0.8 Na-143 K-4.3
Cl-109* HCO3-21* AnGap-13
___ 09:00AM BLOOD ALT-6 AST-13 AlkPhos-73 TotBili-0.8
___ 09:00AM BLOOD Lipase-17
___ 09:00AM BLOOD cTropnT-<0.01
___ 12:30PM BLOOD cTropnT-<0.01
___ 10:01AM BLOOD cTropnT-<0.01 proBNP-1027*
___ 09:00AM BLOOD Albumin-4.3 Calcium-9.6 Phos-3.4 Mg-1.8
___ 10:01AM BLOOD Hapto-25*
SUBSEQUENT/PRIOR TO DISCHARGE:
=============================
On ___:
WBC 7.4, Hgb 10.3 (from 9.2), Plt 182
Retic 2.5%
BMP WNL
Ca/Mg/Phos WNL
LFTs WNL
LDH 164 -> 263
Haptoglobin 25 -> <10
Other notable:
Trop <0.01 x 3, BNP 1027
24h urine:
- Volume 2.8L
- 24h Cr 1311
- 24h protein 257
- Prot/Cr 0.2
- metanephrines: pending
- catecholamines: pending
- cortisol: pending
Utox (___): + opiates, + oxycodone, neg for benzos, barbit,
cocaine, amphet, methadone
Utox (___): + opiates, neg for benzos, barbit, cocaine, amphet,
methadone
UA: negative
UCG: negative
UCx (___): mixed flora
UCx (___): mixed flora
BCx (___): negative
IMAGING/OTHER STUDIES:
======================
Chest wall U/S ___:
No soft tissue abnormalities in the area of concern in left
chest
wall.
Renal artery Doppler ___:
Normal renal ultrasound. No evidence of renal artery stenosis.
CTA chest ___. No evidence of pulmonary embolism or aortic abnormality.
2. Scattered bilateral ground-glass opacities bilaterally, less
conspicuous than on previous CT, and most likely represents
resolving pneumonia/edema. No new consolidation.
EKG ___
NSR at 75 bpm, nl axis, LVH, PR 162, QRS 86, QTC 437, TWI V1-V6
(compared to ___, TWI in V4-V6 more pronounced, QTC shorter; of
note, similar to ___
TTE ___:
There is normal regional left ventricular systolic function.
Overall left ventricular systolic function is normal. The right
ventricle has normal free wall motion. There is trace aortic
regurgitation. There is trivial mitral regurgitation. There is a
trivial circumferential pericardial effusion.
CXR ___
No acute cardiopulmonary abnormality.
Brief Hospital Course:
___ undomiciled female with hx ___ cell (HgbSC) disease
requiring multiple hospitalizations for pain crises and acute
chest syndrome, depression/anxiety, GERD, likely opiate-use
disorder who presents to the ED with recurrent chest pain,
likely secondary to VOC vs opiate-use disorder, with course c/b
hypertensive urgency.
# Chest pain:
# Possible vaso-occlusive crisis:
# Chronic pain with c/f opiate use disorder:
Patient has multiple recent admissions at ___ for chest pain
___ for ACS from PNA/influenza; ___ initially
attributed to ___ but subsequently c/f opiate-use-disorder and
malingering). After d/c presented to ___, where she left AMA
after staff refused to dose narcotics per her specifications and
presented to ___ ___. Etiology of chest pain unclear. No
hypoxia, and CXR without infiltrate to suggest acute chest
syndrome. CTA chest without PE or aortic dissection; scattered
GGOs likely consistent with mild edema vs resolving PNA from
prior hospitalization for PNA ___ (rather than recurrent
acute chest). EKG showed diffuse TWI, likely LVH with
repolarization abnormalities and similar to prior from ___
low suspicion for acute coronary syndrome given trop neg x 3 and
nl TTE w/o WMAs. Could not rule out vaso-occlusive crisis,
although evidence for robust hemolysis was underwhelming (low
haptoglobin and mildly elevated LDH but with stable anemia and
an unimpressive reticulocytosis). She was treated initially with
IVFs and oxycontin 20mg BID (her typical home dose) with
mini-bagged dilaudid 6mg IV (in place of her home oxycodone 30mg
q6h PRN) x 4d with no significant improvement in pain. IV
benadryl was mini-bagged for opiate-induced pruritus given
patient's report of inefficacy of oral dosing. In discussion
with inpatient hematology team, chronic pain service, and
addiction psychiatry, ongoing pain was thought unlikely to be
attributable to ___ and was instead concerning for opiate-use
disorder and malingering (secondary gain including housing,
food, narcotics). Communicated with outpatient hematologist (Dr.
___ at ___ and prior PCP (Dr. ___ in
___ who believe that many of Ms. ___ presentations to
multiple area hospitals (from which she has often left AMA when
narcotics demands are not met) are for chronic pain rather than
vaso-occlusive crises. Red flags for opiate use
disorder/possible malingering this admission included: 1) she
often appeared comfortable vs intermittently intoxicated on
opiates despite c/o ___ pain, 2) she demanded IV pushes of
opiates/Benadryl, 3) she declined SW resources including
referral to ___, referral to outpatient psych/mental
health services, assistance with ___ application, or
treatment for opiate use disorder with methadone or
buprenorphine . IV dilaudid taper was therefore initiated (6mg
q4h PRN -> 4mg q4h PRN -> 3mg q4h PRN -> 2mg q4h PRN -> 1mg qh4
PRN -> 1mg q6h PRN -> oxycodone 30mg q6h PRN ) over the course
of ~ 7 days). Throughout the taper Ms. ___ complained of
ongoing 10 out of ___s symptoms of withdrawal,
including headaches, nausea, anxiety, tremors. She was seen by
addiction psychiatry and chronic pain on multiple occasions, who
were not concerned for severe acute withdrawal given her
clinical appearance and the pace of her taper. On HD #10 she was
transitioned back to her home regimen of oxycontin 20mg BID
(equivalent of her home Xtampza 18mg BID) and oxycodone 30mg q6h
PRN. She will be discharged with a 6-day supply of narcotics
(with Narcan and a bowel regimen) to bridge her to her intake
hematology appointment on ___ ___. Alternatively,
her existing hematologist (Dr. ___ at ___
expressed a willingness to continue seeing Ms. ___ on a
weekly basis and prescribing current dosing of narcotics in 7d
increments. Ms. ___ was informed of these options prior to
discharge. Given multiple presentations concerning for opiate
use disorder, meeting was held with addiction psychiatry,
chronic pain service, and social work, with input from
hematology. The following plan was generated to guide care
during future hospitalizations, with the understanding that Ms.
___ should be evaluated thoughtfully and thoroughly on each
presentation and that care should be tailored to her clinical
circumstances appropriately.
Care plan:
----------
1) early hematology evaluation to assess for likelihood of
___ related acute process
2) early addiction psych consultation; with offer of opioid-use
disorder treatment
3) IV narcotics minibagged
4) IV Benadryl minibagged
5) once acute processes ruled out/thought unlikely, clear and
consistent taper of IV narcotics in predictable fashion (would
suggest not dosing initial IV dilaudid more than 4mg IV q4h PRN,
and would suggest not increasing discharge PO regimen beyond
oxycontin 20mg BID with oxycodone 30mg q6h PRN)
6) could consider requiring patient to accept PCA for pain
control, which she has previously refused
# SCD:
Followed by Dr. ___ at ___ for the last year,
who has been prescribing her narcotics. Patient has declined
Hydrea or other disease modifying therapy. As above, could not
rule out initial vaso-occlusive crisis definitively, but in
discussion with the hematology service there was increasingly
low suspicion in absence of impressive hemolysis and no clear
response to initial hydration and high-dose narcotics. No e/o
acute chest syndrome as above. Discussed with Dr. ___
described a pattern of similar presentations at multiple
hospitals ___, ___, ___), more
consistent with chronic pain than vaso-occlusive crises. Her
pain was managed as above. Home folic acid was continued. On a
prior hospitalization, Ms. ___ had requested transition of
her longitudinal hematology care to ___, and she has a
follow-up appointment scheduled with Dr. ___ on ___. She
did express, however that she may ultimately opt to continue
with Dr. ___ at ___. She was encouraged to
choose a single longitudinal provider to facilitate her care.
# Hypertensive urgency:
Noted to be intermittently hypertensive on this and prior
admissions, with SBPs as high as 170s-180s/110s-120s, without
clear evidence of end-organ damage. Patient reports long history
of intermittent HTN, most marked after initiation of OCPs a few
years ago and for which she was initially started on metoprolol
(discontinued for bradycardia per patient, replaced with
lisinopril 5mg daily on recent admission ___. Etiology of
hypertensive urgency unclear, but likely contribution from
anxiety. Not clearly associated with pain, as she often appeared
relatively comfortable in setting of urgency and BPs did not
reliably improve with high doses of IV narcotics. Utox negative
for cocaine/amphetamines x2. Denied benzo or ETOH use and no
tremors/tachycardia, making ETOH/benzo withdrawal unlikely (CIWA
scores were low). ___ have been some contribution from mild
opiate withdrawal, less likely given e/o hypertension at high
doses of narcotics and a slow taper. Renal artery dopplers
without e/o renal artery stenosis. Lower suspicion for
pheochromocytoma or ___, but 24h urine collection for
metanephrines/ catecholamines and cortisol performed (results
pending). Low suspicion for nephritic syndrome given bland urine
sediment and nl renal function. Possible contribution from
estrogen-containing OCP, which may have been associated with HTN
previously per patient, d/c'd this admission. CTA chest w/o e/o
aortic dissection. Home lisinopril was increased from 5 mg daily
to 40 mg daily, and she was intermittently treated with
clonidine PRN for a component of anxiety/withdrawal. She will
require close longitudinal f/u for further w/u of her
hypertension and consideration of cardiology referral. Patient
requested that her primary care be transitioned to ___ on a
prior hospitalization, and she has an appointment pending with
Dr. ___ on ___. Going forward could consider transitioning
from lisinopril (which requires intermittent electrolyte
monitoring) to a calcium channel blocker.
# Bilateral lower extremity edema:
Likely secondary to IVFs. DDx includes DVT, but patient declined
LENIs, stating that prior U/S have been negative and that her
legs "always swell" in the hospital. Albumin WNL and 24h urine
protein collection nl (ruling out nephrotic syndrome). Resolved
prior to discharge.
# Contraception:
In setting of hypertension, home Loryna was held in hospital and
discontinued on discharge. She would benefit from a
non-estrogen-containing oral contraceptive or consideration of
non-estrogen-containing alternatives such as an IUD. She was
encouraged to discuss this with her primary care provider.
# GERD:
Continued home pantoprazole.
# Left chest wall soft tissue mass:
Patient complained of L chest wall lesion, not clearly
appreciable on exam. No corresponding lesion on CTA chest or
soft tissue U/S.
# Hx domestic violence:
# Homelessness:
# Passive SI:
Patient currently homeless, staying at shelter. Awaiting
approval for emergency housing. Declines SW and addiction psych
offers of assistance with housing and ___. She did
endorse passive SI on one occasion during this hospitalization
without active SI or plan. She was thought to be at low risk
for self-harm. She would likely benefit from referral to
outpatient psychiatry, but she was resistant to this notion.
Would continue to address as outpatient.
** TRANSITIONAL **
[ ] f/u urine metanephrines/catecholamines
[ ] f/u urine cortisol
[ ] titrate antihypertensives - consider transition to calcium
channel blocker
[ ] continue to offer treatment for opiate use disorder
[ ] will need alternative form of contraception - would consider
IUD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. Loratadine 10 mg PO DAILY
4. Loryna (28) (drospirenone-ethinyl estradiol) ___ mg oral
DAILY
5. OxyCODONE (Immediate Release) 30 mg PO Q6H:PRN Pain -
Moderate
6. Senna 8.6 mg PO BID
7. Tizanidine 8 mg PO TID
8. DiphenhydrAMINE 50 mg PO QHS:PRN itching
9. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
10. Xtampza ER (oxyCODONE myristate) 36 mg oral BID
11. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Naloxone Nasal Spray 4 mg IH ONCE MR1 overdose Duration: 1
Dose
RX *naloxone [Narcan] 4 mg/actuation 1 spray intranasal one to
two times Disp #*1 Spray Refills:*0
3. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. DiphenhydrAMINE 50 mg PO QHS:PRN itching
5. FoLIC Acid 1 mg PO DAILY
6. Loratadine 10 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
8. OxyCODONE (Immediate Release) 30 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 30 mg 1 tablet(s) by mouth every six (6) hours
Disp #*28 Tablet Refills:*0
9. Pantoprazole 40 mg PO Q24H
10. Senna 8.6 mg PO BID
11. Tizanidine 8 mg PO TID
12. Xtampza ER (oxyCODONE myristate) 18 mg oral BID
RX *oxycodone myristate [Xtampza ER] 18 mg 1 capsule(s) by mouth
twice a day Disp #*14 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
___ cell disease (with possible vaso-occlusive crisis)
Hypertensive urgency
Opiate use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with chest pain, possibly
related to your ___ cell disease. You were treated with
intravenous fluids and pain medications with no clear
improvement in your pain. Imaging of your chest showed no
abnormalities of your heart or lungs that would explain your
pain. Given lack of improvement with high doses of pain
medications and the risks associated with those medications, you
were gradually weaned down on narcotics and transitioned back to
your home pain regimen prior to discharge.
While hospitalized you were found to have intermittent high
blood pressure. Evaluation for dangerous causes of high blood
pressure was unrevealing, although some testing has not yet
resulted. Your home lisinopril was increased to 40 mg a day.
You should not take estrogen containing oral contraceptives in
the setting of high blood pressure, so please talk to your
primary care doctor about alternatives.
It is critically important that you establish care with
providers who will follow you over time and get to know you.
You are opting to transition your care in both hematology and
primary care to this hospital. Please follow-up with your new
providers as scheduled and keep your appointments. Should you
ever decide they are interested in treatment for opiate use
disorder with methadone or buprenorphine, we would be happy to
arrange a referral to the addiction specialists here at ___.
With best wishes,
___ Medicine
Followup Instructions:
___
|
10283216-DS-22 | 10,283,216 | 27,933,824 | DS | 22 | 2181-11-03 00:00:00 | 2181-11-03 10:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L hip pain
Major Surgical or Invasive Procedure:
___ - Removal of Hardware from L Femur; Hip
Hemiarthroplasty L hip
History of Present Illness:
___ female with PMH of AS s/p AVR on Coumadin, HTN, and
recent L hip fx s/p L TFN ___, ___ presents with
the
above fracture s/p mechanical fall. Patient sustained her
initial
hip fracture one month ago and underwent L TFN at ___
(Dr. ___. Patient describes persistent pain
post-operatively while working with ___. Over the past three
days,
she has been unable to get up. Patient denies any falls or
antecedent trauma. She denies any numbness tingling distally.
Past Medical History:
Severe aortic stenosis s/p TAVR ___
mod-severe mitral regurgitation
Systolic CHF (EF 35%) - recent echo 45-50%, newly ~60%
Single vessel CAD
NSTEMI II
lumbar spine stenosis (RLE neuropathy with foot drop)
Anemia
Pulmonary HTN (PA 60/31)
Laminectomy
endometriosis -Hysterectomy
Macular degeneration (photophobia)
Breast Ca s/p lumpectomy
bilateral cataract surgery
tonsillectomy
L hip fracture s/p nailing ___
Social History:
___
Family History:
FAMILY HISTORY: Both parents died in their ___ in the "___
___ Fire" (___). One sister deceased ___ ___ ago.
Physical Exam:
Vitals:
___ ___ Temp: 97.5 PO BP: 126/76 HR: 67 RR: 18 O2 sat: 97%
O2 delivery: Ra
General: resting in bed, comfortable, no acute distress,
pleasant to conversation
Pulmonary: No increased work of breathing, able to maintain
conversation without difficulty
Cardio: regular rate and rhythm
MSK:
Left lower extremity:
Today her dressings are both well appearing without any
staining.
The surrounding skin is not erythematous or indurated.
Sensation is intact in the S/S/SP/DP/T distributions
She fires the ___, FHL, TA, ___
Toes are warm and well-perfused
Pertinent Results:
ECHO ___:
The left atrial volume index is mildly increased. There is no
evidence for an atrial septal defect by 2D/
color Doppler. The estimated right atrial pressure is ___ mmHg.
There is mild symmetric left ventricular
hypertrophy with a normal cavity size. There is normal regional
left ventricular systolic function.
Quantitative 3D volumetric left ventricular ejection fraction is
66 %. Left ventricular cardiac index is
normal (>2.5 L/min/m2). There is no resting left ventricular
outflow tract gradient. No ventricular septal
defect is seen. Tissue Doppler suggests an increased left
ventricular filling pressure (PCWP greater than
18mmHg). 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 is mildly dilated
with a mildly dilated descending aorta. A ___ 3 aortic valve
bioprosthesis is present. The prosthesis is
well seated with normal leaflet motion and gradient. The
effective orifice area index is normal (>=1.0
cm2/m2). There is no aortic regurgitation. The mitral valve
leaflets are mildly thickened with no mitral
valve prolapse. There is no mitral regurgitation. The tricuspid
valve leaflets appear structurally normal.
There is no tricuspid regurgitation. The pulmonary artery
systolic pressure could not be estimated. There
is a trivial pericardial effusion. Liver cyst(s) are seen.
IMPRESSION: Well seated, normal functioning ___ 3 TAVR with
normal gradient and no
aortic regurgitation. Normal biventricular cavity sizes,
regional/global systolic function.
Brief Hospital Course:
Ms. ___ to the ___
with a chief complaint of left hip pain. She had had a fall in
___ for which she underwent fixation of her femur. She
continued to have pain postoperatively and continued to have
poor mobility despite attempts at progress in rehab. Workup
demonstrated that her recently inserted hardware had failed
causing her pain and inability to ambulate. She was therefore
admitted to the orthopedic surgery service. Given her complex
medical comorbidities including aortic stenosis with a recent
valve replacement in ___, consultation regarding preoperative
clearance was sought from internal medicine team. Once medical
clearance had been achieved, a long discussion regarding the
risks and benefits of further procedure was held. The patient
expressed interest in removal of her failed implants and
conversion to a left hip hemiarthroplasty. The patient was
therefore taken to the operating room on ___ after being
seen and evaluated by the anesthesia team. She underwent an
uncomplicated removal of hardware and conversion to left hip
hemiarthroplasty. She tolerated the procedure well. For full
details regarding her operation please see the separately
dictated operative note. Following her procedure she was taken
to the postanesthesia care unit where she was closely monitored
for several hours before ultimately being transferred to the
floor for continued monitoring. She was initially treated with
intravenous fluids and intravenous pain medications before being
transitioned to a regular diet and oral pain medications. In
the postoperative period,
She did develop symptomatic anemia for which she received a
total of 2 units of packed red blood cells. She tolerated the
transfusions well. Since receiving these transfusions she has
done well, been hemodynamically stable, without signs or
symptoms of anemia.
Samples taken from the operating room were found to grow
coagulase-negative staphylococcus. Consultation was therefore
sought from the infectious disease team. She was placed on
empiric antibiotics while her cultures grew out. Knowing that
she would need long-term antibiotics a PICC line was placed
without complication and was functioning well. She will be
maintained on Vancomycin (1000mg q12h and Rifampin (450mg PO
BID). She will need follow-up for monitoring of her bloodwork
while she is on her antibiotics. She will be followed by the
___ clinic. She will need weekly: CBC with differential, BUN,
Cr, LFTs, CRP, Vancomycin trough. The results can be sent to
___ CLINIC - FAX: ___. Additionally, her
atorvastatin has been held while she is on her Rifampin.
The patient was seen and evaluated by the physical therapy team
who determined that discharge to rehab was appropriate. At the
time of discharge the patient pain is well controlled with oral
pain medications and she was tolerating a diet, and moving her
bowels as well as voiding without issue. Patient was provided
with return precautions as well as information regarding her
expected recovery course. She expressed full understanding of
her care plan and was in full agreement.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Gabapentin 300 mg PO TID
4. Aspirin 81 mg PO DAILY
5. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
6. Atorvastatin 20 mg PO QPM
7. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
Do not exceed 4000mg acetaminophen (Tylenol) total, daily.
2. Calcium Carbonate 1000 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
Use while taking your narcotic pain medication. Hold for loose
stools
4. Enoxaparin Sodium 40 mg SC QHS
The expected end date of this medication is ___.
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
Do not drink while using this medication. Beware sedative
effects.
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
4h Disp #*40 Tablet Refills:*0
6. Rifampin 450 mg PO Q12H Synergy
7. Vancomycin 1000 mg IV Q 12H
8. Vitamin D 1000 UNIT PO DAILY
9. Metoprolol Succinate XL 12.5 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Gabapentin 300 mg PO TID
12. Omeprazole 20 mg PO DAILY
13. Pantoprazole 40 mg PO Q24H
14.Outpatient Lab Work
CBC with differential, BUN, Cr, LFTs, CRP, Vancomycin trough
These can be sent to the ___ CLINIC - FAX: ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Failure of Fixation L Femur
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC 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:
-Weightbearing as tolerated and range of motion as tolerated in
the left lower extremity
MEDICATIONS:
1) Take Tylenol around the clock. This is an over the counter
medication.
2) Add dilaudid as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take enoxaparin 40 mg subcutaneously daily for 4 weeks
total from the date of your operation. The expected end date of
your operation is: ___.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
Weight bearing as tolerated and range of motion as tolerated in
the left lower extremity.
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Followup Instructions:
___
|
10283304-DS-10 | 10,283,304 | 29,133,043 | DS | 10 | 2186-03-11 00:00:00 | 2186-03-11 13:18:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with history of
invasive ductal carcinoma (ER/PR+, HER2-) s/p 4 cycles DDAC and
now on weekly taxol who presents with fever.
Patient says that she has felt 'cold' over the past two days.
She
was planning on going to a dinner party so took a nap ___
afternoon. When she awoke she was concerned that she still felt
very cold despite wearing multiple layes. She took her
temperature and it was 102.0. She took Tylenol with improvement.
She called the on-call fellow who recommended going to the ED.
She presented to ___ where labs notable
for
hyponatremia to 130, dirty UA, and CXR with possible infiltrate.
Other than fever, she is feeling quite well. She reports more
fatigue this past week after her second dose of taxol compared
to
the first. She reports that she wakes up in the early morning
with mild runny nose and dry cough since ___ which resolves
in a few hours and is stable. She denies sick contacts. She is
otherwise very active. She walked 2 miles the day of her
admission. Her appetite is good. She recently took a flight to
___ to visit her daughter. She does note that she has
been experiencing constipation over the past several months. She
is taking hydrocortisone and nitroglycerin rectal cream for
hemorrhoids. She continues to experience some bleeding with
defecation.
On arrival to the ED, initial vitals were 100.6 85 123/72 18 99%
RA. Exam was notable for systolic murmur and clear lungs. Labs
were notable for WBC 6.8, H/H 10.3/30.7, plt 262, Na 130, K 4.1,
BUN/Cr ___, lactate 2.5, and UA with small leuks, negative
nitrite, 20 WBCS, and bacteruria. CXR noted possible left base
opacity either atelectasis vs. pneumonia. Patient was given
vancomcyin 1g IV, cefepime 2g IV, and 1L LR. Prior to transfer
vitals were 99.9 95 138/77 18 98% RA.
On arrival to the floor, patient reports feeling well. No acute
concerns. She denies headache, vision changes,
dizziness/lightheadedness, weakness/numbnesss, sore throat,
stuffy nose, sinus tenderness, shortness of breath, cough,
hemoptysis, chest pain, palpitations, abdominal pain,
nausea/vomiting, diarrhea, hematemesis, dysuria, hematuria, and
new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
She is a ___ patient with newly diagnosed right-sided
breast cancer. To summarize, Ms. ___ has a personal history of
DCIS, grade 1, diagnosed back in ___, presenting at that time
with an abnormal mammogram. At that time, she went for
reexcision
to obtain margins. She did not undergo treatments with medicinal
prophylaxis or radiation. She saw Dr. ___ at that time
back in ___ and together they decided against medicinal primary
prophylaxis. The patient continued to undergo diagnostic
mammographies every ___. Her ___ mammogram showed no
evidence for malignancy. Back in ___, the patient noticed a
firmness around the lumpectomy scar in the upper outer quadrant
of the right breast. She brought this to the attention of Dr.
___ ordered a mammogram on ___. This showed an
area of density in the area of the right lumpectomy scar, 3.7 x
2.9 cm. Ultrasound confirmed a mass. The breast was scanned,
there were two abnormal lymph node measuring 0.7 cm. The patient
had a biopsy of the right breast and the cytology FNA of the
right axilla. The pathology revealed a HER-2 negative, ER
positive (95%), PR negative (5%), HER-2 equivocal (IHC 2+
negative by ___) breast cancer. The tumor was a grade 3
carcinoma.
PAST MEDICAL HISTORY:
- Hypertension
- Breast DCIS in ___
Social History:
___
Family History:
Mother - malignant HTN
Father - deceased, hx of 5 vessel CABG at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 100.4, BP 123/69, HR 83, RR 18, O2 sat 98% RA.
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, ___ systolic murmur.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
DC exam unchanged, except SBP in 90-low 100s range overnight and
this morning at time of DC. Afebrile since arrival to the floor.
Pertinent Results:
___ 07:36PM BLOOD WBC-6.8 RBC-3.36* Hgb-10.3* Hct-30.7*
MCV-91 MCH-30.7 MCHC-33.6 RDW-18.3* RDWSD-59.3* Plt ___
___ 05:00AM BLOOD WBC-2.6* RBC-2.94* Hgb-8.8* Hct-27.6*
MCV-94 MCH-29.9 MCHC-31.9* RDW-18.6* RDWSD-61.5* Plt ___
___ 07:36PM BLOOD Glucose-129* UreaN-14 Creat-0.6 Na-130*
K-4.1 Cl-96 HCO3-20* AnGap-18
___ 05:00AM BLOOD Glucose-93 UreaN-10 Creat-0.5 Na-136
K-4.4 Cl-103 HCO3-23 AnGap-14
___ 07:36PM BLOOD ALT-479* AST-193* AlkPhos-200*
TotBili-0.8
___ 07:20AM BLOOD ALT-346* AST-101* CK(CPK)-39 AlkPhos-163*
TotBili-0.7
___ 05:00AM BLOOD ALT-246* AST-57* AlkPhos-155* TotBili-0.3
___ 07:20AM BLOOD GGT-268*
___ 07:36PM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative IgM HAV-Negative
___ 07:36PM BLOOD Acetmnp-17
___ 07:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG
___ 07:36PM BLOOD HCV Ab-Negative
___ 10:46PM BLOOD Lactate-2.5*
___ 07:31AM BLOOD Lactate-0.9
liver u/s
IMPRESSION:
1. A hepatic segment V lesion measuring up to 2.7 cm
demonstrates
characteristics most compatible with a hemangioma or focal fatty
infiltration.
A vague area of hypoattenuation is seen in this region on prior
CT-PET (series
4, image 123), without accompanying FDG accumulation. If
further evaluation
is desired, recommend contrast enhanced CT or MRI.
2. Small amount of biliary sludge without evidence of
cholecystitis or biliary
ductal dilatation.
RECOMMENDATION(S): A hepatic segment V lesion measuring up to
2.7 cm
demonstrates characteristics most compatible with a hemangioma
or focal fatty
infiltration. If further evaluation is desired, recommend
contrast enhanced
CT or MRI.
Brief Hospital Course:
___ female with history of invasive ductal carcinoma
(ER/PR+, HER2-) s/p 4
cycles DDAC and now on weekly taxol who presents with fever,
found to have marked transaminitis.
# Fever
# Transaminitis
Ultimately felt that transaminitis in this case even with fever
was most consistent with drug reaction (likely taxol, possibly
the medical marijuana she had recently started using). No ETOH
use, and only 1x APAP use on the day of admission for fever
(apap level accordingly 17 initially when added on but
subsequently rapidly negative). No other supplement/OTC use. No
prior recent LFTs for comparison. Liver u/s showed no portal
vein thrombus or parenchymal issue (? solitary lesion likely
hemangioma, can't r/o metastasis but one solitary met would not
explain this degree of LFT elevation). NO evidence of
cholangitis or leukocytosis or biliary dilation. Pt was
initially given cefepime/vanc at OSH urgent care for possible
pneumonia, but really had no respiratory sx at all (mild
intermittent rhinorrhea for weeks, but no dyspnea/cough) and it
was felt her CXR was not actually reflective of pneumonia
either. CTX initially continued on admission for possible
cholangitis vs UTI but no dysuria and abx discontinued as felt
most likely not bacterial infectious process. Pt remained
afebrile after admission and LFTs trended down (ALT from almost
500 on admission down to 250 at time of discharge). She never
had any nausea/vomiting/abd pain. ID was consulted to guide
workup of possible other viral etiologies (the hope was to be
able to exonerate taxol, in particular). Hep serologies
negative. Flu PCR neg. Parasite smear (eval for anaplasma)
negative. She had h/o genital herpes but no rash or active
lesions at this time so ID felt reasonable not to treat
empirically with IV acyclovir as very low suspicion for HSV
hepatitis. She also agreed to stop her medical marijuana in case
that was causing/potentiating this effect. Instructed not to use
Tylenol. Her simvastatin was also held in this context and she
will await further direction from outpt providers pending
normalization of LFTS for decision on when to resume this (doubt
simvastatin was the offending agent here, more likely taxol, but
prudent to DC all the same esp given marked degree of LFT
abnormalities on admission).
At the time of discharge the following studies still pending:
- CMV VL, EBV VL, HBV/HCV VL, anaplasma PCR, VZV pcr. Also for
autimmune causes of transaminitis: pending at discharge - AMA,
anti-smooth muscle, ___.
These labs will be followed up by Dr. ___ in clinic day after
discharge along with LFT recheck. The patient was advised to
remain in the hospital another day until 48 hrs fully of
negative cultures and ensured ongoing downtrend of LFTs, and
results of the above studies, however it was her strong
preference to be discharged and follow up the next day in
clinic, accordingly a plan for that was coordinated with Dr.
___. The patient is aware that should any of these studies
result abnormally or she develops fever at home tonight she will
need to come back through the emergency department.
# HTN - pt reports lower BPS in low 100s if not ___ at home
recently after starting medical marijuana. SBP in ___
overnight after admission despite IVF, pt asymptomatic, she
checks BP at home, we decided to have her hold her home
lisinopril for now, she will be seen in clinic tomorrow for
further check/discussion of this. We discussed likely need to
restart soon if she stops medical marijuana as advised,
anticipate BP may increase again.
# Hyponatremia: Likely due to hypovolemic/poor PO intake.
Resolved with IVF on admit.
# Anemia: Appears at baseline. Likely secondary to chemotherapy.
No e/o bleeding
# Hemorrhoids
- Continued nitroglycerin cream prn
EMERGENCY CONTACT HCP: ___ (husband/HCP)
___
DISPO: OMED for now
Greater than 30 minutes were spent in planning and execution of
this discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID:PRN
mouth pain
2. hydrocortisone-pramoxine ___ % rectal BID:PRN rectal pain
3. Lidocaine-Prilocaine 1 Appl TP PRN port accessing
4. Lisinopril 10 mg PO DAILY
5. LORazepam ___ mg PO QHS:PRN insomnia
6. nitroglycerin 0.4 % (w/w) rectal BID
7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
8. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
9. Simvastatin 10 mg PO QPM
10. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
11. Ranitidine 150 mg PO BID:PRN acid reflux
Discharge Medications:
1. hydrocortisone-pramoxine ___ % rectal BID:PRN rectal pain
2. Lidocaine-Prilocaine 1 Appl TP PRN port accessing
3. LORazepam ___ mg PO QHS:PRN insomnia
4. nitroglycerin 0.4 % (w/w) rectal BID
5. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
6. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
7. Ranitidine 150 mg PO BID:PRN acid reflux
8. HELD- Simvastatin 10 mg PO QPM This medication was held. Do
not restart Simvastatin until liver function tests normalize
and you have clearance from Dr. ___
___ Disposition:
Home
Discharge Diagnosis:
Transaminitis
Breast cancer
Fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
you were admitted with fever and very high liver function tests
which reflect liver damage. This was probably from your taxol
and maybe from medical marijuana. It is possible a virus was
causing this and some testing is still pending regarding viral
causes. Dr. ___ will follow these tests.
For now, stop your simvastatin (not good to take with liver
dysfunction). Also stop your lisinopril because your blood
pressure was low. If your blood pressure is consistently up to
120 (top number) you can go ahead and resume your lisinopril,
and/or discuss with Dr. ___ Dr. ___. Check your blood
pressure at home daily in the meantime, but since we are
stopping the marijuana there is a chance your blood pressure
will go back up - this remains to be seen.
If you have fever today/tonight it is absolutely necessary that
you come back through the emergency room tonight or at the very
least contact the oncology fellow on call overnight to discuss -
your neutrophil count is still pending right now but if the
neutrophils are very low (type of ___ blood cell) fever can be
an emergency and require hospitalization.
Followup Instructions:
___
|
10283819-DS-11 | 10,283,819 | 20,186,637 | DS | 11 | 2161-07-30 00:00:00 | 2161-07-30 20:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
codeine / lisinopril
Attending: ___.
Chief Complaint:
Abdominal incision drainage
Major Surgical or Invasive Procedure:
s/p ___ drain placement and drainage
History of Present Illness:
___ is a ___ year old male w/ a complicated medical
history including pT3N0 stage IIIA intrahepatic
cholangiocarcinoma s/p L hepatectomy, caudate lobe resection,
roux-en-y hepaticojejunostomy ___ c/b bile leak requiring
vac drainage with high output hepatic artery thrombosis s/p
tPA/stent and bleeding from HA pseudoaneurysm, with liver
infarcts. He was last seen in the ED on ___ with low grade
fevers and was noted to have improved appearance of his
hematoma/fluid collection of the margin of the resection of the
liver at that time. He now represents to the ED with a 24 hour
history of erythema, pain and swelling along his subcostal
incision. He reports purulent drainage from the site with pain
around the wound. He denies fevers, chills, SOB, chest pain. Of
note he has a history of blood and bile cultures positive for
multi drug resistant E. coli treated previously with
meropenem/ertapenem. He presented to his PCP several days ago
with concern for pneumonia and was started on cipro/doxy.
Past Medical History:
PMH:recently diagnosed DM II (HbA1c of 8), HTN, HL, obesity (BMI
38.8), osteoarthritis, cholangiocarcinoma
PSH: right total knee replacement, left partial knee
replacement, left inguinal hernia repair ___, lipoma excision
from b/l shoulders, ex-lap/left hepatectomy, RNY
___, hepatic artery thrombectomy with
stent
Social History:
___
Family History:
mother deceased - breast CA to bone, father deceased - EtOH
abuse, cirrhosis, sister with breast CA in remission. no family
Hx of gallbladder or liver cancer.
Physical Exam:
Admission Physical Exam:
Vitals: 97.5 79 165/81 99 RA
GEN: A&Ox3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, nontender, no rebound or guarding,
right
subcostal incision with opening draining bile with surrounding
erythema
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
T 98.2 HR 81 BP 143/91 Rr 20 98RA
NAD
RRR
CTAB
abd soft, minimally tender, no rebound or guarding, one drain
and one ostomy appliance still in place on his abdomen
Pertinent Results:
___ 10:03AM GLUCOSE-159* UREA N-6 CREAT-0.6 SODIUM-131*
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-26 ANION GAP-13
___ 06:16AM LACTATE-1.8
___ 05:30AM GLUCOSE-225* UREA N-7 CREAT-0.6 SODIUM-129*
POTASSIUM-5.9* CHLORIDE-94* TOTAL CO2-25 ANION GAP-16
___ 05:30AM estGFR-Using this
___ 05:30AM ALT(SGPT)-77* AST(SGOT)-113* ALK PHOS-361*
TOT BILI-1.1
___ 05:30AM ALBUMIN-3.5
___ 05:30AM WBC-15.2* RBC-4.48* HGB-13.1* HCT-39.7*
MCV-89 MCH-29.2 MCHC-33.0 RDW-13.2
___ 05:30AM NEUTS-76.8* LYMPHS-15.5* MONOS-6.1 EOS-1.3
BASOS-0.3
___ 05:30AM PLT COUNT-409#
___ 05:30AM ___ PTT-33.4 ___
___ 06:40AM BLOOD WBC-9.2 RBC-4.19* Hgb-12.0* Hct-36.4*
MCV-87 MCH-28.7 MCHC-33.0 RDW-13.4 Plt ___
___ 05:15AM BLOOD Glucose-156* UreaN-7 Creat-0.7 Na-134
K-4.3 Cl-99 HCO3-29 AnGap-10
___ 06:40AM BLOOD ALT-30 AST-31 AlkPhos-275* TotBili-1.4
CT ___- Fluid collection at the margin of the liver resection,
decreased in size, but likely communicating with a new
subcutaneous air/fluid collection at the wound site. Infection
of this collection cannot be excluded.
2. Improved hepatic and splenic infarcts.
3. SMV thrombus seen on prior exam is not seen today, likely
resolved.
Brief Hospital Course:
___ is a ___ year old male with history of intrahepatic
cholangiocarcinoma s/p L hepatectomy, caudate lobe resection,
roux-en-y hepaticojejunostomy ___ c/b
bile leak with high output hepatic artery thrombosis s/p
tPA/stent and bleeding from HA pseudoaneurysm, with subsequent
liver infarcts who presents with high output bilious drainage
via his subcostal incision likely from biloma. He was
hospitalized on ___ following spontaneous drainage from the
superior aspect of his prior abdominal incision.
He had a CT abdomen pelvis in the emergency department, which
was concerning for a fluid collection at the margin of the liver
resection, decreased in size,
but likely communicating with a new subcutaneous air/fluid
collection at the
wound site. Infection of this collection could not be excluded.
The imaging demonstrated improved hepatic and splenic infarcts.
Additionally, the ___ thrombus seen on prior exam is not seen
today, likely resolved.
Mr. ___ was placed on NPO status, and IV fluids were
initiated. He was treated with meropenem initially given his
prior history of multidrug resistent ecoli, and subsequently
with vancomycin per infectious disease recommendations. On
___, he underwent CT guided drainage of his right anterior
perihepatic fluid collection, during which an ___ drainage
catheter was insertion into the right perihepatic fluid
collection. Four cc's of pus was aspirated and sent for
microbiology. Gram stain from the purulent aspirate demonstrated
gram positive rods, gram negative rods, and gram positive cocci.
Infectious disease was consulted. They initially recommended
the addition of vancomycin to his antibiotic regimen. After
drainage and his improved clinical appearance he was taken off
antibiotics with the agreement of infectious disease. He was
then discharged on no antibiotics with an ostomy appliance over
his abdomen and ___ drain still in place. Radiation oncology also
assessed Mr. ___ during his hospital stay, and planned to
meet further to develop his treatment plan as an outpatient.
Throughout his hospitalization, the patient appeared well. He
was afebrile, and was hemodynamically stable. He was ambulating
regularly, tolerating regular diet, voiding without difficulty,
and had normal bowel function. He had output that was both
serosanguenous and bilious in nature. He had follow-up
scheduled prior to his discharge, and was discharged with
understanding of his discharge instructions.
Medications on Admission:
aspirin 81', pantoprazole 40 ___, insulin sliding scale,
losartan 100', carvedilol 3.125'', trazodone 50 qhs prn sleep,
clopidogrel 75', ciprofloxacin 300''', doxycycline 100''
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carvedilol 3.125 mg PO BID
3. Clopidogrel 75 mg PO DAILY
4. Insulin SC
5. Pantoprazole 40 mg PO Q12H
6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN drain insertion
site pain
7. Losartan Potassium 100 mg PO DAILY
8. TraZODone 50 mg PO HS:PRN insomnia
9. pneumoc ___ conj-dip cr(PF) 0.5 mL injection ONCE
Duration: 1 Dose
To be given by ___ disease MD at clinic visit ___.
Followed in 8 weeks by 23 valent pneumovax
Discharge Disposition:
Home
Discharge Diagnosis:
incisional drainage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr ___ office at ___ for fever > 101,
chills, nausea, vomiting, diarrhea, constipation, increased
abdominal pain, pain not controlled by your pain medication,
swelling of the abdomen or ankles, yellowing of the skin or
eyes, inability to tolerate food, fluids or medications,
incisional redness, increased drainage or bleeding, drain output
increases by more than 100 cc from the previous day, drain
output becomes bloody, green or develops a foul odor, the drain
insertion site has redness, drainage or bleeding, the fluid in
the pouch or any other concerning symptoms.
You may shower. Allow water to run over the incision. Pat the
area dry, do not apply lotions or powders to the incision area.
Do not allow the JP drain to hang freely at any time.
Please place a new drain sponge around the drain site after your
shower or daily.
No lifting more than 10 pounds
No driving if taking narcotic pain medication
Please drain and record the JP drain output twice daily and as
needed. Bring copy of the drain output with you to clinic
appointment
Followup Instructions:
___
|
10283819-DS-12 | 10,283,819 | 26,238,035 | DS | 12 | 2161-12-19 00:00:00 | 2161-12-19 16:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine / lisinopril
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o cholangiocarcinoma who underwent lt hepatectomy with RNY
HJ followed by multiple complications here with altered mental
status. As an outpatient he was found to have metastatic cells
in
his peritoneal fluid and had a positive margin on his surgical
resection. He has been undergoing chemotherapy as an outpatient.
He had completed capecitabine that finished in ___ and was
having chemo held for rising bilirubin. He was the started on
chemotherapy gemcitabine and cisplatin in ___ and had
received his second dose on ___, was his normal self on ___
and then was noticed to have a slowly worsening mental status up
through this morning and so his wife brought him to the ED. He
was tolerating a diet, but had lighter stools moving his bowels
at lest twice daily. He was having no fevers at home and his
family had not noticed any focal neuro deficits (ie slurring of
speech, assymetry, motor dysfunction). He did not complain of
any
abdominal pain during this time.
Of note is that he went to PA for chemo as he could also see a
naturopathic doctor and was placed on multple supplements
including ___ ginseng, high dose melatonin, milk of
thistle,
and cordycep mushrooms.
Past Medical History:
PMH:recently diagnosed DM II (HbA1c of 8), HTN, HL, obesity (BMI
38.8), osteoarthritis, cholangiocarcinoma
PSH: right total knee replacement, left partial knee
replacement, left inguinal hernia repair ___, lipoma excision
from b/l shoulders, ex-lap/left hepatectomy, RNY
___, hepatic artery thrombectomy with
stent
Social History:
___
Family History:
mother deceased - breast CA to bone, father deceased - EtOH
abuse, cirrhosis, sister with breast CA in remission. no family
Hx of gallbladder or liver cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS:98.1, 133/77, 108, 18, 98% RA
Gen: NAD, AAOx3 but slowed, pleasant, conversational
HEENT: scleral icterus, MM dry
Neck: normal
CV: RRR, no m/r/g
Lungs: CTAB, no w/r/c
Abdomen: +BS, distended, ND, NT, +fluid wave
Ext: wwp, 1+ ___ edema
Neuro: +asterixis
Skin: jaundiced
DISCHARGE PHYSICAL EXAM:
Vitals - 97.9, 118/80, 86, 18, 98RA
GENERAL: NAD, well appearing sitting up at the side of the bed
SKIN: Jaundiced, no visible rashes
HEENT: icteric sclera, dry mucus membranes
NECK: no lymphadenopathy
CARDIAC: RRR, III/VI holosystolic murmur with radiation to
carotids LUNG:CTAB
ABDOMEN: Distended tympanic. Soft and NT. No fluid shift
appreciated.Asymmetric secondary to well healed scar
EXTREMITIES: 2+ bilateral symmetric pitting edema.
NEURO: CN II-XII intact. No asterixis.
Pertinent Results:
ADMISSION LABS:
___ 11:30AM BLOOD WBC-6.0 RBC-2.96* Hgb-9.7* Hct-27.3*#
MCV-92# MCH-32.8* MCHC-35.7*# RDW-15.9* Plt Ct-56*#
___ 11:30AM BLOOD ___ PTT-29.9 ___
___ 11:30AM BLOOD Glucose-184* UreaN-27* Creat-1.0 Na-129*
K-4.4 Cl-95* HCO3-23 AnGap-15
___ 11:30AM BLOOD ALT-40 AST-63* AlkPhos-218* TotBili-9.0*
DirBili-4.9* IndBili-4.1
___ 11:30AM BLOOD Albumin-2.5* Calcium-8.1* Phos-2.0*
Mg-1.2*
___ 11:42AM BLOOD Lactate-4.1*
___ 02:27AM BLOOD Hapto-95
DISCHARGE LABS
___ 03:30AM BLOOD WBC-9.0 RBC-2.52* Hgb-8.6* Hct-24.2*
MCV-96 MCH-34.2* MCHC-35.7* RDW-26.0* Plt Ct-51*
___ 03:30AM BLOOD Glucose-138* UreaN-8 Creat-0.6 Na-129*
K-4.0 Cl-96 HCO3-26 AnGap-11
___ 03:30AM BLOOD ALT-49* AST-77* AlkPhos-327* TotBili-7.6*
___ 03:30AM BLOOD Albumin-2.2* Calcium-7.3* Phos-2.0*
Mg-1.4*
IMAGINING:
RUQ US ___ post left hepatic lobectomy and
cholecystectomy.
Patent main portal vein. Mild intrahepatic biliary ductal
dilatation, unchanged from prior. No evidence of extrahepatic
biliary ductal dilatation. Mild ascites.
CXR: ___: IMPRESSION: No acute cardiopulmonary process.
___: MRCP
1. Mild intrahepatic bile duct dilation, stable to slightly
improved since ___. Central biliary strictures just
proximal to the
hepaticojejunostomy with stable hypoenhancing soft tissue at
this site, remains concerning for cholangiocarcinoma.
Post-surgical changes of left hepatic/caudate lobe resection,
cholecystectomy and hepaticojejunostomy.
2. Interval increase in the moderate amount of abdominal ascites
compared to the prior study of ___.
3. Stable chronic occlusion of the right hepatic artery.
4. Extensive wall edema in the stomach, imaged small and large
bowel loops, likely relate to third spacing.
Brief Hospital Course:
___ h/o cholangiocarcinoma s/p L hepatectomy, RNY HJ c/b bile
leak, HAT s/p tPA/stent, HA pseudoaneurysm, liver infarcts w/
biloma/drainage then recurrent CA who presented with hepatic
encephelopathy.
# ALTERED MENTAL STATUS: Likely from hepatic encephalopathy
given improvement on lactulose/rifaximin. At discharge patient
was AOx3 with approrpiate level of consciousness and thought
content.
# CHOLANGIOCARCINOMA/HCV CIRRHOSIS: On admission pt with
transaminitis, worrisome in context of cholangiocarcinoma. RUQ
U/S showed patent portal flow. MRCP done for evaluation of
possible malignant stricture which found mild intrahepatic bile
duct dilation, stable to slightly improved and central biliary
strictures just proximal to the hepaticojejunostomy with known
post-surgical changes of left hepatic/caudate lobe resection,
cholecystectomy and hepaticojejunostomy. Pt had moderate
ascites. Given improvement in AMS symptoms and transaminitis,
ERCP was deferred.
# ANEMIA/TCP: Pt with formed guaiac positve stool in-house but
w/o active melena. EGD in ___ w/o varices. No signs of DIC.
At this time the cell line suppression is thought to be from
liver dz and chemotherapy. On this admission he has recieved a
unit of platelets and a unit of pRBCs with appropriate response.
# VOLUME OVERLOAD: After transfusions, pt had noticable volume
overload, likely from third spacing from hypoalbuminemia. Pt was
started per hepatology on spironolactone 50mg daily and diuresed
with PO and IV lasix. Pt responds to 40mg IV Lasix. At
discharge, pt still with 2+ edema in bilateral ___ and is being
discharged on 40mg PO lasix daily and 50 mg PO spironolactone.
TRANSITIONAL ISSUES
- Pt requires O/P EGD to eval for anemia with guaiac positive
stool
- Continue diuresis with lasix/spironolactone. At discharge pt
is on 40mg Lasix daily
- Pt endorses chronic swelling in bilateral extremities, R>L for
months. Given asymmetry and liver dysfunction, pt likely should
have ___ to evaluate for clot
EMERGENCY CONTACT: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Novolog 2 Units Breakfast
Novolog 2 Units Lunch
Novolog 2 Units Dinner
Novolog 2 Units Bedtime
3. Carvedilol 3.125 mg PO BID
4. Losartan Potassium 100 mg PO DAILY
5. Metoclopramide 10 mg PO TID
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. Pantoprazole 40 mg PO Q24H
8. Prochlorperazine 10 mg PO Q8H:PRN nausea
9. Spironolactone 50 mg PO DAILY
10. TraZODone 50 mg PO HS
11. zinc lozenges 25 mg oral daily
12. ginseng unknown oral unknown
Discharge Medications:
1. Carvedilol 3.125 mg PO BID
2. Pantoprazole 40 mg PO Q24H
3. Spironolactone 50 mg PO DAILY
4. Novolog 2 Units Breakfast
Novolog 2 Units Lunch
Novolog 2 Units Dinner
Novolog 2 Units Bedtime
5. TraZODone 50 mg PO HS:PRN insomnia
6. Lactulose 30 mL PO TID
RX *lactulose 10 gram/15 mL 30 ml by mouth three times a day
Disp #*2700 Milliliter Refills:*0
7. Multivitamins 1 TAB PO DAILY
8. Rifaximin 550 mg PO DAILY
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
9. Metoclopramide 10 mg PO TID
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. Prochlorperazine 10 mg PO Q8H:PRN nausea
12. zinc lozenges 25 mg oral daily
13. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
-Hepatic encephalopathy
-Cholangiocarcinoma
Secondary diagnosis
-Diabetes
-HCV cirrhosis
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ due to
altered mental status. You were seen by the liver specialists
and were started on a medication called lactulose which should
continue as an outpatient. You should continue to titrate your
dose at home for a goal of ___ bowel movements per day. It is
extremely important that you continue to take this medication to
prevent encephalopathy.
In addition you had an MRCP preformed which was similar to the
MRCP you had preformed in ___. As a result no further
intervention was preformed but you do need to follow-up with
hepatology by the end of the week. We trended your daily liver
and blood count labs which will need to be followed as an
outpatient.
**PLEASE HAVE YOUR LABS DRAWN ON ___ These will be
followed by the ___ and will call you if changes need
to be made or if further interventions are needed.
You will also need an upper endoscopy in the future to monitor
for esophageal varices; this will be arranged through
hepatology.
For your diuresis, we will start you on 40 mg of furosemide
daily in addition to your 50 mg of spironolactone. This will be
titrated by one of your outpatient providers.
If you have blood in your stool your other bleeding at home
please come to the ED to have your labs checked as you may need
a repeat transfusion of blood or platelets in the future.
Followup Instructions:
___
|
10283824-DS-23 | 10,283,824 | 26,978,940 | DS | 23 | 2143-11-07 00:00:00 | 2143-11-08 13:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o male with a history of CAD (s/p CABGx4 and coronary stent
placement), ___ esophagus (s/p esophageal resection), and
chronic normocytic anemia that presented with several hours of
nausea. Pt is concerned because this seems consistent with his
prior MI symptoms. Pt also has possibly a marrow problem that's
currently being evaluated by a hematologist. Nausea not
accompanied by CP or SOB. NO fevers, chills, abd pain, diarrhea,
rashes. At baseline states he has mildly jaundiced skin
ED course:
triage v/s 16:50 4 97.9 55 161/62 20 100%
labs:
CBC 6.2>11.3/35.2 <180. (HCT at or higher than prior b/l). PMNs
80%. INR 1.1. LFTs: AST 18 ALT 36. Tbili 4.2 Alk phos 67. LDH
284
EKG showed sinus brady at 56, LAD, diffuse inf/lat TWF. TW
deflections noted to be lower in amplitude then prior in ___,
but no significant changes otherwise. Also has first degree AV
block.
CXR without acute process. Pt was givevn 325mg ASA in the ED.
Right lower extremity noted to be mildly swollen but right ___
negative for DVT. RUQ u/s performed for elevated Tbili
(chronically elevated though) and showed cholelithiasis without
cholecystitis or ductal dilatation. Pt also received 5mg reglan
IV, 20mg famotidine po, visous lidocaine, and alum-mg hdrox
simethicone.
On the floor pt feels well. No longer dry heaving and nausea is
improved. Denies cp/sob.
Past Medical History:
___ esophagus s/p esophagal resection (stomach was ___
more superior, done in BWH by Dr. ___ (___)
*CAD s/p CABGx4 (LIMA-->LAD, RSVG-->D1, OM1, PDA) (___) and
coronary stent placement (x3 with 2 reocclusion, and subsequent
x2: drug-eluted stent to LMCA, LCx) (___)
*chronic normocytic anemia
*chronic mild hyperbilirubinemia
*gastritis
*diabetes mellitus (last HbA1C 5.8%)
*hypertension
*dyslipidemia
Social History:
___
Family History:
*Parents: father, died ___ y/o from coronary thombus; mother,
died ___ y/o from emphysema
*Siblings: 1 brother, died in accident
*Children: 3 sons, 6 grandchildren, all healthy
Physical Exam:
VS - Temp 98.5F, BP 144/80, HR 90, R 18, O2-sat 97% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - 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
Pertinent Results:
___ 05:45PM BLOOD WBC-6.2 RBC-4.00* Hgb-11.3* Hct-35.2*
MCV-88 MCH-28.3 MCHC-32.1 RDW-16.2* Plt ___
___ 05:45PM BLOOD Ret Aut-3.3*
___ 05:45PM BLOOD Glucose-154* UreaN-13 Creat-1.1 Na-138
K-3.9 Cl-97 HCO3-28 AnGap-17
___ 07:23AM BLOOD ALT-19 AST-33 LD(LDH)-226 AlkPhos-60
TotBili-3.9* DirBili-0.3 IndBili-3.6
___ 05:45PM BLOOD CK-MB-2
___ 05:45PM BLOOD cTropnT-<0.01
___ 12:35AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:23AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:45PM BLOOD Albumin-4.4 Calcium-9.4 Phos-3.7 Mg-2.1
___ 05:45PM BLOOD Hapto-128
CXR ___
Two views of the chest were obtained. The lungs are well
expanded
and clear with linear left mid-lung atelectasis. There is no
pleural effusion
or pneumothorax. The heart remains enlarged with postsurgical
changes. The aortic contour is normal and unchanged from the
prior study. Small hiatal hernia may be present.
IMPRESSION: No acute intrathoracic process.
RLE Doppler
Gray scale and color Doppler sonographic evaluation was
performed of
the right lower extremity. Normal compressibility, flow and
response to
augmentation is seen in the right common femoral, superficial
femoral and
popliteal veins. Normal flow and compressibility is seen in the
peroneal and popliteal veins.
RUQ US
The liver is normal in echotexture without focal lesion. There
is no
intra or extrahepatic ductal dilatation with CBD measuring 4mm.
The spleen is top normal in size at 12.6 cm. The main portal
vein is patent with hepatopetal flow. Multiple stones in the
gallbladder without findings of cholecystitis. Single views of
both kidneys are without hydronephrosis. Pancreas and aorta are
not well seen due to overlying bowel gas. The IVC is
unremarkable. There is no free fluid.
IMPRESSION: Cholelithiasis without cholecystitis. No ductal
dilatation
Brief Hospital Course:
___ y/o male with a history of CAD (s/p CABGx4 and coronary stent
placement), ___ esophagus (s/p esophageal resection), and
chronic normocytic anemia that presented with several hours of
nausea ruled out for MI.
# nausea/dry heaves - most likely secondary to h/o ___
esophagus s/p esophageal resection and/or GERD. ACS was
initially a consideration particularly as pt stated these
symptoms seemed exactly the same as his prior MI symptoms, but
his EKG showed only diffuse lateral TW flattening which was
stable from the ED and on repeat arrival to the floor.
Furthermore pt was no longer symptomatic once on the floor and
finally cardiac enzymes x2 were negative. He was continued on
his home sucralfate and protonix and remained asymptomatic
during his hospital stay.
# elevated Tbili - chronic dating back to ___, per patient has
been chronic for ___ years. Patient slightly jaundiced.
Haptoglobin normal, only slightly elevated retic count, did not
appear to be hemolyzing. Indirect bili fraction was up in the
setting of otherwise apparently normal liver function, ddx
includes ___ or perhaps a mild variation of
___'s.
Chronic issues:
# h/o CAD - continued ASA, plavix
#. Hypertension: stable, continued home regimen
#. Dyslipidemia: stable, continued atorvastatin
#. Diabetes mellitus: well controlled, last A1c 5.8 per pt.
Transitional Issues:
aspirin/plavix - will follow up with primary cardiologist and GI
to determine ideal dosages
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Valsartan 80 mg PO DAILY
hold for SBP<110
3. Atorvastatin 80 mg PO DAILY
4. MetFORMIN (Glucophage) 250 mg PO BID
5. Pantoprazole 40 mg PO Q12H
6. Sucralfate 1 gm PO QID
7. Calcium Carbonate 500 mg PO DAILY
8. Carvedilol 25 mg PO BID
hold for HR<55 or SBP<100
9. iFerex ___ *NF* (polysaccharide iron complex) 150 mg iron
Oral daily
10. Senna 1 TAB PO BID:PRN constipation
11. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Carvedilol 25 mg PO BID
hold for HR<55 or SBP<100
5. Docusate Sodium 100 mg PO BID
6. Pantoprazole 40 mg PO Q12H
7. Senna 1 TAB PO BID:PRN constipation
8. Sucralfate 1 gm PO QID
9. Valsartan 80 mg PO DAILY
hold for SBP<110
10. iFerex ___ *NF* (polysaccharide iron complex) 150 mg iron
Oral daily
11. MetFORMIN (Glucophage) 250 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
nausea
rule out heart attack
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at ___
___. You came to the hospital after an episode of
nausea that was similar to your prior heart attack. As you have
recently stopped your Plavix and reduced your aspirin dose, you
were concerned that this might be a new heart attack. Your
blood work and EKGs were normal.
We made no changes to your medications. You should continue to
work with your Gastroenterologist and Cardiologist to determine
the appropriate dose of aspirin and Plavix. Please follow-up
with your physicians as listed below.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10283863-DS-8 | 10,283,863 | 27,425,584 | DS | 8 | 2161-05-09 00:00:00 | 2161-05-10 10:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
___
1. Exploratory laparotomy.
2. Drainage of pelvic abscess.
3. Placement of VAC sponge
___:
CT-guided aspiration of 2 fluid collections ___ the pelvis
History of Present Illness:
___ w/ recently diagnosed with stage Ib endometrial
adenocarcinoma s/p robotic-assisted total hysterectomy, BSO,
pelvic LN dissection ___ who now presents with abdominal
pain, distension, fevers for past 6 days. She reports she has
been doing well overall at home ___ terms of her recovery, but
starting 6 days ago, she had fevers daily, up to ___, and
increasing abdominal pain, mostly RUQ, and diarrhea (12 episodes
___ last 24 hours). She denies any nausea or emesis, and has been
able to take ___ PO. However, she initially attributed her
symptoms to heartburn and her known diagnosis of GERD. Her pain
continued to worsen and grew severe today and she was continuing
to be febrile, and so she presented to ___.
Her initial workup was concerning for cholangitis, per report,
as her pain was located ___ RUQ and ultrasound showed
cholelithiasis and dilated CBD (no ultrasound report available
at current time). She was transferred to ___ for ERCP
evaluation. Here, she underwent a CT scan that showed
pneumoperitoneum and free abdominal fluid.
Past Medical History:
Past Medical History: Obesity, irritable bowel syndrome, urinary
incontinence, gastroesophageal reflux disease, osteoarthritis, a
high rheumatoid factor, pulmonary hypertension and sleep apnea.
Obstetrical History: Gravida 3, para 3, 3 spontaneous vaginal
deliveries ___ ___ and ___. Largest baby was 8 pounds.
Past Gynecologic History: Menarche at age ___, very regular q.
monthly periods lasting four to five days with moderate flow.
Last menstrual period and age of menopause, ___, roughly
age
___. She reports abnormal Paps. Her first abnormal Pap smear
was
this year, ___. However, as noted ___ the HPI, she
has
had a few years of high-risk HPV positive Pap smears. She is
not
currently sexually active. She does report a distant history of
OCP use for one year and a one-year history of hormone
replacement at the start of menopause that she was weaned off of
and had no further symptoms, thus stopped using. She denies any
history of gynecologic infections, does note a history of yeast
infections and her history of positive HPV on Pap smears.
Past Surgical History:
- ___, tubal ligation via mini lap at ___.
- ___, instillation of InterStim at ___, by Dr.
___.
- ___, right total knee replacement at ___.
- ___, left total knee replacement at ___.
- ___ Total hysterectomy, robotic assisted
Social History:
___
Family History:
No history of breast, ovarian, uterine or colon
cancers. Some family history of high blood pressure and heart
disease.
Physical Exam:
Admission Physical Exam:
PE: 98.1 58 98/45 14 92% RA
Gen: NAD, uncomfortable, laying ___ bed, A&Ox3, conversant
HEENT: EOMI, no scleral icterus, dry mucous membranes
CV: RRR
Pulm: No respiratory distress
Abd: moderately firm, diffusely tender to palpation although
mostly on right side of abdominal, distended, port site
incisions
healing without any drainage or erythema
Ext: WWP
Discharge Physical Exam:
VS: 98.2, 74, 128/42, 18, 95%ra
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: soft, nontender to palpation incisionally,
non-distended. Incisions: granulating healthy tissue, covered
with with VAC dressing. Bilateral JP drain sites CDI.
Serosanguinous drainage.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
Pertinent Results:
___ 04:10AM BLOOD WBC-9.1 RBC-3.30* Hgb-9.4* Hct-30.3*
MCV-92 MCH-28.5 MCHC-31.0* RDW-18.1* RDWSD-59.9* Plt ___
___ 04:00AM BLOOD WBC-12.4* RBC-3.12* Hgb-9.0* Hct-28.5*
MCV-91 MCH-28.8 MCHC-31.6* RDW-18.1* RDWSD-58.6* Plt ___
___ 04:40AM BLOOD WBC-13.3* RBC-3.18* Hgb-9.3* Hct-29.0*
MCV-91 MCH-29.2 MCHC-32.1 RDW-17.7* RDWSD-58.6* Plt ___
___ 05:15AM BLOOD WBC-11.8* RBC-3.27* Hgb-9.4* Hct-30.0*
MCV-92 MCH-28.7 MCHC-31.3* RDW-17.9* RDWSD-58.6* Plt ___
___ 05:00AM BLOOD WBC-12.1* RBC-3.44* Hgb-10.0* Hct-31.6*
MCV-92 MCH-29.1 MCHC-31.6* RDW-18.1* RDWSD-58.5* Plt ___
___ 05:00AM BLOOD WBC-10.8* RBC-3.17* Hgb-9.2* Hct-28.4*
MCV-90 MCH-29.0 MCHC-32.4 RDW-17.5* RDWSD-56.3* Plt ___
___ 01:10AM BLOOD WBC-12.3* RBC-3.49* Hgb-10.2* Hct-31.3*
MCV-90 MCH-29.2 MCHC-32.6 RDW-17.5* RDWSD-56.3* Plt ___
___ 04:40AM BLOOD WBC-9.9 RBC-3.10* Hgb-9.1* Hct-28.1*
MCV-91 MCH-29.4 MCHC-32.4 RDW-17.4* RDWSD-57.7* Plt ___
___ 04:00AM BLOOD Glucose-104* UreaN-8 Creat-0.7 Na-138
K-3.9 Cl-101 HCO3-28 AnGap-13
___ 04:40AM BLOOD Glucose-99 UreaN-11 Creat-0.6 Na-139
K-3.7 Cl-102 HCO3-29 AnGap-12
___ 05:15AM BLOOD Glucose-86 UreaN-12 Creat-0.6 Na-142
K-3.6 Cl-103 HCO3-23 AnGap-20
___ 05:00AM BLOOD Glucose-98 UreaN-12 Creat-0.7 Na-139
K-3.9 Cl-100 HCO3-26 AnGap-17
___ 05:00AM BLOOD Glucose-108* UreaN-12 Creat-0.6 Na-139
K-3.7 Cl-102 HCO3-28 AnGap-13
___ 04:00AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.9
___ 04:40AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.7
___ 05:15AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.7
================================================================
Imaging:
___: ___ this suboptimal study, the left ventricular wall
thickness, cavity size, and global systolic function appear to
be normal (LVEF>55%). Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. No
mitral regurgitation is seen. There is no pericardial effusion.
There is an anterior space which most likely represents a
prominent fat pad. The right ventricle is not well seen, but its
size may be mildly dilated and its systolic function is likely
normal.
___ CT A/P:
1. Numerous loops of fluid-filled, dilated small bowel and
pneumoperitoneum is worrisome for small bowel ileus following
bowel rupture/ leak.
2. Increasing free fluid within the pelvis and tracking along
the bilateral pericolic gutters. ___ the setting of
pneumoperitoneum, this low-density fluid likely represent
enteric contents although residual hemorrhage is not excluded.
3. Cholelithiasis with a moderately distended gallbladder and
trace fluid
seen within the right pericolic gutter. If clinically
indicated, right upper quadrant ultrasound could be performed
for further evaluation.
4. 3 mm right middle lobe solid pulmonary nodule. If the
patient is at high risk for malignancy, follow-up chest CT can
be performed ___ ___ year to document stability. Otherwise, no
discrete followup is required.
___ CXR:
Radiograph centered at the thoracoabdominal junction
demonstrates a
nasogastric tube terminating ___ the body of the stomach. Lung
volumes are
low. Pulmonary vascular congestion and mild edema are new
compared to ___ chest radiograph, as well as patchy
and linear atelectasis at the right lung base.
___ CXR:
Comparison to ___. No relevant change is noted. The
nasogastric
tube was removed. Lung volumes continue to be low. Areas of
atelectasis are visualized at both the left and the right lung
bases but have slightly
decreased ___ severity. Moderate cardiomegaly persists. No
overt pulmonary edema.
___: CT A/P
1. Loculated fluid collection ___ the right hemipelvis measuring
up to 5.2 cm does not have thick rim enhancement or air locules,
likely an organizing seroma, less likely an abscess.
2. Free fluid is seen ___ the pelvis, predominantly on the left
side, located away from the tip of the left-sided surgical
drain.
3. A 1.3 x 2.4 cm rim enhancing ovoid lesion along the right
external iliac vessels is likely another tiny loculated fluid
pocket.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:33 am PERITONEAL FLUID
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ ___ ___
16:20.
ESCHERICHIA COLI. RARE 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 (Final ___:
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
BETA LACTAMASE POSITIVE.
___ 6:49 am TISSUE Site: PELVIS PELVIC ABSCESS.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
Reported to and read back by ___ @ 13:17,
___.
TISSUE (Preliminary):
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
ESCHERICHIA COLI. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI. RARE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h. SECOND MORPHOLOGY.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Final ___:
BACTEROIDES FRAGILIS GROUP. HEAVY GROWTH.
BETA LACTAMASE POSITIVE.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Brief Hospital Course:
Ms. ___ is a ___ yo F status post robotic-assisted
hysterectomy 1 month ago admitted to the Acute Care Surgery
Service on ___ with persistent diarrhea and increased lower
abdominal pain. She had a CT scan that showed numerous loops of
fluid-filled, dilated small bowel and pneumoperitoneum
concerning for a bowel perforation or leak. Her white blood cell
count was 6.6, her lactate was 1.3, and creatinine was elevated
at 2.7. On ___ she was taken emergently to the operating
room for exploration. No intestinal leak was found and the
presumed wource intra-abdominal sepsis was a vaginal cuff leak
given her prior operation. Her abdomen was washed out and she
was closed with a wound vac. Post operatively she was extubated
and transferred to the TSICU.
ICU Course:
On POD0 she initially required BiPAP to maintain her oxygenation
but was weaned to nasal cannula without issues. She was given a
total of 3L lactated ringers and required a phenylephrine drip.
She had a pelvic exam by the GYN team with some brown discharge
but no evidence of cuff leak.
On POD1 she was given albumin for hypotention and her
phenylephrine drip was weaned off. She was given methylene blue
that was negative for drainage from JP drains to vagina. She had
a PICC line placed for plan for long term antibiotics ___ setting
of difficult IV access.
On POD2 she was hemodynamically stable, started on a regular
diet, and transferred to the surgical floor for further
management. Her IV antibiotics were transitioned to oral
Augmentin, for which she completed a 5 day course.
Hospital Floor Course:
Throughout her hospitalization she remained alert and oriented.
Pain was initially controlled with IV pain medication that was
transitioned to oral once tolerating a regular diet. On POD2 she
required a 500 mL fluid bolus for low urine output. She remained
hemodynamically stable; vital signs were routinely monitored.
Her oxygen was weaned to room air without difficulty. She
tolerated a regular diet without nausea, vomiting, or abdominal
pain. On POD5 she had multiple bowel movement and sample was
sent for clostridium difficile which was negative. Her foley
catheter was removed and she voided adequate urine without
difficulty. Her JP drains initially put out copious serous
drainage >3000 mL ___ 24 hours. Her outputs gradually decreased.
On POD5 she was given 20 mg PO furosemide for diuresis. The
patient's blood counts were closely watched for signs of
bleeding, of which there were none. The patient received
subcutaneous heparin and ___ dyne boots were used during this
stay and was encouraged to get up and ambulate as early as
possible. Her midline abdominal wound vac was changed routinely
and shows signs of progressive healing.
The patient's fever curves were closely watched for signs of
infection. Due to a gradually rising WBC, a repeat CT scan was
done on POD7 which showed 2 fluid collections. On POD8 the
patient went to ___ for drainage of the fluid collections, which
she tolerated well. Preliminarily there was no growth to date on
those cultures. Following drainage of the fluid collectio9ns,
the patient's WBC normalized.
The patient was seen and evaluated by physical therapy who
recommended discharge to acute rehabilitation to continue her
recovery.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding with assistance, and pain was well
controlled. Bilateral JP drains were slowly decreasing ___ output
so they remained ___ and will be removed ___ ___ clinic.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. The case manager met with the patient and
discharge to rehab was arranged.
Medications on Admission:
1. DICYCLOMine 10 mg PO DAILY WITH LARGEST MEAL
2. FLUoxetine 20 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY -- stopped
4. Hydroxychloroquine Sulfate 400 mg PO DAILY Q MON, WED, FRI
5. Omeprazole 20 mg PO BID
6. Simvastatin 10 mg PO QPM
7. Acetaminophen 650 mg PO TID pain
Do not take more than 4000mg ___ 24 hours.
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day
Disp
9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
Do not drink or drive while taking.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
10. Hydroxychloroquine Sulfate 200 mg PO DAILY Q TUES, THURS,
SAT, SUN
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC BID
4. LOPERamide 2 mg PO QID:PRN diarrhea
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
6. Sarna Lotion 1 Appl TP BID:PRN rash
7. DICYCLOMine 10 mg PO DAILY
8. FLUoxetine 60 mg PO DAILY
9. Hydroxychloroquine Sulfate 400 mg PO MWF
10. Omeprazole 20 mg PO BID
11. Simvastatin 10 mg PO QPM
12. TraZODone 50 mg PO QHS:PRN Insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Peritonitis, pneumoperitoneum, perforated hollow viscus, sepsis,
probably due to vaginal cuff leak from prior hysterectomy.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
with abdominal pain. You had a CT scan that was concerning for a
perforation or hole ___ your intestine. You were given IV
antibiotics and taken emergently to the operating room for an
exploratory laparotomy. No bowel perforation was found.
Considering your previous surgery, the most probable source of
intra-abdominal infection was from a vaginal cuff leak. You had
drains placed and the fluid output was closely monitored and
remained clear. You had a wound vac placed to the midline
surgical incision.
You are now doing well, tolerating a regular diet, ambulating
with assistance, and ready to be discharged to rehab to continue
your recovery from surgery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood ___ your
urine, or experience a discharge.
*Your pain ___ 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 ___ your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid ___ the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes ___ character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself ___
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
10283863-DS-9 | 10,283,863 | 29,837,419 | DS | 9 | 2161-05-21 00:00:00 | 2161-05-21 20:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Bactrim / Penicillins
Attending: ___
Chief Complaint:
fever, abdominal pain, intra-abdominal abscess
Major Surgical or Invasive Procedure:
___: US-guided placement of ___ pigtail catheter into
pelvic
collection.
History of Present Illness:
Ms. ___ is a ___ old woman who had a robotic-assisted
laparoscopic total hysterectomy on ___, who
presented one month later with evidence of multiple organ system
failure, elevated Cr and Bilirubin, high fever, and peritoneal
findings, as well as free air on abdominal CT scan. She
underwent exploratory laparotomy with washout of a pelvic
abscess at that time, as well as a wound vac placement on
___. On ___, she underwent ___ drainage for bilateral
intra-abdominal fluid collections, and was then sent to rehab
without antibiotics, as culture data showed no growth. On the
day prior to admission, she experienced acute abdominal pain
which has persisted, as well as a fever to ___. At her rehab
facility, the ___ changing the wound vac had noted a
well-healing wound. Reportedly, the two JP drain sites, which
Ms. ___ had been discharged with, looked irritated but
not infected; however, they did appear to have lower output. She
experienced no nausea/vomiting, no change in bowel habits, no
change in oral intake, and no urinary symptoms.
Past Medical History:
Past Medical History: Obesity, irritable bowel syndrome, urinary
incontinence, gastroesophageal reflux disease, osteoarthritis, a
high rheumatoid factor, pulmonary hypertension and sleep apnea.
Obstetrical History: Gravida 3, para 3, 3 spontaneous vaginal
deliveries in ___ and ___. Largest baby was 8 pounds.
Past Gynecologic History: Menarche at age ___, very regular q.
monthly periods lasting four to five days with moderate flow.
Last menstrual period and age of menopause, ___, roughly
age
___. She reports abnormal Paps. Her first abnormal Pap smear
was
this year, ___. However, as noted in the HPI, she
has
had a few years of high-risk HPV positive Pap smears. She is
not
currently sexually active. She does report a distant history of
OCP use for one year and a one-year history of hormone
replacement at the start of menopause that she was weaned off of
and had no further symptoms, thus stopped using. She denies any
history of gynecologic infections, does note a history of yeast
infections and her history of positive HPV on Pap smears.
Past Surgical History:
- ___, tubal ligation via mini lap at ___.
- ___, instillation of InterStim at ___, by Dr.
___.
- ___, right total knee replacement at ___.
- ___, left total knee replacement at ___.
- ___ Total hysterectomy, robotic assisted
Social History:
___
Family History:
No history of breast, ovarian, uterine or colon
cancers. Some family history of high blood pressure and heart
disease.
Physical Exam:
V/S: T98.6PO, HR93, BP108/59, RR20, Sat94%RA
Gen: NAD, AAOx3, sitting comfortably in bed
HEENT: MMM, no scleral icterus
Resp: nl effort, CTABL, no wheezes/rales/rhonchi
CV: RRR, nl S1/S2, no S3/S4, no murmurs/rubs/gallops
Abd: +BS, soft, obese, ND, appropriately tender to palpation
Midline incision packed, C/D/I with gauze and ABD, L sided
drains in place
Ext: WWP, no edema, 2+ DP
Pertinent Results:
___ 06:20AM BLOOD WBC-11.0* RBC-3.33* Hgb-9.5* Hct-30.1*
MCV-90 MCH-28.5 MCHC-31.6* RDW-18.5* RDWSD-60.0* Plt ___
___ 06:20AM BLOOD Glucose-116* UreaN-9 Creat-0.7 Na-135
K-3.5 Cl-99 HCO3-26 AnGap-14
___ 06:20AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9
Brief Hospital Course:
Ms. ___ presented to the ED on ___ with abdominal
pain and fever of one day duration. She is status post
robotic-assisted laparoscopic total hysterectomy for endometrial
carcinoma in ___, and subsequent ex-lap in ___ for
intra-abdominal abscesses. Upon arrival to ED she was found to
have continued symptoms of abdominal pain as well as decreased
output from surgically placed drains. She underwent a CT scan
showing additional free fluid in the pelvis which was
inadequately drained by the existing JP drains. Given findings,
the patient he underwent ___ drain placement on HD#1 for source
control. There were no adverse events in the ___ suite; please
see the ___ note for details. She recovered well after the
procedure and was transferred to the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain managed with IV and oral agents, and was
transitioned to PO only meds.
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: Patient was initially NPO for ___ procedure, but soon
was able to tolerate diet thereafter. Patient's intake and
output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. She was placed on
levofloxacin and flagyl for intraabdominal fluid collects which
had caused fever and pain. Cultures were obtained from
intra-abdominal fluid collections.
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 at baseline, 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. DICYCLOMine 10 mg PO DAILY WITH LARGEST MEAL
2. FLUoxetine 20 mg PO DAILY
3. Hydroxychloroquine Sulfate 400 mg PO DAILY Q MON, WED, FRI
4. Omeprazole 20 mg PO BID
5. Simvastatin 10 mg PO QPM
6. Acetaminophen 650 mg PO TID pain
Do not take more than 4000mg in 24 hours.
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*50 Tablet Refills:*1
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Tablet Refills:*2
9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
Do not drink or drive while taking.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*30 Tablet Refills:*0
10. Hydroxychloroquine Sulfate 200 mg PO DAILY Q TUES, THURS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Levofloxacin 500 mg PO Q24H
RX *levofloxacin 500 mg 1 tablet(s) by mouth Q24H Disp #*4
Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*14 Tablet Refills:*0
4. DICYCLOMine 10 mg PO DAILY
5. FLUoxetine 60 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. TraZODone 100 mg PO QHS:___ home med
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pelvic fluid collection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with fevers and abdominal pain. CT
imaging showed you had an abdominal fluid collection. You were
taken to Interventional Radiology and underwent drainage of the
abscess. You tolerated this procedure well. You are now
medically cleared to be discharged home with Visiting Nurse
___ to help change your surgical wound dressings and to
monitor your drain output. On the day of your follow-up
appointment in the Acute Care Surgery clinic, please bring your
lab slip to have blood drawn in the ___ lab one hour
prior to your scheduled appointment time.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid 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.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
Followup Instructions:
___
|
10284802-DS-13 | 10,284,802 | 25,193,580 | DS | 13 | 2130-06-21 00:00:00 | 2130-06-22 17:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bloody and frequent stools
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with recent diagnosis of ulcerative colitis by colonoscopy 3
weeks ago, complicated by superinfected with c.diff and
salmonella presenting with ongoing increased bowel movements and
blood in her stools. She was previously on cipro for her
infectious processes but it was discontinued due to nausea and
vomiting side effects and she was later started on flagyl. She
was having ___ watery bowel movements per day prior to
starting on asacol -- now she has ___ watery BMs per day. She
notes that these bowel movements are mixed with bright red blood
and dark stool. Associated symptoms include approximately 10
lbs weight loss, fatigue and occassional vomiting. She has no
other complaints including abdominal pain. Denies dysuria. LMP 2
weeks ago
In the ED, initial vitals were: 97.1 93 137/79 18 99% RA. She
was seen by GI who recommend starting IV vancomycin and start
Methylpred 20 mg q8 IV. She had an AXR, UA, lactate of 2.9, CRP
16.8, K of 2.9, WBC of 13. On the floor, she notes ongoing
diarrhea, which continues to be mixed with bright red blood and
dark stools. She continues to deny abdominal pain.
Past Medical History:
Ulcerative Colitis
Social History:
___
Family History:
Cousin with ___
Physical Exam:
ADMISSION:
Vitals: 98 139/64 78 18 100%
General: Alert, oriented, no acute distress, lying in bed,
conversive
HEENT: normocephalic, no oral lesions, EOMI
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, + bowel sounds, no
rebound tenderness or guarding
Ext: warm, well perfused, no edema
Neuro: alert, oriented, following all commands, gait normal,
moving all extremities to command
DISCHARGE:
98.1, 56-68, 118-138/53-68, ___, 96%RA BM x2
General: Alert, oriented, no acute distress
HEENT: normocephalic, no oral lesions, EOMI
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm
Abdomen: soft, non-tender, non-distended, + bowel sounds, no
rebound tenderness or guarding
Ext: warm, well perfused, no edema
Pertinent Results:
ADMISSION LABS:
___ 04:08PM BLOOD WBC-13.0* RBC-4.90 Hgb-14.9 Hct-42.8
MCV-88 MCH-30.4 MCHC-34.7 RDW-13.1 Plt ___
___ 04:08PM BLOOD Neuts-57.7 ___ Monos-6.1 Eos-1.9
Baso-1.0
___ 04:08PM BLOOD Glucose-110* UreaN-10 Creat-0.9 Na-139
K-2.9* Cl-100 HCO3-24 AnGap-18
___ 06:55AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0
___ 04:23PM BLOOD Lactate-2.9*
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-10.0 RBC-4.47 Hgb-13.4 Hct-39.7
MCV-89 MCH-29.9 MCHC-33.8 RDW-13.1 Plt ___
___ 06:50AM BLOOD Glucose-116* UreaN-11 Creat-0.6 Na-136
K-4.8 Cl-103 HCO3-23 AnGap-15
___ 06:50AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1
IMAGING:
ABDOMINAL XRAY ___:
IMPRESSION: Nonspecific nonobstructive bowel gas pattern.
Brief Hospital Course:
___ year old female with newly diagnosed ulcerative colitis
complicated by superinfection of c. diff and salmonella
infections presenting with persistent diarrhea and bloody
stools.
# Ulcerative colitis, complicatd by Salmonella and C. difficile
infections:
She was diagnosed with concurrent C diff and Salmonella
infections prior to this admission. Despite taking flagyl,
asacol and prednisone 40mg daily, she noted having bloody
diarrhea without improvement in the days prior to admission.
Patient was compliant with low residue diet and home
medications. When she was admitted to the Medicine service she
was seen by the GI consult service who recommended starting her
on methylprednisone IV. GI also recommended treatment with PO
vancomycin for C diff infection and 7 days course of bactrim for
her Salmonella infection. In the following days her diarrhea
improved and she noted have only ___ non-grossly blood bowel
movements per day. She was transitioned to PO prednisone and
continued on PO vancomycin and bactrim. CMV viral load was sent
and pending at the time of discharge. PPD was placed in right
forearm on ___. Patient will follow up with Dr. ___
for reading of PPD on ___.
# Hypokalemia, likely due to diarrhea: The patient presented
with potassium of 2.9 and given 40 mEq in ED and further
repletion on the Medicine floor with appropiate response.
TRANSITIONAL ISSUES:
# PPD need to be read at outpatient visit on ___.
# CMV viral load pending at discharge.
# Patient will follow up with Dr. ___ at ___ for prednisone
taper.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mesalamine ___ 800 mg PO TID
2. PredniSONE 40 mg PO DAILY
3. MetRONIDAZOLE (FLagyl) 500 mg PO TID
4. YAZ 28 *NF* (drospirenone-ethinyl estradiol) ___ mg-mcg Oral
daily
5. Acetaminophen Dose is Unknown PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. YAZ 28 *NF* (drospirenone-ethinyl estradiol) ___ mg-mcg Oral
daily
3. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth every 12 hours Disp #*10 Tablet Refills:*0
4. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp
#*56 Capsule Refills:*1
5. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every 8
hours as needed for nausea Disp #*8 Tablet Refills:*2
6. Calcium Carbonate 500 mg PO BID
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1
tablet(s) by mouth every 12 hours Disp #*60 Tablet Refills:*0
7. Mesalamine Enema 4 gm PR HS
RX *mesalamine 4 gram/60 mL 1 Enema(s) rectally nightly or as
directed Disp #*20 Unit Refills:*0
8. Vitamin D 400 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 1 tablet(s) by mouth
daily Disp #*30 Capsule Refills:*0
9. Mesalamine ___ 2400 mg PO BID
RX *mesalamine [Asacol HD] 800 mg 3 tablet,delayed release
(___) by mouth twice a day Disp #*180 Tablet Refills:*0
10. PredniSONE 40 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Ulcerative colitis
Salmonella infection
C Difficile infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care at ___. You came
to the hospital for ongoing loose stools containing blood. We
treated your with IV steroids. We also gave you antibiotic
medications to treat the infections in your intestine. You will
need to take antibiotics for many days after leaving the
hospital. Please take all medications as prescribed. Please
keep all follow up appointments.
Followup Instructions:
___
|
10284837-DS-21 | 10,284,837 | 27,859,161 | DS | 21 | 2178-01-13 00:00:00 | 2178-03-02 15:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / egg
Attending: ___.
Chief Complaint:
Fall downstairs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ old independent man with a
history of CAD with 1 stent, who slipped on black ice this
morning and fell down a flight of ___ stairs. He did not have
head strike or loss of consciousness. He reported some left
sided chest pain and shortness of breath, as well as some left
shoulder pain. He was brought to an OSH and underwent left sided
rib and
left shoulder xrays, which revealed L sided ___ rib
fractures. He did have an oxygen requirement, and was
transferred to ___ for further evaluation. A c-collar was
placed. Upon our evaluation in the ED, he was complaining of
left sided chest pain consistent with rib fractures, but
otherwise appeared
fairly comfortable.
Past Medical History:
Past Medical History: CAD s/p stent, BPH, HTN, early lymphoma
Past Surgical History: diagnostic laparoscopy with abdominal
lymph node biopsy (___)
Social History:
___
Family History:
Parents both died of cancers
Physical Exam:
Admission Physical Exam:
V/S: T98.1, HR74, BP138/76, RR13, Sat96% 2L NC
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, tenderness to
palpation over left lower chest wall without ecchymosis or
crepitus
ABD: Soft, nondistended, nontender, no rebound or guarding
Back: No midline tenderness, stepoffs, or deformities
Ext: No ___ edema, ___ warm and well perfused, superficial
abraision of right anterior shin, 2cm ecchymosis with 1cm
abrasion of L hip just under ASIS
Neuro: Motor/sensory grossly intact; CNII-XII grossly intact
Discharge Physical Exam:
VS: T: 98.4 PO 124 / 85 R Sitting HR: 79 RR: 18 O2: 92% ra
GEN: A+Ox3, NAD
HEENT: MMM, atraumatic
CHEST: symmetric expansion, no crepitus, old left chest tube
site covered with occlusive dressing
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, non-tender to palpation
EXT: wwp, no edema b/l
Pertinent Results:
IMAGING:
___: CT C-spine:
1. No acute fracture or malalignment. No prevertebral soft
tissue swelling.
2. 1.9 cm right hypodense thyroid nodule for which further
assessment with
thyroid ultrasound is suggested, if not done previously.
___: CT Head:
1. No acute intracranial bleed. No fracture.
2. Mild paranasal sinus disease as described above.
___: CT Torso:
1. Minimally displaced acute fractures of left lateral ribs 7
through 11.
Additionally, there is a segmental fracture of the left lateral
ninth rib.
2. Small left hemothorax. No pneumothorax, evidence of
pulmonary laceration
or contusion.
3. No evidence of solid organ injury or mesenteric injury within
the imaged
abdomen and pelvis.
4. Mild fat stranding of the left lateral gluteal region without
skin
laceration.
5. Mediastinal, right hilar, and abdominal lymphadenopathy in
keeping with
patient's lymphoma history.
6. 1.9 cm heterogeneous right thyroid nodule. Ultrasound follow
up
recommended.
___ College of Radiology guidelines recommend further
evaluation for
incidental thyroid nodules of 1.0 cm or larger in patients under
age ___ or 1.5
cm in patients age ___ or ___, or with suspicious findings.
7. Indeterminate 1.4 cm left adrenal nodule. While this may
reflect an
adrenal adenoma, given the history of malignancy, a dedicated
adrenal CT can
be performed for further assessment.
8. Prostatomegaly.
9. 3 mm left upper lobe pulmonary nodule for which a follow-up
chest CT can be
obtained in 12 months in a high risk patient. See
recommendations below.
RECOMMENDATION(S):
1. 1.5 cm heterogeneous right thyroid nodule. Ultrasound follow
up
recommended. ___ College of Radiology guidelines recommend
further evaluation for incidental thyroid nodules of 1.0 cm or
larger in patients under age ___ or 1.5 cm in patients age ___ or
___, or with suspicious findings.
2. Dedicated adrenal CT can be obtained for further assessment
of the left adrenal nodule.
3. For incidentally detected single solid pulmonary nodule
smaller than 6 mm, no CT follow-up is recommended in a low-risk
patient, and an optional CT in 12 months is recommended in a
high-risk patient.
___: CXR:
Lungs are low volume with subsegmental atelectasis in the left
lung base.
Cardiomediastinal silhouette is stable. Small left pleural
effusion is
unchanged. No pneumothorax is seen. No new consolidations.
There are stable left-sided rib fractures
___: CT Chest:
1. New moderate-sized nonhemorrhagic left pleural effusion with
underlying
left lower lobe atelectasis versus consolidation.
2. Innumerable subcentimeter short axis mediastinal lymph nodes
although do not meet size criteria for pathologic enlargement
are too numerous and
correlation with history of any underlying malignancy such as
lymphoma or
sarcoidosis should be considered. In the absence of such
history, further
workup may be considered.
3. 8 mm enhancing nodule within the pancreatic ___ be
further evaluated by a dedicated MRI for further
characterization. Differentials include intrapancreatic splenic
tissue versus a neuroendocrine tumor.
4. Unchanged left adrenal nodule may be evaluated at the same
time during the MRI. Incidentally noted are multiple bilateral
peripelvic cysts and a 3 mm nonobstructing left renal calculus.
5. Unchanged appearance of minimally displaced acute fracture of
the left
lateral ribs 7, through 11. Segmental fracture of the left
lateral ninth rib also noted.
RECOMMENDATION(S): Please see impression 2 and 3.
___: US THORACENTESIS NEEDLE
Successful US-guided drainage of left hemothorax to completion,
with placement of an ___ pigtail catheter attached to
Pleur-Evac.
___: CXR:
Status post removal of left pigtail catheter. No definite
pneumothorax.
LABS:
___ 07:45PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 07:45PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 07:45PM URINE MUCOUS-RARE*
___ 03:02PM GLUCOSE-139* UREA N-16 CREAT-0.8 SODIUM-140
POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-19* ANION GAP-16
___ 03:02PM WBC-13.8* RBC-4.73 HGB-13.6* HCT-39.4* MCV-83
MCH-28.8 MCHC-34.5 RDW-13.1 RDWSD-39.8
___ 03:02PM NEUTS-81.5* LYMPHS-13.7* MONOS-4.1* EOS-0.1*
BASOS-0.1 IM ___ AbsNeut-11.22* AbsLymp-1.89 AbsMono-0.56
AbsEos-0.01* AbsBaso-0.01
___ 03:02PM PLT COUNT-195
Brief Hospital Course:
Mr. ___ is a ___ yo M who presented to the emergency
department after a fall down 12 stairs after slipping on black
ice per patient report. Denies head strike or loss of
consciousness. Imaging revealed left sided rib fractures ___
and small left sided hemothorax. The patient was admitted to the
Acute Care Trauma surgery service on ___ for pain control
and respiratory monitoring.
On HD1 tertiary survey was preformed and revealed no further
injuries. Interval chest x-rays were obtained and there was
concern that the left pleural effusion was not resolving. A
pigtail chest tube was placed by Interventional Radiology on
___ with an immediate 700 ml sanguineous output. The chest
tube was ultimately removed on ___. Repeat chest x-ray
showed no pneumothorax.
The patient was alert and oriented throughout hospitalization;
pain was managed with oxycodone and acetaminophen. He remained
stable from a cardiovascular and pulmonary standpoint; vital
signs were routinely monitored. Good pulmonary toilet, early
ambulation and incentive spirometry were encouraged throughout
hospitalization.
The patient tolerated a regular diet. Patient's intake and
output were closely monitored. The patient's fever curves were
closely watched for signs of infection, of which there were
none. The patient's blood counts were closely watched for signs
of bleeding, of which there were none. The patient received
subcutaneous heparin and ___ dyne boots were used during this
stay and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, 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. The patient received CD
copies of all his ___ imaging for him to provide to his PCP
and ___ copy of the d/c summary was faxed to his PCP's office.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO QHS
2. Finasteride 5 mg PO DAILY
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID constipation
3. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % Apply patch to area of rib pain QAM
Disp #*15 Patch Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Wean as tolerated. Patient may request partial fill.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Finasteride 5 mg PO DAILY
9. Metoprolol Succinate XL 12.5 mg PO DAILY
10. Senna 8.6 mg PO BID:PRN constipation
11. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left rib fractures ___
Left hemothorax
Left pleural effusion
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 Acute Care Surgery service on ___
after a fall sustaining left sided rib fractures. You were found
to have a moderate amount of fluid in the lung space that was
caused by the injury to your ribs. A chest tube was placed to
help drain this fluid from your lung space and was then later
removed. You were given pain medication, supplemental oxygen,
and encouraged to take deep breaths, walk, and cough to help
your body re-absorb the fluid. You are now doing better, oxygen
levels are adequate, and your pain is better controlled with
pain pills. You were evaluated by the physical therapist who
recommends discharge to home with continued physical therapy at
home. You will also have visiting nursing services come to your
home.
Please have a follow up chest xray done prior to your clinic
visit.
Please note the following discharge instructions:
* Your injury caused left 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 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10285055-DS-14 | 10,285,055 | 23,527,667 | DS | 14 | 2115-03-23 00:00:00 | 2115-03-25 15:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bilateral ureteral stones
Major Surgical or Invasive Procedure:
Cystoscopy, left ureteroscopy, laser lithotripsy, and bilateral
ureteral stent placement.
History of Present Illness:
This is a ___ year old male presenting with 1 day history of left
flank pain and dysuria. Upon further work up, he was found to
have a 5 mm left UVJ stone and 1.9 cm proximal right ureteral
stone. He has a history of kidney stones
in the past which he passed spontaneously. He has never required
surgery for stones. He is afebrile and hemodynamically stable.
WBC 11. Cr 1.5. U/A
negative for infection.
Past Medical History:
overweight
Social History:
___
Family History:
No Family History currently on file.
Physical Exam:
WdWn male, NAD, AVSS
Interactive, cooperative
Abdomen soft, Nt/Nd, obese
Flank pain improved
Lower extremities w/out edema or pitting and no report of calf
pain
Pertinent Results:
___ 06:17AM BLOOD WBC-6.2 RBC-4.87 Hgb-14.8 Hct-44.4 MCV-91
MCH-30.4 MCHC-33.3 RDW-13.0 RDWSD-43.7 Plt ___
___ 10:50AM BLOOD WBC-8.1 RBC-4.84 Hgb-14.4 Hct-44.3 MCV-92
MCH-29.8 MCHC-32.5 RDW-13.1 RDWSD-44.1 Plt ___
___ 01:25PM BLOOD WBC-11.1* RBC-5.77 Hgb-17.4 Hct-51.7*
MCV-90 MCH-30.2 MCHC-33.7 RDW-13.2 RDWSD-43.4 Plt ___
___ 01:25PM BLOOD Neuts-77.0* Lymphs-13.1* Monos-8.6
Eos-0.3*
Baso-0.5 Im ___ AbsNeut-8.55* AbsLymp-1.45 AbsMono-0.95*
AbsEos-0.03* AbsBaso-0.06
___ 06:17AM BLOOD Glucose-134* UreaN-13 Creat-0.9 Na-143
K-4.3 Cl-106 HCO3-24 AnGap-13
___ 10:50AM BLOOD Glucose-132* UreaN-16 Creat-1.5* Na-141
K-4.4 Cl-105 HCO3-24 AnGap-12
___ 09:44PM BLOOD Glucose-151* UreaN-16 Creat-1.7* Na-140
K-5.0 Cl-102 HCO3-21* AnGap-17
___ 01:25PM BLOOD Glucose-153* UreaN-17 Creat-1.5* Na-139
K-4.9 Cl-101 HCO3-20* AnGap-18
___ 01:25PM BLOOD ALT-73* AST-36 AlkPhos-72 TotBili-0.5
___ URINE URINE CULTURE-FINAL INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
Brief Hospital Course:
Mr. ___ was admitted Dr. ___ service for
nephrolithiasis
management with known bilateral ureteral stone and taken
urgently to the operative theatre where he underwent cystoscopy,
left ureteroscopy, laser lithotripsy, and bilateral ureteral
stent placement. He tolerated the procedure well and recovered
in the PACU before transfer to the general surgical floor. See
the dictated operative note for full details. Overnight, the
patient was hydrated with intravenous fluids and received
appropriate perioperative prophylactic antibiotics. Intravenous
fluids and Flomax were given to help facilitate passage of
stones. At discharge on POD1, patients pain was controlled
with oral pain medications, tolerating regular diet, ambulating
without assistance, and voiding without difficulty. His labs
were
checked and he was advised to follow up as directed. He was was
explicitly advised to follow up as directed as the indwelling
ureteral stent must be removed on the left and he will still
need definitive stone management on the right.
Medications on Admission:
NONE
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO ONCE prophylaxis
RX *nitrofurantoin monohyd/m-cryst 100 mg ONE capsule(s) by
mouth once Disp #*2 Capsule Refills:*0
4. Oxybutynin 5 mg PO TID:PRN bladder spasms
5. Senna 8.6 mg PO ONCE Duration: 1 Dose
6. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral ureterolithiasis.
acute kidney injury (creatinine up to 1.7)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter. This is normal from the stent irritation.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor.
-___ ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks
Followup Instructions:
___
|
10285309-DS-9 | 10,285,309 | 27,628,357 | DS | 9 | 2127-08-21 00:00:00 | 2127-08-21 16:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
High Output UGI Fistula
Major Surgical or Invasive Procedure:
UGI endoscopy with dobhoff tube placed past fistula
History of Present Illness:
This patient is a ___ year old male with hx of enterocutaneous
fistula, prior open cholecystectomy with complicated course
including abdominal compartment syndrome and multiple
reconstructive surgeries who presents with worsening of existing
fistula.
To ___ summarize his operative history, he had an open CCY
___ that was complicated by duodenal perforation, leading to
peritonitis and abdominal compartment syndrome, for which he
required decompression. He had a prolonged hospital course of
approximately six months and has PTSD because of this.
Eventually, he had reconstruction and delayed graft placement
with tissue expanders in ___. Since that time he was healthy.
In ___ he noted a small spot, like a pimple, in the middle of
his abdomen. This gradually enlarged and started draining. He
was seen in the ED on ___, where a CT abd/pelvis was done.
The ___ surgery team saw and placed an ostomy, with plan for
follow up in clinic. ___ ostomy RN saw him on ___ and was
concerned about his fisulta output. From there, he was sent to
the ED and admitted to the ___ surgery service. Patient
reports poor appetite due to concern over fistula output but
denies any nausea, vomiting, or diarrhea. No fevers or chills.
Past Medical History:
PMH: cholecystitis, peritonitis, PTSD, abdominal compartment
syndrome,duodenal perforation
PSH: open cholecystectomy, extensive abdominal wall
reconstruction
Social History:
___
Family History:
Denies family history of GI cancers, fistulas, CAD
Physical Exam:
Vitals:
General: AOx3, NAD
Lungs: CTAB
Cardiac: RRR, nl S1/S2
Abdomen: Soft, NTND, ~1.5cm midline fistula with ostomy bag in
place, CDI, no erythema, draining yellow appearing gastric fluid
Extremities: WWP, no CCE
Pertinent Results:
___ 05:00PM BLOOD Glucose-165* UreaN-27* Creat-1.1 Na-141
K-3.0* Cl-91* HCO3-33* AnGap-20
___ 06:20AM BLOOD Glucose-223* UreaN-33* Creat-1.1 Na-141
K-3.7 Cl-89* HCO3-39* AnGap-17
___ 06:05AM BLOOD Glucose-215* UreaN-50* Creat-1.8* Na-145
K-2.9* Cl-75* HCO3-GREATER TH
___ 04:12AM BLOOD Glucose-133* UreaN-65* Creat-2.8* Na-146*
K-3.8 Cl-89* HCO3-47* AnGap-14
___ 01:14AM BLOOD Glucose-119* UreaN-54* Creat-2.1* Na-139
K-3.9 Cl-98 HCO3-39* AnGap-6*
___ 05:08AM BLOOD Glucose-137* UreaN-44* Creat-1.7* Na-142
K-4.0 Cl-107 HCO3-30 AnGap-9
___ 08:43AM BLOOD Glucose-129* UreaN-37* Creat-1.5* Na-142
K-4.2 Cl-109* HCO3-25 AnGap-12
___ 06:00AM BLOOD Glucose-115* UreaN-32* Creat-1.4* Na-138
K-3.7 Cl-107 HCO3-27 AnGap-8
___ 07:01AM BLOOD Glucose-160* UreaN-29* Creat-1.5* Na-136
K-3.8 Cl-106 HCO3-24 AnGap-10
___ 05:40AM BLOOD Glucose-148* UreaN-29* Creat-1.3* Na-135
K-3.6 Cl-105 HCO3-24 AnGap-10
___ 06:28AM BLOOD Glucose-142* UreaN-29* Creat-1.3* Na-136
K-3.7 Cl-105 HCO3-25 AnGap-10
___ 03:35PM BLOOD Glucose-118* UreaN-28* Creat-1.5* Na-137
K-3.7 Cl-103 HCO3-27 AnGap-11
___ 05:35AM BLOOD Glucose-187* UreaN-28* Creat-1.5* Na-134
K-3.9 Cl-101 HCO3-27 AnGap-10
___ 06:06AM BLOOD Glucose-177* UreaN-29* Creat-1.3* Na-135
K-4.4 Cl-100 HCO3-29 AnGap-10
___ 10:33AM UGI SGL CONTRAST W/ KUB
Impression:
1. Gastrocutaneous fistula extending from the antrum of the
stomach, filling an anterior abdominal wall cavity, and exiting
through the skin.
2. Small bowel appears to fill from the fistula tract.
___ 11:36AM FISTULOGRAM/SINOGRAM
Impression:
Nonvisualized enterocutaneous fistula
Brief Hospital Course:
The patient was admitted to the ___ Surgery Service from the
Emergency Department for a high output gastrocutaneous fistula
with concerns of dehydration and electrolyte abnormalities.
Please refer to the HPI for details of his initial presentation.
On admission to the floor, the patient was treated with IVF
boluses for dehydration. His labs showed a
hypochloremic/hypokalemic contraction alkalosis. His potassium
was repleted and he was kept on IVF. His fistula output was
recorded to be 550 cc for the day of admission. HD2 his
potassium improved after being repleted the day prior, but he
continued to have a contraction alkalosis. his fisula output
increased to 5485 cc. On HD3 he continued to have severe
electrolyte derangements. In addition, his BUN and Cr were
elevated with reduced UOP, likely ___ prerenal azotemia. He was
transferred to the SICU for central access for adequate fluid
and electrolyte repletion and closer monitoring.
In the SICU, he had a central line placed. His fluid and
electrolytes were closely monitored and repleted. He was made
NPO and put on maintenance IVF because it was noted that his
fistula output increased with PO intake. He was administered
octreotide, which helped to decrease his fistula output. On HD4
(___), he had a fistulogram that was non-diagnostic. His
fistula output had decreased to 700 cc for the day. He was
started on a 1:1 repletion with ___.
His electrolyte abnormailities began to improve and he was
started on TPN.
HD5 his electrolyte and hydration status had improved and he was
transferred back to the floor.
HD6 the patient had a UGI BS that showed a gastrocutaneous
fistula without distal obstruction. Given that he was found to
be without obstruction, GI was consulted for EGD exploration of
etiology of GC fistula as well as placement of NJ tube to wean
off TPN. HD11 the patient had an UGI endoscopy and placement of
an ___ Dobhoff tube past the fistula site. After placement of
the Dobhoff tube, he was put on tube feeds and weaned off of
TPN. He tolerated the tube feeds at his goal rate.
His electrolyte abnormalities and hydration status stablized
over the course of his hospitalization (please see Pertinent
Results for exact values). On HD13, his tube feeds were cycled
and repletions were switched from IV to doboff in preparation
for the pt's d/c home.
During his stay, plastic surgery was consulted for wound closure
planning. Since the patient was stable and doing well, it was
decided that the procedure could be done this hospitalization.
On HD15, his tube feeds were d/c at midnight in preparation for
his case. Later that day, he was taken to the OR with plastic
surgery for tissue expanders. The operation was uncomplicated.
During his procedure, it was noted that he had R abdominal wall
cellulitis. He was given Ancef for the procedure, which will be
continued for 7 to cover the cellulitis. He recovered in the
PACU and was transferred back to the floor. His tube feeds were
re-started and were well-tolerated.
On HD16, he was remained stable and was ready for discharge. He
was set up with home nursing for assistance with tube feeds and
repletions. He was informed abou the sgns and symptoms of
dehydration, and was informed to call Dr. ___
and/or to report to the Emergency Department if he experienced
any signs or symptoms. Otherwise, he will follow-up with Dr.
___ in clinic.
Medications on Admission:
Tylenol PRN
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*50 Capsule Refills:*0
2. Octreotide Acetate 100 mcg SC Q8H
RX *octreotide acetate 100 mcg/mL 1 ml SC three times daily Disp
#*100 Ampule Refills:*2
3. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
RX *lansoprazole [Prevacid SoluTab] 30 mg 1 tablet(s) by mouth
twice daily Disp #*100 Tablet Refills:*2
4. Potassium Chloride (Powder) 40 mEq PO DAILY
Hold for K > 4.5
RX *potassium chloride 20 mEq 2 packet(s) by mouth once daily
Disp #*100 Packet Refills:*2
5. Cephalexin 500 mg PO Q6H
6. Clindamycin Solution 300 mg PO Q6H
RX *clindamycin palmitate HCl [Cleocin] 75 mg/5 mL 300 mg by
tube every six (6) hours Refills:*0
7. OxycoDONE-Acetaminophen Elixir ___ mL PO Q4H:PRN pain
control
RX *oxycodone-acetaminophen [Roxicet] 5 mg-325 mg/5 mL 10 ml per
tube every four (4) hours Disp #*200 Milliliter Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
High Output Gastrocutaneous Fistula
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 hospital stay
at ___. You were admitted for management of your high output
fistula. You have recovered well and are now ready for
discharge.
Visting nursing will come to your home to assist you with tube
feeds.
PLEASE MONITOR FOR SIGNS AND SYMPTOMS OF DEHYDRATION: Large
increases of your fistula output can lead to dehydration.
Decreased urine output, dry mouth, rapid heartbeat, or feeling
dizzy or faint when standing are all sign of dehydration. If you
notice large outputs from your fistula site or experience any of
the signs and symptoms mentioned above, please contact a
healthcare provider. If during business hours, please call Dr.
___. If during off hours, please report to the
Emergency Department.
Followup Instructions:
___
|
10285455-DS-9 | 10,285,455 | 22,472,652 | DS | 9 | 2128-08-12 00:00:00 | 2128-08-12 15:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
niacin / simvastatin
Attending: ___.
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
Closed reduction percutaneous pinning of left hip
History of Present Illness:
This is a ___ yo gentleman in his USOH until the 2 days prior to
presentation when he sustained a mechanical fall. OSH plain
films
concerning for hip fracture. The patient denies LOC, premonitory
symptoms and ROS is otherwise at baseline.
Past Medical History:
Systolic CHF - ECHO ___ LVEF = 55%
Tricuspid Regurg
HTN
Atrial Fibrillation
T2DM
Onychomycosis
Social History:
___
Family History:
Non contributory
Physical Exam:
AFVSS
Gen: A&Ox3, No actue distress
Ext: LLE staples in place, wound c/d/i, ___, SILT
___, WWP
Pertinent Results:
___ Hip nailing in OR: FINDINGS: Images from the operating
suite show placement of three nails across previous fracture of
the proximal femur. Further information can be gathered from
the operative report
___ 02:00PM ___ PTT-29.9 ___
___ 02:00PM PLT COUNT-165
___ 02:00PM NEUTS-85.2* LYMPHS-6.3* MONOS-3.8 EOS-4.3*
BASOS-0.4
___ 02:00PM WBC-13.2* RBC-3.70* HGB-11.8* HCT-36.4*
MCV-98 MCH-31.9 MCHC-32.4 RDW-12.2
___ 02:00PM estGFR-Using this
___ 02:00PM GLUCOSE-123* UREA N-38* CREAT-1.7* SODIUM-141
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-30 ANION GAP-16
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for CRPP L hip, which the patient
tolerated well (for full details please see the separately
dictated operative report). The patient was taken from the OR to
the PACU in stable condition and after recovery from anesthesia
was transferred to the floor. The patient was initially given
IV fluids and IV pain medications, and progressed to a regular
diet and oral medications by POD#1. The patient was given
perioperative antibiotics and anticoagulation per routine. The
patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
left lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Medications on Admission:
1. Aspirin 325 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 325 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Enoxaparin Sodium 30 mg SC Q24H Start: ___, First Dose:
Next Routine Administration Time
RX *enoxaparin 30 mg/0.3 mL 30 mg sub-q Daily for 10 days after
discharge Disp #*10 Syringe Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
L femoral neck fracture (non-displaced)
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 30mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated left lower extremity
Physical Therapy:
Weight bearing as tolerated left lower extremity
Treatments Frequency:
Staples will be removed at follow up appointment. No need to
redress unless for comfort.
Followup Instructions:
___
|
10286301-DS-10 | 10,286,301 | 28,567,609 | DS | 10 | 2140-06-03 00:00:00 | 2140-06-03 21:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / chlorhexidine
Attending: ___.
Chief Complaint:
Subdural Hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with PMH severe COPD, CAD
s/p CABG in ___, HFrEF (EF 35-40%), HTN, HLD who was brought to
___ by family for AMS and agitation. Per his sisters
who brought him to OSH ___, they have noticed gradual behavioral
changes over the past month with reported falls. He was agitated
requiring multiple staff to keep him in bed and visibly SOB. He
was started on BiPAP but continues to be in respiratory distress
requiring intubation. Patient was paralyzed with vecurronium
prior to transfer. CT head w/o contrast showed right parietal
subdural hematoma with mass effect but no midline shift. Patient
was transferred to ___ for further management of ___,
respiratory failure. Prior to transfer, he also received
vancomycin and levaquin for empiric coverage of pneumonia.
In ___ initial VS: BP 118/66, HR 60-70
Labs significant for: Trop-T 0.13, Hgb 10.3, Hct 34.3, WBC 4.6,
Plts 72, ___ 17.5, PTT 33.2, INR 1.6, proBNP 6053, Ca 8.4, Mg
1.5, Ph 1.7, AST 24, ALT < 5, AP 89, Tbili 1.7, Alb 2.9, CK 192,
MB 12, MBI 6.3, Na 134, K 4.1, Cl 86, HCO3 38, BUN 12, Cr 0.6,
Glc 79, Lactate 1.5, VBG pH 7.49, pCO2 ___
Patient was given: Furosemide 40 mg IV, Phytonadione 10 mg IV
Imaging notable for:
CT Head W/O Contrast showing right intracranial extra-axial
hematoma stable compared to CT 3 hours before.
CT C-Spine W/O Contrast: no fracture, moderate to large right
pleural effusion
Consults: Neurosurgery
VS prior to transfer: T 97.9, HR 68, BP 118/66, RR 19, SpO2 100%
intubated
On arrival to the MICU, patient is sedated and intubated on APV.
He is not responding to sternal rub or spontaneously opening his
eyes.
Past Medical History:
1. CAD, status post CABG x2 in ___ at the ___
___, status post cardiac catheterization ___ with patent grafts managed medically.
2. Hypertension.
3. Hypercholesterolemia.
4. Severe COPD with EF of 35% to 40% by echocardiogram,
___ with grade 1 diastolic dysfunction and mild pulmonary
hypertension.
5. History of tobacco abuse. Continues to smoke.
6. History of obesity.
7. History of polycythemia ___.
8. History of obstructive sleep apnea not adherent to BiPAP.
9. History of a long-standing nonadherence in general.
10.Status post fundoplication.
Social History:
___
Family History:
Positive for premature CAD, father deceased of myocardial
infarction at age ___.
Physical Exam:
ADMISSION EXAM
====================================
VITALS: Reviewed in metavision
GENERAL: sedated, intubated, not spontaneously opening eyes,
foley catheter draining clear yellow urine
HEENT: Eyes closed, pinpoint pupils slowly reactive to light,
intubated
NECK: supple, elevated JVD to 10 cm
LUNGS: Mechanical breath sounds, no crackles or rhonchi
appreciated
CV: RRR, ___ holosystolic murmur, no rubs or gallops
ABD: soft, non-tender, no guarding, normoactive bowel sounds
EXT: warm, well perfused, left elbow abrasion, trace edema
bilateral lower extremities to ankle
SKIN: bilateral lower extremity erythema to below the knee, thin
skinning with abrasions of upper extremities
NEURO: sedated, intubated
DISCHARGE EXAM
====================================
VITALS: T 98.0 BP 100/49 HR 97RR 18 HR 90 SpO2 3L
GENERAL: Alert and interactive. In no acute distress.
HEENT: Normocephalic, abrasion on forehead. Pupils equal, round,
and reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Moist mucous membranes, poor
dentition. Oropharynx is clear.
NECK: JVP 8cm.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___
holosytolic murmur heard best at ___
LUNGS: Faint bibasilar crackles, No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: trace edema. Pulses DP/Radial 2+ bilaterally. RUE
with erythema contained within demarcation
SKIN: Warm. 2-3cm circular, raised scabbed plaque on left
forearm
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. AOx3.
Pertinent Results:
ADMISSION LABS
=========================
___ 01:40AM BLOOD WBC-4.6 RBC-3.42* Hgb-10.3* Hct-34.3*
MCV-100* MCH-30.1 MCHC-30.0* RDW-16.3* RDWSD-60.1* Plt Ct-72*
___ 01:40AM BLOOD Neuts-76.6* Lymphs-13.1* Monos-9.2
Eos-0.0* Baso-0.4 Im ___ AbsNeut-3.51 AbsLymp-0.60*
AbsMono-0.42 AbsEos-0.00* AbsBaso-0.02
___ 01:40AM BLOOD ___ PTT-33.2 ___
___ 01:40AM BLOOD Glucose-79 UreaN-12 Creat-0.6 Na-134*
K-4.1 Cl-86* HCO3-38* AnGap-10
___ 01:40AM BLOOD ALT-<5 AST-24 LD(LDH)-323* CK(CPK)-192
AlkPhos-89 TotBili-1.7*
___ 01:40AM BLOOD CK-MB-12* MB Indx-6.3* proBNP-6053*
___ 01:40AM BLOOD Albumin-2.9* Calcium-8.4 Phos-1.7*
Mg-1.5*
___ 02:19PM BLOOD VitB12-415 Hapto-43
___ 08:07AM BLOOD Triglyc-100
___ 02:19PM BLOOD TSH-8.8*
RELEVANT STUDIES
=========================
___ TTE:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. LV systolic function appears moderately-to-severely
depressed (LVEF = 30%) secondary to direct ventricular
interaction (reverse Bernheim effect). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular free wall is hypertrophied.
The right ventricular cavity is markedly dilated with severe
global free wall hypokinesis. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The ascending aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Severe (4+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Severe [4+] tricuspid regurgitation is seen. The main
pulmonary artery is dilated. The branch pulmonary arteries are
dilated. There is no pericardial effusion.
___ CT C-SPINE W/O CONTRAST:
1. No evidence for a fracture.
2. 2 mm retrolisthesis of C5 on C6 is most likely degenerative,
though there are no comparison exams to confirm chronicity.
3. Disc herniations moderately narrowing the spinal canal at
C5-C6 and at
least mildly narrowing the spinal canal at C6-C7.
4. Left mandibular periapical lucency associated with an
incompletely
extracted molar. Please correlate with dental exam.
5. Partially visualized right pleural effusion.
___ CT HEAD W/O CONTRAST:
1. Stable acute right subdural hematoma, up to 5 mm at the level
of the right temporal lobe, with stable mild mass effect. No
new hemorrhage.
2. Wall thickening/sclerosis in the partially visualized
maxillary sinuses, indicating sequela of chronic sinusitis.
___ CT HEAD W/O CONTRAST:
1. Stable acute subdural hematoma along the right convexity, up
to 5 mm at the level of the right temporal lobe, with stable
mild mass effect. No new hemorrhage.
2. 1.8 cm subcutaneous cystic lesion overlying the right
maxilla, not imaged previously.
3. Bilateral maxillary sinus wall sclerosis/thickening,
indicating sequela of chronic sinusitis. Left maxillary
alveolar ridge lucency at the level of the extracted molars
causes thinning of the left maxillary sinus floor without
dehiscence.
___ CTA CHEST:
1. Exam slightly limited by respiratory motion artifact
particularly in the right upper lobe. Within these limitations,
no evidence of pulmonary embolism or aortic abnormality.
2. Moderate right and small left pleural effusions with
associated compressive atelectasis. Additional consolidation in
the right middle and right lower lobes concerning for multifocal
pneumonia.
3. Enlargement of the main pulmonary artery suggestive of
pulmonary
hypertension.
4. Small volume perisplenic ascites.
___ RUQ U/S:
1. No sonographic evidence of cholecystitis identified. Focal
thickening of the fundal gallbladder wall is consistent with
adenomyomatosis.
2. Trace ascites and right pleural effusion are noted.
3. Mild splenomegaly.
___ Bilateral ___ U/S:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ RUE U/S:
No evidence of deep vein thrombosis in the right upper
extremity.
MICROBIOLOGY
=========================
___ 12:31 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 9:00 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
SERRATIA MARCESCENS. SPARSE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=1 S
__________________________________________________________
___ 9:00 pm BLOOD CULTURE Source: Venipuncture 1 OF 2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 3:20 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 6:06 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:47 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
RARE GROWTH Commensal Respiratory Flora.
__________________________________________________________
___ 2:19 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 12:07 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 8:45 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 1:40 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS
=========================
White Blood Cells6.94.0 - 10.0K/uLW
Red Blood Cells4.58*4.6 - 6.1m/uLW
Hemoglobin13.0*13.7 - 17.5g/dLW
Hematocrit43.940 - 51%W
MCV9682 - 98fLW
MCH28.426 - 32pgW
MCHC29.6*32 - 37g/dLW
RDW15.7*10.5 - 15.5%W
RDW-SD56.1*35.1 - 46.3fLW
Glucose135*70 - 100mg/dLW
If fasting, 70-100 normal, >125 provisional diabetes
Urea Nitrogen86 - 20mg/dLW
Creatinine0.70.5 - 1.2mg/dLW
Sodium139135 - 147mEq/LW
New reference range as of ___
Potassium3.73.3 - 5.1mEq/LW
Chloride90*96 - 108mEq/LW
Bicarbonate38*22 - 32mEq/LW
Anion Gap1110 - 18mEq/LW
Calcium, Total9.28.4 - 10.3mg/dLW
Phosphate2.2*2.7 - 4.5mg/dLW
Magnesium1.91.6 - 2.6mg/dLW
Brief Hospital Course:
==========
SUMMARY
==========
Mr. ___ is a ___ male with PMH severe COPD, CAD
s/p CABG in ___, HFrEF (EF 35-40%), HTN, HLD who was brought to
___ by family for AMS and agitation. Per his sisters
who brought him to OSH ___, they have noticed gradual behavioral
changes over the past month with reported falls. He was agitated
requiring multiple staff to keep him in bed and visibly SOB. He
was started on BiPAP but continued to be in respiratory distress
requiring intubation. A NCHCT showed a right parietal subdural
hematoma with mass effect but no midline shift. He was
transferred to ___ for further management of his respiratory
status & Neurosurgical evaluation.
Upon arrival, he was evaluated by Neurosurgery who recommended a
repeat NCHCT & a brain MRI. NCHCT confirmed a stable,
non-enlarging SDH. Brain MRI also showed the SDH but showed an
additional acute to subacute subarachnoid hemorrhage. The
patient was deemed to require no urgent Neurosurgical
intervention.
His respiratory status was managed w/ active diuresis & inhaler
therapy and was extubated successfully ___. On the floor,
patient was restarted on his home medications and remained
stable. A problem-based assessment is provided below:
#Acute Metabolic Encephalopathy:
Encephalopathic on admission of unclear etiology. Treated
infection & brain hemorrhage as below. Per neurosurgery, deficit
does not align with size of brain bleed. Therefore,
encephalopathy likely multifactorial from brain bleed as well as
ICU delirium, pneumonia, hypercarbia, and seizures. Upon
extubation, remained agitated consistent w/ ICU delirium. He was
initially managed w/ dexmedetomidine and his home trazadone was
re-started. He remained agitated so received IV olanzapine & PO
quetiapine but was noted to have increasing QTc > 500. He was
also started on clonidine TD to wean off of dexmedetomidine. On
arrival to the floor, patient was alert and oriented x and w/o
agitation. Discontinued clonidine patch and changed Seroquel
dosing to PRN.
#Acute Subdural Hematoma:
#Acute Subarachnoid Hemorrhage:
The patient was evaluated by neurosurgery and there was no
immediate surgerical intervention needed. Patient was started on
Keppra 1000mg BID for 7 days ___ to prevent seizures.
Repeat Non-Con Head CT demonstrated slight increase in right
parietal SDH with new redistribution along the posterior falx
and right tentorium. Neuro exam remained intact throughout
hospitalization and no indication for intervention. Patient will
require Neurosurgery follow-up appointment with Dr. ___ in
1 week. Will continue to hold ASA at discharge.
#Acute hypoxic/hypercarbic respiratory failure:
Hypoxic at OSH and not responsive to BiPAP thus requiring
intubation. Likely multifactorial from pneumonia, HFrEF, COPD,
and encephalopathy of unclear
source. He was extubated on ___ and was weaned to baseline
___ NC currently.
He is on ___ O2 at home due to severe COPD
#Acute on chronic HFrEF (last echo in ___ showed LVEF 30%)
#Severe MR and TR:
HFrEF due to ischemic cardiomyopathy. Last EF on ___
35-40%, CXR w/ pulmonary congestion, CTA w/ b/l effusions,
proBNP elevated at 6053, all suggestive of CHF exacerbation.
Patient also with severe TR and MR making more prone to overload
and very sensitive to afterload. Patient actively diuresed with
40mg IV Lasix in MICU and transitioned to home PO furosemide
40mg.
#Multifocal serratia bacterial pneumonia:
Patient presumed to have pneumonia while in MICU given hypoxic
resp failure, left retrocardiac opacity and fevers. Sputum
cultures grew sparse growth of Serratia. He was on levofloxacin
and vancomcyin from ___ but was transitioned
to aztreonam ___ due to continued fevers. Fevers resolved and
now s/p 7 days of antibiotics (___). WBC normal and
___ CXR without evidence of PNA.
#NSTEMI:
Patient with troponin T elevation to 0.___hanges on
EKG. Patient with CAD s/p CABG. Therefore, likely secondary to
type 2 NSTEMI from increased demand in the setting of fixed
stenosis.
#Severe COPD: O2-dependent. PFTs from ___ showing mixed
restrictive-obstructive picture. COPD likely secondary to
chronic tobacco use ___ year hx). On Daliresp (roflumilast) 500
mcg oral DAILY at home, continued on duonebs and Spiriva while
inpatient. Should continue home inhalers and roflumilast at
discharge
#RUE Erythema: Noted on admission & progressively enlarging. UE
US w/o clot ___. Area of erythema was monitored and did not
advance from level of demarcation. Appears to have resolved on
exam ___.
# Deconditioning
# Falls
Patient presented with fall with head strike and had another
fall in MICU prior to transfer to the floor. ___ saw patient
___ and recommended rehab.
#Thrombocytopenia: Plts 72 upon admission. Monitored w/o
intervention. On discharge, level was 208
#Hyperbilirubinemia: Tbili 1.7. RUQUS normal. Other LFTS
unremarkable. Patient was monitored w/o intervention.
===================
Medication Changes
===================
- Stopped ASA 325mg daily in setting of acute SDH
- Stopped lamotrigine
====================
Transitional Issues
====================
[ ] Patient will require Neurosurgery follow-up appointment with
Dr. ___ in 1 week
[ ] Holding ASA at discharge. Would follow-up neurosurgery
recommendations regarding restarting ASA as is an important
medication given extensive CAD history. Would restart on
low-dose 81mg as opposed to 325mg dose
[ ] Would follow-up a CBC and LFTs at next PCP appointment to
evaluate thrombocytopenia and hyperbilirubinemia. Thought to be
secondary to acute illness during this admission.
[ ] Would consider stress test as outpatient given type II
NSTEMI with troponin elevated to peak of 0.13 on admission.
Patient also with persistent anterolateral ST depressions on ECG
that are likely chronic. Has extensive CAD history with prior
CABG.
#CODE: Full
#CONTACT: HCP ___ (sister) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. TraZODone 100-200 mg PO QHS:PRN Insomnia
3. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Daliresp (roflumilast) 500 mcg oral DAILY
3. Dulera (mometasone-formoterol) 100-5 mcg/actuation
inhalation DAILY
4. Finasteride 5 mg PO DAILY
5. Furosemide 40 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY
7. Lisinopril 2.5 mg PO DAILY
8. Metoprolol Succinate XL 12.5 mg PO DAILY
9. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
10. TraZODone 100-200 mg PO QHS:PRN Insomnia
11. HELD- Aspirin 325 mg PO DAILY This medication was held. Do
not restart Aspirin until discussing at Neurosurgery follow up
12. HELD- LamoTRIgine 25 mg PO DAILY This medication was held.
Do not restart LamoTRIgine until discussed with PCP. Patient
says he is not taking this.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
==================
Subdural Hematoma
Subarachnoid Hemorrhage
Secondary Diagnosis:
====================
Multifocal Serratia Pneumia
NSTEMI
Severe COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was privilege to care for you at the ___
___. You were transferred to our hospital for further
evaluation of a brain bleed that you sustained after falling at
home. You were evaluated by our neurosurgeons who feel that no
operation is indicated at this time. During your stay in the
ICU, you were diagnosed with a pneumonia and treated with
antibiotics.
After you leave, it is very important that you follow up with
the neurosurgeons. Do NOT take your medication aspirin until you
discuss this at your appointment with the neurosurgeons. It is
also very important that you work with the physical therapists
at home in order to reduce your risks of falling.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10286475-DS-24 | 10,286,475 | 21,466,887 | DS | 24 | 2147-01-22 00:00:00 | 2147-01-23 11:34:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Dilaudid / Gleevec
Attending: ___.
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
- EGD ___
- ___ angiography ___
- Colonoscopy ___
- IVC Filter placed ___
History of Present Illness:
___ w/ CML on hydroxurea, CAD with hx of NSTEMI/STEMI, Afib on
xeralto, CHF (EF 40-45% in ___ who presents after he was found
by the patient's personal secretary in down on the ground by the
side of his bed, there was blood around this area. He then went
to use the bathroom and went "hiding" for 2 hours. He was
complaining of some left lower quadrant pain. He states that he
has been feeling fatigued for the last several days and has
noted intermittent episodes of red blood per rectum since
___. He was brought to ED. He denies prior episodes of GI
Bleeding and states that it has been over ___ years since his
last colonoscopy. He denies the use of nsaids. He has not had
any nausea or vomiting.
In the ED, initial vs were: 95.6 71 102/59 22 93% 3L. His NG
lavage was notable to be without blood. He was noted to have red
blood with stool in the rectal vault. Three peripherals with
large bore access were placed. Patient's initial labs were
notable for a Hct of 23.3 with his last being 34.4 from 5 days
previously. Lactate was 12.9. Creatinine was 2.2 from a baseline
of 1.2. Troponin was 0.22. Potassium 5.9, bicarb 9, BNP>19000.
Patient was given 1L IVF, 2U PRBCs, started on pantoprazole.
Lactate was 11.6 on recheck after 1L, and 1U PRBCs with K on
recheck being 5.3. UA was unremarkable. Initially there was
concern for possible ischemia of the bowel, but CT Abdomen was
negative for evidence of ischemia. CT Head was negative for
intracranial abnormalities. Ordered for FFP in ED but did not
receive.
On the floor, the patient states his abdominal pain is much
improved. He does not feel dizzy but still feels fatigued. He
has ace bandages wrapped around his bilateral extremities which
he is adamant that he does not want removed. Patient denies
fevers/chills, no dysuria, no cough. The platelet level was
discussed with hematology who stated that this was not an
emergent issue and related to his CML.
Brief Oncologic History:
The patient was initially treated with a tyrosine kinase
inhibitor, imatinib, but apparently had developed a rash. He was
then started on Sprycel, but developed some pleural effusions
and some edema, which is a commonly known side effect. He did
not want to take the Sprycel anymore and therefore was offered
Tasigna, but he did not want to take that medication because of
the potential side effects and also told me that he thought it
was too expensive. He therefore was started on hydroxyurea and
he has had a good response from the standpoint of his white
count. However, he understands that hydroxyurea was not going
to get him into a remission, which one of the tyrosine kinase
had the potential to do.
Past Medical History:
Hyperlipidemia
Hypertension
NSTEMI in ___ - placement of bare metal stent of proximal and
mid left anterior descending, BMS also of OM1
STEMI in ___ - mid RCA stent placed
-Chronic myelogenous leukemia
-chronic venous stasis since approximately ___ with ulcers
-right eye blindness status post traumatic injury
Past Surgical History:
-Cardiac cath ___: stenting of ___, mid LAD
-Cardiac cath ___: stenting of mid RCA and pacemaker placement
Social History:
___
Family History:
No history of cancers including leukemia/lymphoma. No CAD in
the family. Father died at age ___ from choking on food.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.6 77 120/93 18 96%RA
General: Alert, oriented to place and person, to year but not
month or date
HEENT: Sclera anicteric, Dry MM, oropharynx clear, R eye with
chronic injury and prosthesis,
Neck: supple, JVP not elevated, no LAD
Lungs: +bilateral decreased breath sounds bilaterally, no
wheezes, rales, ronchi
CV: Irregularly irregular, , normal S1 + S2, ___ SEM heard at
LUSB
Abdomen: soft, +splenomegaly, non-tender, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: warm, ace bandages wrapped
DISCHARGE PHYSICAL EXAM:
VS- 98.1 ___ 18 96/RA Weight: 176 pounds (Dry weight per
patient is ___ pounds)
General- Alert, oriented, lying flat in bed with one pillow
comfortably in no distress
HEENT- MMM, oropharynx clear, slightly pale conjunctiva
Lungs- Coarse breath sounds laterally, anterior clear (unable to
listen posteriorly this am)
CV- irregularly irregular and rhythm, II/VI systolic murmur
heard best in upper sternal borders
Abdomen- soft, distended, non-tender, bowel sounds present, no
rebound tenderness or guarding
Ext- warm, ___, tight and weeping edema (L>R) to the knees, no
pain
Pertinent Results:
ADMISSION LABS:
====================
___ 01:20PM BLOOD WBC-7.9 RBC-2.22*# Hgb-6.0*# Hct-23.3*#
MCV-105* MCH-27.3 MCHC-25.9* RDW-20.4* Plt ___
___ 01:20PM BLOOD Neuts-76.1* Lymphs-11.4* Monos-10.8
Eos-0.3 Baso-1.4
___ 01:20PM BLOOD ___ PTT-29.8 ___
___ 05:00AM BLOOD Fact V-38* FacVIII-___*
___ 01:20PM BLOOD Glucose-83 UreaN-91* Creat-2.2* Na-139
K-5.9* Cl-101 HCO3-9* AnGap-35*
___ 01:20PM BLOOD ALT-85* AST-130* CK(CPK)-942* AlkPhos-52
TotBili-0.6
___ 01:20PM BLOOD CK-MB-45* MB Indx-4.8 ___
___ 01:20PM BLOOD Albumin-3.9 Calcium-9.6 Phos-8.4*#
Mg-3.5* UricAcd-8.1*
___ 11:56PM BLOOD calTIBC-346 ___ Ferritn-24* TRF-266
___ 08:35PM BLOOD ___ pO2-15* pCO2-38 pH-7.38
calTCO2-23 Base XS--3
___ 01:31PM BLOOD Lactate-12.9* K-5.3*
DISCHARGE LABS:
====================
___ 07:05AM BLOOD WBC-4.3 RBC-2.55* Hgb-7.9* Hct-24.7*
MCV-97 MCH-31.0 MCHC-32.0 RDW-18.6* Plt ___
___ 07:05AM BLOOD Glucose-102* UreaN-13 Creat-0.9 Na-137
K-4.2 Cl-107 HCO3-25 AnGap-9
___ 07:40AM BLOOD ALT-51* AST-21 LD(LDH)-318* AlkPhos-38*
TotBili-0.7
___ 07:05AM BLOOD Calcium-7.4* Phos-2.5* Mg-2.0
IMAGING:
====================
Chest Xray ___:
IMPRESSION: Small right pleural effusion. No convincing
evidence of pneumonia.
CT Abdomen ___:
IMPRESSION:
1. Unchanged calcified aneurysm of the right coronary artery.
2. Severe atherosclerotic disease with aneurysm of the
infrarenal abdominal aorta measuring up to 3 cm, unchanged.
3. Scattered colonic diverticula. Otherwise, unremarkable
appearance of the bowel makes mesenteric ischemia less likely.
The patient was uncomfortable with continuing contrast
administration given the elevated creatinine and the
contrast-enhanced portion was not performed.
4. Moderate right, small left bilateral pleural effusions.
EGD ___
Esophagus: There was some sloughed mucosa seen in the distal
thrid of the esophagus without active bleeding. There was a
prominent vessel crossing the esophagis just below the UES that
was not bleeding and did not have stigmata of bleeding.
Stomach:
Mucosa: The pyloric channel was edematous and mildly
erythematous with redundant folds. The area was closely examined
and there was no evidence for ulceration or mass.
Duodenum:
Mucosa: Normal mucosa was noted in the whole duodenum.
Impression: Abnormal mucosa in the esophagus
Abnormal mucosa in the stomach
Normal mucosa in the whole duodenum. There was no evidence of
bleeding and no cuase for prior bleeding seen on this
examination
Otherwise normal EGD to third part of the duodenum
CTA ABD & PELVIS ___
FINDINGS:
LUNG BASES: Interval increase of bilateral non-hemorrhagic
pleural effusions, especially to the left, now moderate,
previously small (series 3a: image 14), with adjacent
atelectasis of the posterobasal segment of the lower lobes.
Right lower lobe calcified nodules (series 3a: images 15, 22,
28) are granulomas, unchanged since ___. Moderate
cardiomegaly and known right coronary artery aneurysm are
unchanged since ___.
Filling defect in segmental vessels for the right lower lobe is
suspicious for pulmonary embolism. Dedicated CTA for PE is
recommended.
ABDOMEN: The liver is unremarkable without evidence of focal
hepatic lesions. There are stable scattered calcifications in
the spleen compatible with calcified granulomas. Fatty atrophic
changes of the pancreas are normal aging findings. Right
adrenal ground is normal. The thickening of the left adrenal
gland is unchanged since ___. Mild kidney bilateral
atrophy is unchanged with stable large 5.4 x 6.1 cm right kidney
cyst. There is no mesenteric or retroperitoneal
lymphadenopathy. There has been interval increase of large
bowel wall distention, mainly for air distention with increased
amount of stool especially in the ascending colon and cecum.
In the delayed phase, a small amount of contrast is in the
distal portion of the transverse colon (series 3b: image 239)
and proximal descending colon (3b:227). This is suspicious for
active gastrointestinal bleeding (3b:237) from colon
diverticula. There is no free abdominal air.
New small amount of ascites is mainly perihepatic, in the right
paracolic
gutter, and in the left inferior quadrant alongside the left
aspect of the bladder. Diffuse anasarca is mild. Bladder is
well distended and
unremarkable. Significant atherosclerotic disease involving
abdominal aorta and visceral branches is unchanged since ___, with stable appearance of the infrarenal abdominal
aorta aneurysm which has maximal diameter of 3.1 cm. Mild
ectasia of the right common iliac artery is unchanged since
___ (series 3b: image 293). Stable enlargement of
the prostate with maximal diameter of 5.4 cm.
BONES: There are no bone lesions suspicious for malignancy or
infection. Multilevel degenerative changes of the spine with
disc height los at multiple levels and disc vacuum phenomenon is
unchanged since ___.
IMPRESSION:
1. Areas of contrast accumulation in the distal transverse and
proximal
descending colon in the delayed venous phase consistent with
active
gastrointestinal bleeding; the source is apparently a
diverticulum at the
splenic flexure.
2. Filling defect in the segmental vessels for the right lower
lobe are
suspicious for pulmonary embolism. Dedicated CTA is recommended.
3. Interval increase of bilateral pleural effusions, especially
to the left, since ___, with adjacent opacification
probably due to atelectasis of the left lower lobe.
___ Angiogram ___
FINDINGS: No evidence of active extravasation from the superior
mesenteric artery.
2 branches of the left collic artery (ascending and descending)
were
cannulated with excellent visualization of the splenic flexure.
There was no of active extravasation seen in this region.
Given small vessel caliber and vessel fragility a short
contained mural
dissection was noted following contrast injection of a
peripheral mesenetric
vessel, of unlikely clinical significance given extensive
colateral flow.
IMPRESSION:
No evidence of active extravasation.
Colonoscopy ___
Multiple diverticula with large openings were seen in the whole
colon. Diverticulosis appeared to be of moderate severity.
Other Large amout of old blood and clots mixed with some stool
was noted in the whole colon. This was copiously irrigated and
the patient was re-positioned to improve mucosal visualization.
Despite these measures, small and medium size pathology may have
been missed.
Impression: Large amout of old blood and clots mixed with some
stool was noted in the whole colon.
Diverticulosis of the whole colon
Otherwise normal colonoscopy to cecum
LENIS ___
IMPRESSION:
1. Partially occlusive thrombus involving the left deep femoral
vein.
2. Calf veins are not visualized bilaterally.
CTA Chest ___
*Multiple filling defects in the segmental branches of the
pulmonary arteries
in the right upper lobe, right middle lobe and left upper lobe.
Evaluation of
the lower lobe pulmonary artery branches is limited given the
moderate to
large size pleural effusions.
*Marked cardiomegaly, with reflux of contrast into the IVC and
hepatic veins
suggestive of increased right heart pressure and tricuspid
regurgitation.
*Markedly dilated main pulmonary artery measuring up to 4.5 cm
in keeping with
pulmonary arterial hypertension.
*Known thrombosis of the right coronary artery aneurysm
measuring up to 3.4
cm. This demonstrates interval increase in size from ___. If
clinically indicated, further evaluation with cardiac CTA could
be considered.
*Calcified granulomas of the lung and spleen.
*Perihepatic ascites. Body wall anasarca.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION
___ with hx of CAD, CHF, Afib and xarelto, CML on hydroxyurea
who presents with BRBPR
ACTIVE ISSUES
# GI Bleed, anemia The patient noted both having bright red
blood per rectum and melena making this initially unclear if it
was upper or lower GI bleed. CT of abdomen was not concerning
for ischemic colitis. Did receive 2U of PRBCs in ED with
initially inappropriate response. However, after that received
2U of PRBCs in MICU with appropriate response and remained
stable. Had an EGD done that did not show any bleeding or
stigmata bleeding. On the first night did received a dose of
ddavp with concern for poor platelet function. NG tube did not
lavage blood and his xarelto was held throughout his MICU stay.
He was maintained on protonix BID and after negative EGD was
transferred to the floor with plan for colonoscopy to further
evaluate bleed. On the floor while being prepped he put out
maroon stool and dropped his pressure to sbp of ___ and stated
he was lightheaded. He received 1L of fluid and 1U PRBCs and on
arrival to the MICU he was normotensive and at his baseline. His
hematocrits were trended and did not have any decrease. This
episode was thought to be old blood that was evacuated with the
prep and volume shifts secondary to the prep and not a rebleed.
He then had acute bleed on ___, losing about 2 units. He
underwent CTA that showed active bleeding from the splenic
flexure, but ___ did not see further evidence of extravasation.
He then underwent colonoscopy on ___ which showed moderate
diverticulosis but did not see active bleeding but because of
the old blood, clots and stool given he did not prep. After
prepping, he underwent ___ that showed severe diverticulosis
but not active bleeding. He subsequently had no further episodes
of large volume bleeding and remained hemodynamically stable.
Discharge H/H: 7.___.7
# PE and DVT: On CTA Abd Pelvis for GI bleed (please see above),
cuts of lower lung fields showed a filling defect in segmental
vessels for the right lower lobe. He then underwent LENIs that
showed a filling defect in segmental vessels for the right lower
lobe. Dedicated CTA Chest showed filling defects in segmental
vessels for the right lower lobe. After family discussion, an
IVC filter was placed with plans for starting coumadin as an
outpatient at the discretion of his PCP.
___ on CKD He initially presented with elevated creatinine.
This was thought likely to be prerenal and FeNa was consistent
with prerenal etiology. He was given fluids and blood slowly and
his creatinine returned. to baseline. He maintained adequate
urine output throughout his stay. His Lasix was initially held
given his hypovolemia and ___ but restarted prior to discharge.
Discharge Cr:0.9
# Congestive Heart Failure, systolic: Last EF 40% in ___. On
admission, he appeared very volume down despite elevated BNP.
His home lasix (120mg qam, 80mg qpm) was held initially and he
received IVF and blood transfusions as needed. He had worsening
bilateral pleural effusions, ascites and bilateral lower
extremity edema prior to discharge. He was diuresed with IV
furosemide. His breathing remained comfortable and he did not
require supplemental O2. He will be discharged on lasix 120mg IV
daily and will need this adjusted to improve his fluid status.
#Thrombocytosis: Patient had elevated platelets to 1601. This
was likely reactive in the setting of GIB on top of CML. It was
thought that his platelets were not functional given his disease
and this level. ___ was consulted and initially recommended
holding Hydrea. He was given DDAVP as above x1 to try to improve
platelet function. He was restarted on his home dose of hydrea
the next day and his platelets downtrended.
#Metabolic abnormalities: When he presented he was
hyperuricemia, hyperphosphatemia. LDH up, with a normal calcium.
There was concern for possible tumor lysis and he was given
fluids although slowly given his heart failure. He was continued
throughout on his allopurinol and his metabolic derangements
improved and he symptomatically appeared well.
#Transaminitis: He initially had elevated LFTS that trended up
during his first few days of admission. He was found down but
there was no objective evidence that he was profoundly
hypovolemic. It was therefore thought possible but unlikely to
be shock liver. Further workup showed normal hepatitis viral
serologies and an unremarkable RUQ ultrasound. His simvastatin
was held. His LFTs trended down and he remained asymptomatic.
#Atrial fibrillation: CHADS score high at 3. On xarelto for
anticoagulation was on metoprolol at home. Both these were held
initially upon concern for patient's GI bleed. He received
occasional metop 12.5mg po for tachycardia which was limited by
low blood pressures.
CHRONIC ISSUES:
#CML: He had been stable on hydroxyurea for several years this
was initially held on the first day and then continued.
#Hyperlipidemia: His simvastatin was held as above due to
transaminitis.
#Hypertension: His metoprolol was initially held as above due to
concern for hypovolemia. It was intermittently restarted to help
control his rates but was stopped again with acute bleeding. He
will need ongoing monitoring and his metoprolol could be
restarted if blood pressure permits.
# Coronary artery disease: The patient reported having been told
that he should not take aspirin many years ago. Review of
records showed that he had been on full strength asa but had
been told to stop after an episode of likely BRBPR. Given his
CAD, he was restarted on asa 81mg.
TRANSITIONAL ISSUES:
- Anticoagulation: Rivaroxaban stopped given GI bleed. On asa
81mg. IVC Filter placed ___ for DVT. Plan for anticoagulation
with coumadin will be at discretion of his outpatient providers
(as will determining when/if IVC filter should be removed)
- CML: The patient was continued on hydroxyurea
- CTA Chest showed that his known RCA thrombosed aneurysm had
increased in size to 3.4cm. For further evaluation, cardiac CTA
could be considered
- He will need continued diuresis based on fluid status. Will be
discharged on lasix 120mg IV daily and should have lytes checked
BID. Please adjust lasix dose as needed.
- He was on metoprolol succ 25mg that was held given
hypotension. He should have his beta blocker restarted/titrated
based on heart rates and blood pressure
- The patient had mild transaminitis the improved prior to
discharge. Statin was held initially and not restarted.
- Code status: DNR/DNI, OK to be reversed temporarily for
invasive procedures
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 120 mg PO QAM
2. Furosemide 80 mg PO QPM
3. Rivaroxaban 15 mg PO DAILY
4. Hydroxyurea 1000 mg PO DAILY
5. Simvastatin 80 mg PO DAILY
6. Allopurinol ___ mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
10. Docusate Sodium (Liquid) 100 mg PO BID
Discharge Medications:
1. Acetaminophen ___ mg PO PRN pain
2. Allopurinol ___ mg PO DAILY
3. Hydroxyurea 1000 mg PO DAILY
4. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
5. Aspirin 81 mg PO DAILY
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Furosemide 120 mg IV DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Lower gastrointestinal bleeding
Deep vein thrombosis
Pulmonary embolism
Secondary diagnoses:
Chronic myelogenous leukemia
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure participating in your care here at ___.
You were admitted on ___ after having large bleeding from
your gut. You blood counts were low and you required blood
transfusions during your stay. You had multiple tests including
endoscopies, colonoscopies and even procedures by Interventional
Radiology to stop your bleeding. Fortunately, the bleeding
stopped and your counts remained stable. Most likely the
bleeding was from little outpouching of your gut lining called
'diverticuli' as the colonoscopy showed you have many of these
throughout your colon.
Also during your admission, you were found to have a blood clot
in your leg and clots in your lungs. You had a special filter
placed in one of your large veins to keep the clot in your leg
from showering more blood clots to your lungs. You will have
close follow-up with your primary care physician and may start a
blood thinner in the future.
You also had fluid build up in your legs. You were given lasix
to help reduce the fluid in your legs.
You are being discharged to a rehabilitation facility where your
blood counts and fluid status can be monitored. You will also
get physical therapy to get stronger.
Thank you for the opportunity to participate in your care.
We wish you the very best,
- Your ___ Medicine Team -
Followup Instructions:
___
|
10286475-DS-26 | 10,286,475 | 29,102,640 | DS | 26 | 2148-04-04 00:00:00 | 2148-04-04 19:27:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Dilaudid / Gleevec
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Thoracentesis and Chest tube placement
History of Present Illness:
Mr. ___ is an ___ year old male, with prior history of CAD
s/p stenting, HTN, HLD, CML on hydroxyurea (had tried TKI in
past but could not tolerate), who prseents with altered mental
status. He was recently admitted to ___ from ___, for
altered mental status, and thought to be secondary from a
medication side effect as at the time he was taking tramadol,
oxycodone, and ambien. Per discharge summary, patient initially
was admitted for concerns and hallucinations, and at that time
underwent workup notable for pulmonary congestion, hyperkalemia
(6.2), and these medications were discontinued on discharge. At
that time, his medications were managed by ___, at home, who
puts it in pillboxes, and was noted that he had the behavior of
sometimes taking medication innappropriately.
Per ED report, shortly after returning home his family noted
that he was intermittently confused, speaking in ___ (grew up
there, but does not speak ___ at home), and was disoriented.
Per report, he was complaining of abdominal discomfort
intermittently, and had some diarrhea with brown stool. Further,
patient often sneaks into bathroom and hides stool, and
previously had a large volume GI Bleed. Patient has also misused
OTC immodium in the past. EMS was called on ___ after increased
confusion. Per pt's son, at baseline they are able to converse
fairly normally.
In the ED, ER triage VS on ___: Pain 0; 97.6 100 124/83 18
80% RA. Per ED, patient was not cooperative, AOx2, guiac +,
hematocrit at baseline. He underwent CT imaging which showed
anasarca, pleural effusions, no other acute process. CXR with
RLL infiltrate ___, in addition increase pulmonary edema.
Patient was given IV 80 furosemide at 5AM on ___, and was given
olanzapine several times in the ED, as intermittently shouting,
agitated. Patient also received IV metoprolol, as HR 105-120s.
Patient's labs concerning for K 8 hemolyzed, and then 3.6 with
unchanged EKG. Patient was given IV Zosyn and Cipro for
pulmonary source infection, and changed abx to vanc+cefepime for
pulmonary source given HCAP and MRSA+ in past. ___
continues to clime and stool studies with C. diff negative.
VS upon transfer: 98.8 90 100/67 23 100% RA
On the floor, patient continues to be confused. Patient reports
no acute complaints, reports that he is thirsty. Patient was
talking to the wall prior to interview, and continued to yell at
interviewer and would like to leave the hospital. Patient is
talking in non-sensesical language.
ROS: Per HPI. Unable to assess further given poor mental status.
Past Medical History:
- Hyperlipidemia
- Hypertension
- Chronic myelogenous leukemia, followed at ___, on
hydroxyurea
- Chronic venous stasis since approximately ___ with ulcers
- Right eye blindness status post traumatic injury
- NSTEMI in ___ - placement of bare metal stent of proximal and
mid left anterior descending, BMS also of OM1
- STEMI in ___ - mid RCA stent placed
- Afib on coumadin
Past Surgical History:
-Cardiac cath ___: stenting of ___, mid LAD
-Cardiac cath ___: stenting of mid RCA and pacemaker placement
Social History:
___
Family History:
No history of cancers including leukemia/lymphoma. No CAD in
the family. Father died at age ___ from choking on food.
Physical Exam:
>> Admission Physical Exam:
Vitals: T 98.6 117/68 108, irregular, 93 RA
General: Patient is talking to the wall, yelling. Patient is
oriented to person, not place or time, no insight. Not oriented
to time, or location.
HEENT: No cervical lymphadenopathy. Mucous membranes dry. Unable
to fully participate in exam. Right eye enucleation. Left eye
with reaction.
CV: Irregular, S1, S2. Distant. No extra sounds heard.
Lungs: Right soft crackles on posterior, left clear to
auscutlation bilaterally.
Abdomen: Soft, mildly distended. +BS. No abdominal tenderness.
GU: Uncircumcised no foley.
Ext:
Lower Extremities: Mottling of skin, with gross skin breakdown.
Various skin lesions with covering, with ulceration type
apperance in the lower extremities.
Right lower extremity with increased blistering. Warm
extremities.
Neuro: Moving extremities grossly in upper / lower extremities.
CN II-XII grossly intact.
.
>> Discharge Physical Exam:
Vitals: T 98.1 92-104 / 60 18 78-109 99 RA
General: Thin, elderly male. Oriented x 3. Speech is good,
content good.
HEENT: MMM. Right eye enucleated. temporal wasting.
CV: Irregular, S1, S2, distant. Systolic III murmur heard
throughout, loudest at LUSB.
Lungs:
Site of previous chest tube with dressing on right side, no
erythema. No tenderness to palpation.
Lungs with trace rhonchi on right side. No wheezing.
Abd: Soft, NT, Distended. No tenderness to palpation. No
rebound, +BS.
Lower Extremities:
Very thin, emaciated legs. Boots, dressed. Warm extremities.
Skin is thickened, with multiple ulcerations with dressing on
top, C/D/I.
Neuro: A&O x3. Face symmetric. Tongue midline. SCM/trap ___.
Hand grip intact bilaterally. Strength 4+/5 in upper
extremities.
Has lower extremtiy edema 2+ posterior calf on L > R, and
sacral/back edema .
Pertinent Results:
>> Admission Labs:
___ 08:10PM BLOOD WBC-16.7* RBC-3.61* Hgb-12.5* Hct-41.7
MCV-115* MCH-34.6* MCHC-30.0* RDW-18.1* Plt ___
___ 08:10PM BLOOD Neuts-74* Bands-4 Lymphs-8* Monos-3 Eos-2
Baso-1 ___ Metas-3* Myelos-4* Promyel-1* NRBC-1*
___ 08:10PM BLOOD Plt Smr-VERY HIGH Plt ___
___ 08:10PM BLOOD Glucose-104* UreaN-27* Creat-1.1 Na-136
K-5.0 Cl-97 HCO3-25 AnGap-19
___ 08:10PM BLOOD ALT-17 AST-46* AlkPhos-99 TotBili-0.8
___ 08:10PM BLOOD cTropnT-0.02* ___
___ 10:26AM BLOOD cTropnT-0.02*
___ 12:35AM BLOOD ___ pO2-41* pCO2-45 pH-7.43
calTCO2-31* Base XS-4 Comment-GREEN TOP
___ 08:36PM BLOOD Lactate-2.7*
___ 10:31AM BLOOD Lactate-2.9* K-8.0*
___ 12:59PM BLOOD K-3.6
.
>> Pertinent Reports:
___ CT head:
Prominence of the ventricles and sulci is compatible with global
volume loss. Hypodensities in the right cerebellar hemisphere
are compatible with prior infarct. There is no acute
intra-axial or extra-axial hemorrhage, mass, midline shift, or
acute vascular territorial infarct. Right sided pthysis bulbi is
reidentified. There is no fracture. The paranasal sinuses,
mastoid air cells and middle ear cavities are clear. Extensive
vascular calcifications are present.
IMPRESSION: No acute intracranial process.
___ CT abd/pelvis:
IMPRESSION:
1. Large bilateral pleural effusions, trace intraperitoneal free
fluid, extensive anasarca, and congestive appearance of the
liver raise concern for congestive heart failure.
2. Interval increase of spleen size compared with ___ without
evidence of lymphoproliferative disorder may be secondary to
chronic congestive heart failure with retrograde increase in
portal venous pressure.
3. No evidence of free air, fluid collection, retroperitoneal
hematoma, or solid organ injury within the abdomen.
4. Extensive vasculopathy, with severe stenosis of the origin of
the celiac trunk and the right renal artery are unchanged from
___. Recanalized 3 cm right coronary artery aneurysm is also
unchanged from ___. Ectasia of the bilateral common iliac
arteries as well as aneurysm of the right internal iliac artery
measuring 1.2 cm are also unchanged from ___.
5. Stable fat containing right sided inguinal hernia. Stable
prostatic enlargement.
___ CXR:
FINDINGS:
AP upright and lateral view of the chest were provided.
Cardiomegaly is noted with partially layering bilateral pleural
effusions. Pulmonary edema is noted. No pneumothorax. Bony
structures intact.
IMPRESSION: Cardiomegaly with bilateral pleural effusions and
pulmonary edema.
___: TTE: The left atrium is moderately dilated. The right
atrium is markedly dilated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is severe regional left ventricular systolic dysfunction with
thinning and akinesis of the infero-septum, inferior and
infero-lateral segments. The remaining segmetns appear
hypokinetic. The apex moves best. No masses or thrombi are seen
in the left ventricle. There is no ventricular septal defect.
The right ventricular cavity is moderately dilated with severe
global free wall hypokinesis. The aortic root is mildly dilated
at the sinus level. The ascending aorta is mildly dilated. The
aortic arch is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild to
moderate (___) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Severe (4+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the report of the prior study (images unavailable
for review) of ___, LVEF and RVEF have decreased.
___ Imaging CHEST (PORTABLE AP): In comparison with the
study of ___, there are lower lung volumes. Continued
enlargement of the cardiac silhouette, probably with mild
elevation of pulmonary venous pressure. Hazy opacification in
the right hemithorax is again seen, consistent with layering
pleural effusion. An area of more confluent opacification is
suggested right above the minor fissure, raising
the possibility of developing consolidation in the appropriate
clinical
setting. Poor definition of the left hemidiaphragm again is
consistent with pleural fluid and volume loss in the left lower
lobe.
.
CT CHEST: No good evidence for pneumonia or empyema, although
diagnosis of the nature of pleural effusions, moderate and
stable on the left, small and decreased on the right would
require thoracentesis. Relatively mild pulmonary edema and basal
atelectasis. Chronic severe pulmonary hypertension, probably due
to a history of chronic pulmonary emboli. No large central
pulmonary artery filling defect today. Stable calcified
pseudoaneurysm, right coronary artery and fusiform aneurysm
ascending thoracic aorta. New vocal cord asymmetry, could be a
right laryngeal palsy, less likely followup.
.
>> MICROBIOLOGY:
__________________________________________________________
___ 1:30 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___. ___ (___) AT
3:08 ___
___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
__________________________________________________________
___ 1:33 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
LEFT PLEURAL EFFUSION.
Fluid Culture in Bottles (Preliminary): NO GROWTH.
__________________________________________________________
___ 1:33 pm PLEURAL FLUID LEFT PLEURAL EFFUSION.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 1:32 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
Fluid Culture in Bottles (Preliminary): NO GROWTH.
__________________________________________________________
___ 1:32 pm PLEURAL FLUID
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 6:42 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 6:18 am BLOOD CULTURE X 1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 4:40 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 11:30 pm STOOL CONSISTENCY: SOFT
**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.
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.
__________________________________________________________
___ 8:10 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
.
>> Discharge Labs:
___ 07:16AM BLOOD WBC-39.0* RBC-3.58* Hgb-12.4* Hct-40.5
MCV-113* MCH-34.7* MCHC-30.7* RDW-18.3* Plt ___
___ 07:16AM BLOOD Neuts-70 Bands-0 Lymphs-11* Monos-6 Eos-0
Baso-3* ___ Metas-1* Myelos-1* Promyel-1* Blasts-7* NRBC-1*
___ 07:16AM BLOOD ___ PTT-38.8* ___
___ 07:16AM BLOOD Glucose-84 UreaN-17 Creat-0.7 Na-137
K-5.0 Cl-103 HCO3-26 AnGap-13
___ 07:16AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.2 UricAcd-4.2
___ 07:16AM BLOOD ___ 07:16AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.2 UricAcd-4.2
Brief Hospital Course:
This is an ___ year old male past medical history of CML on
hydroxyurea, CAD, admitted ___ with acute metabolic
encephalopathy, found to have HCAP pneumonia, acute systolic
CHF, course complicated by Cdiff colitis, treated with
antibiotics, diuresed, and discharged to rehab
>> ACTIVE ISSUES:
# Sepsis / Health Care Associated Acute Bacterial Pneumonia -
Patient initially signs of sepsis with unclear source, including
elevated lactate, tachycardic AF. Sources at that time included
lower extremity ulcerations, although did not appear to be
grossly infected. Other source included pulomonary given right
lower infiltrate. Patient required IV fluids, broad spectrum
antibiotics. Given recent hospitalization, there was concern
for resistant gram negative organisms. He completed 8 day
course of cefepime
# Pleural Effusions / Acute Systolic CHF - had large pleural
effusions on admission; given concurrent pneumonia, concern for
infectious etiology / parapneumonic effusion; bilateral
thoracenteses performed, showed transudative etiology. TTE
showed signficant LVEF depression from 40% to ___, new
hypokinetic/akinetic segments, and severe MR 4+ with moderate TR
2+. Patient was then restarted on an lasix, lisinopril 2.5 mg
daily. Patient's metoprolol to be restarted as an outpatient
setting upon visit with cardiology.
# Leukocytosis / Cdiff Colitis - course was complicated by
significant leukocytosis > 30k, initially without focal
symptoms; differential of WBC contained blasts (<10%) and other
immature cells; initial concern was for transformation of his
CML; hematology/oncology consulted but believed this was a
stress reaction; several days subsequent to this, patient
developed diarrhea and was found to have cdiff colitis; he was
started on PO vancomycin
# C. diff Colitis: As detailed above, patient started to have
increased diarrhea, and was found to have C. diff colitis.
Patient was started on PO Vancomycin given severity (WBC
elevated), and had improvement in his stool frequency. Patient
to continue this x 14 days, end date of ___, and be
monitored as an outpatient.
# Toxic Metabolic Encephalopathy: Upon admission, patient was
found to have gross confusion, and this signficantly worsened to
the point where patient was intermittently speaking in ___.
Patient was treated as above for sepsis, and had improvement in
his orientation and conversation. Patient was placed on delirium
precatuions, and family continued to visit. Patient at high risk
for delirium given CT head findings showing global volume loss,
however no other focal findings. With treatment of his PNA and
C. diff colitis, patient had improvement in his symptoms back to
mental status baseline. He did not have any further
waxing/waning delirium, no focal neurologic deficits.
# NSVT: Patient has a prior history of NSVT, and on telemetry
had varying NSVT ranging from ___ beats at a time,
asymptomatic. Per records, patient had prior discussion and
refusal of ICD. Patient with high risk of NSVT given now
worsened structural heart disease (new EF ___. With
cardiology consulted, recommended starting metoprolol 6.25 mg
TID SBP > 110, however given softer BPs, it was agreed to defer
to outpatient setting.
# CT Findings / Aspiration Risk / Dysphagia: Patient initially
on modified diet due to concern for aspiration; once mental
status improved, he was re-evaluated with ability to be upgraded
to regular diet. CT chest incidentally showed "New vocal cord
asymmetry, could be a right laryngeal palsy, less likely
followup." This was clarified with reading radiologist who did
not believe radiologic follow-up was necessary; on discussing
with speech language pathology, they recommended continue SLP
and repeat swallow eval as outpatient
# Atrial Fibrillation: CHADS=3 (age, CHF, HTN), previously on
metoprolol, not currently on rate/rhythm control. Patient
currently anticoagulated with warfarin, which was continued
without episodes of bleeding. Discharge INR of 2.2.
# Lower Extremity Ulcerations: Patient's wounds were dressed per
previous wound care records, and did not appear overtly
infected. Per family, wounds improved compared to previous.
# Gout: Continued on home allopurinol without gout flare.
.
>> TRANSITIONAL ISSUES:
# C. diff: Patient to complete PO vancomycin on ___
# CML: Patient has standing labs at Dr. ___ office on
___ weekly. Please continue to f/u with diff for blast %
to compare for improvement in leukocytosis and peripheral
blasts.
# CHF: Patient's discharge weight of 70.2 kg. Diuretic
management per outpatient as BPs have decreased (previous 120 AM
/ 80 ___ lasix)
# NSVT: Please start metoprolol as outpatient given h/o NSVT and
worsened structural heart disease. Monitor BPs and start when
appropriate.
# Pending Labs: Pleural fluid cultures (transudative on tap)
# Code Status: Full
# Contact Information: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q8H:PRN pain
2. allopurinol ___ oral DAILY
3. Furosemide 120 mg PO QAM
4. Furosemide 80 mg PO QPM
5. Hydroxyurea 1500 mg PO DAILY
6. Lidocaine 5% Ointment 1 Appl TP BID:PRN pain
7. Warfarin 3 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN pain
2. allopurinol ___ oral DAILY
3. Furosemide 80 mg PO EVERY OTHER DAY
4. Hydroxyurea 1500 mg PO DAILY
5. Warfarin 3 mg PO DAILY
6. Lisinopril 2.5 mg PO DAILY
7. Vancomycin Oral Liquid ___ mg PO Q6H
Please take this medication until ___. Lidocaine 5% Ointment 1 Appl TP BID:PRN pain
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: 1. Severe C. difficile Colitis 2. Right
lower lobe pneumonia
SECONDARY DIAGNOSES: 1. Chronic Myelogenous Leukemia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were admitted to
the hospital after feeling confused at home. We believe this
confusion stemmed from an infection, and you were treated for a
pneumonia and for an infection that we found in your stool that
was causing you to have diarrhea. With antibiotic treatment,
your confusion improved and you felt better.
While here, we also found that you had a large amount of fluid
buildup in your lungs. You underwent an echocardiogram or an
ultrasound of your heart that showed that your heart was not
pumping as effectively as before. You were seen by our
cardiologists, and underwent a procedure called a thoracentesis
to remove this fluid. Please continue to weigh yourself daily
and notify your primary care physician if you increase/decrease
your weight by 3 lbs.
While here, you were also seen by our hematology/oncology team
because of your underlying leukemia. Your immune cells were
quite high, however we believe that this is a sign of your
underlying infection and not your underlying leukemia. Please
follow up with your oncologist and have your blood drawn next
week.
Please continue to take your home medications as prescribed, and
please follow up with your primary care physician and your
specialists upon discharge from the hospital.
Take Care,
Your ___ Team.
Followup Instructions:
___
|
10286521-DS-15 | 10,286,521 | 28,984,130 | DS | 15 | 2135-05-14 00:00:00 | 2135-05-15 19:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Augmentin / phenylephrine
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
___ Placement of Left sided chest tube
___ Removal of Left sided chest tube
History of Present Illness:
This is a ___ with severe COPD/emphysema on 3 L NC at baseline
s/p Spiration endobronchial valve placement LUL x5 on ___
presenting with worsening dyspnea.
Her post procedure course was complicated with emergent chest
tube placement for pneumothorax. She had a 16 day hospital
course
with persistent airleak - air leak resolved and chest tube was
discontinued.
In regards to current presentation, patient states that symptoms
initially began with COPD flare approximately 2 weeks ago for
which she completed a course of increased prednisone and
standing nebulizers. Of note, patient states on ___ had a
outpatient CXR in OSH, showing no pneumonia or pneumothorax. She
felt worse last week despite treatment and called in to Dr. ___
on ___. She continued to have dyspnea with ambulation and had
noted little improvement in cough. Her oxygen requirement had
increased to 5L NC. She was told to remain on increased dose of
prednisone 60mg daily and to start tapering ___ as tolerated.
Patient states she is currently on prednisone 55mg daily as
prescribed by her PCP. She also completed a 5 day course of
levaquin for possibility of bronchitis. After completion of
levaquin, she has restarted her home azithromycin. Patient noted
that by ___ she felt worse in terms of dyspnea. Yesterday
afternoon at 12pm, however, she started having stabbing chest
pain when ambulating up the stairs. Symptoms dissipated but
recurred again at approximately 3pm and radiated across her
chest into her left shoulder and upper back. She had minimal
improvement with nitroglycerin. She contacted IP office who
recommended that she come into ED for evaluation given concern
for recurrent pneumothorax. She went to local ED and was
transferred to BI Ed for definitive management. CXR showed
moderate left pneumothorax without evidence of tension.
In the ED, initial vitals:
03:43 6 98.7 85 118/78 20 98% Nasal Cannula
On exam mildly uncomfortable, on NC O2 with SpO2 97% and RR
___, LS diminished on L.
Today at 06:05, vitals significant for 5 75 140/79 14 99%
Non-Rebreather
Labs were significant for wbc 11 with abs monos 1.1
Imaging showed initial CXR with moderate left pneumothorax
without evidence of tension. IP placed ___ tube in the L
midclavicular line. Repeat CXR showed insertion of a left chest
tube and re-expansion of the left lung with no appreciable
pneumothorax on the left.
Patient was administered: 2mg morphine X 3, 4mg IV Zofran.
Plan was made to admit for 24 hours of suction and re-evaluation
with repeat CXR in AM.
Vitals prior to transfer:
Today 08:54 4 98.4 90 131/67 22 95% Nasal Cannula
On the floor, patient has minimal complaints and reports pain
___ at chest tube insertion site. Otherwise, she does note that
she feels dry and would like to order something to eat.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No nausea or
vomiting. No diarrhea or constipation. No dysuria or hematuria.
No hematochezia, no melena. No numbness or weakness, no focal
deficits. Last BM 2 days ago.
Past Medical History:
COPD/emphysema
GERD
Pneumonia
Adrenal insufficiency - ?steroid induced
Osteoporosis
Social History:
___
Family History:
Father: ___, died of pancreatic CA
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T98.3 BP137/80 HR86 RR16 96%3L NC
GEN: Alert, chronically ill appearing, lying in bed, no acute
distress
HEENT: dry MM, anicteric sclera, no conjunctival pallor
NECK: Supple without LAD
CHEST: anterior left chest with chest tube in place with mild
erythema but no pustulence, mild ttp
PULM: Clear, no wheeze, rales, or rhonchi
COR: RRR, normal S1/S2, no murmurs
ABD: Obese, soft, NT ND, normal BS
EXTREM: Warm, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM
Vitals: T97.4 BP129/73 HR69 RR18 93%3L NC ___ CT25cc
GEN: Alert, chronically ill appearing, sitting up in bed, no
acute distress
HEENT: dry MM, anicteric sclera, no conjunctival pallor
NECK: Supple without LAD
CHEST: anterior left chest with gauze in place over site of
prior chest tube
PULM: Clear, no wheeze, rales, or rhonchi
COR: RRR, normal S1/S2, no murmurs
ABD: Obese, soft, NT ND, normal BS
EXTREM: Warm, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
___ 04:47AM BLOOD WBC-11.0* RBC-4.05 Hgb-12.3 Hct-37.6
MCV-93 MCH-30.4 MCHC-32.7 RDW-15.1 RDWSD-51.5* Plt ___
___ 04:47AM BLOOD Neuts-70 Bands-3 Lymphs-16* Monos-10
Eos-1 Baso-0 ___ Myelos-0 AbsNeut-8.03* AbsLymp-1.76
AbsMono-1.10* AbsEos-0.11 AbsBaso-0.00*
___ 04:47AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
___ 04:47AM BLOOD ___ PTT-19.8* ___
___ 04:47AM BLOOD Glucose-97 UreaN-17 Creat-0.8 Na-139
K-3.8 Cl-102 HCO3-22 AnGap-19
___ 04:47AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.4
DISCHARGE LABS
___ 05:24AM BLOOD WBC-8.7 RBC-3.45* Hgb-10.4* Hct-32.3*
MCV-94 MCH-30.1 MCHC-32.2 RDW-15.0 RDWSD-50.9* Plt ___
___ 05:24AM BLOOD Plt ___
___ 05:24AM BLOOD Glucose-107* UreaN-10 Creat-0.6 Na-137
K-3.5 Cl-101 HCO3-27 AnGap-13
___ 05:24AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.2
PERTINENT IMAGING
___ CXR 4:07AM
FINDINGS:
Left apical lateral pneumothorax measuring up to 3.4 cm in
largest dimension.
No appreciable right pneumothorax is noted. Atelectasis of the
left lung base
with elevation of the left hemidiaphragm. Re-expansion of the
left upper lobe
___ chest radiograph. Bronchial valves project over the
left mid
lung. The heart is normal in size. Mediastinum is not widened.
No evidence
of tension.
IMPRESSION:
1. Moderate left pneumothorax without evidence of tension.
2. Left bronchial valves - if assessment of location is
desired, CT is needed.
___ CXR 7:41AM
1. Insertion of a left chest tube and re-expansion of the left
lung.
2. No appreciable pneumothorax on the left.
3. Clear right lung.
___ CXR
IMPRESSION:
No evidence of pneumothorax. Left pleural catheter is unchanged
in position.
Brief Hospital Course:
___ with severe COPD/emphysema on 3 L NC at baseline s/p
Spiration endobronchial valve placement LUL x5 on ___
presenting with worsening dyspnea found to have left sided
pneumothorax with resolution s/p chest tube placement ___.
ACTIVE ISSUES
# Left sided pneumothorax in the setting of recent copd
exacerbation: Pneumothorax resolved on repeat cxr after chest
tube was placed. Patient passed clamping trial on day of
discharge and was without any shortness of breath. She had
minimal chest pain at prior site of chest tube for which she was
given 5 tab of oxycodone at discharge. She was discharge home
with follow-up with Dr. ___ in 6 weeks (with repeat CXR prior
to that).
# Severe COPD: enrolled into the EMPROVE trial s/p LUL 5 EBV
placement on ___. No signs or symptoms of recurrent COPD
exacerbation, and she has now completed appropriate treatment
for her recent COPD exacerbation. Patient was continued on
current prednisone dose 55mg daily with plan to taper in the
outpatient setting with taper plan provided by her PCP. She was
also maintained on her home azithromycin, alb nebs/tiotropium,
and medications equivalent to her home qvar and
mometasone-formoterol that were on formulary. Patient did not
require increased oxygen from her baseline (3L NC) after chest
tube placement.
# H/o adrenal insufficiency: Likely secondary chronic steroid
use. Patient had previously been on prednisone 10mg daily but
was uptitrated more recently in the setting of copd
exacerbation.
Patient was continued on current prednisone dose 55mg daily with
plan to taper in the outpatient setting with taper plan provided
by her PCP.
CHRONIC ISSUES
# GERD: Continue home omeprazole.
# Osteoporosis: continued equivalent dose home vitamin D
# HTN: Continued home diltiazem.
# Transitional issues
- complete prednisone taper as prescribed by outpatient
pulmonologist/primary care doctor
- Please consider need for initiating PCP prophylaxis if patient
remains on long steroid taper
- She should follow-up with Dr. ___ in 6 weeks with a CXR to
be performed prior to appointment.
# CODE STATUS: FULL CODE
# CONTACT: Husband ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Azithromycin 250 mg PO Q24H
3. Diltiazem Extended-Release 120 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. mometasone-formoterol 200-5 mcg/actuation inhalation BID
7. Qvar (beclomethasone dipropionate) 80 mcg/actuation
inhalation BID
8. Calcium Carbonate 750 mg PO BID
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
10. PredniSONE 55 mg PO DAILY
11. Vitamin D 400 UNIT PO QID
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Azithromycin 250 mg PO Q24H
4. Calcium Carbonate 750 mg PO BID
5. Omeprazole 40 mg PO DAILY
6. PredniSONE 55 mg PO DAILY
7. Tiotropium Bromide 1 CAP IH DAILY
8. Vitamin D 400 UNIT PO QID
9. Diltiazem Extended-Release 120 mg PO DAILY
10. mometasone-formoterol 200-5 mcg/actuation inhalation BID
11. Qvar (beclomethasone dipropionate) 80 mcg/actuation
inhalation BID
12. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every 6 hours Disp #*14 Tablet Refills:*0
13. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN breakthrough
pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Pneumothorax in the setting of COPD
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 worsening shortness of breath and chest
pain. You were found to have a left sided pneumothorax most
likely due to your COPD. You had a chest tube placed and were
monitored for 72 hours. Your symptoms improved and we were able
to send you home after pulling out your chest tube. Please
continue the prednisone taper as prescribed by your primary care
doctor. We wish you all the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10286521-DS-17 | 10,286,521 | 27,814,440 | DS | 17 | 2135-08-12 00:00:00 | 2135-08-13 11:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Augmentin / phenylephrine
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ L sided chest tube
History of Present Illness:
___ female with history of emphysema and recurrent
pneumothorax, followed by pulmonary and enrolled in pulmonary
stent trial (EMPROVE) currently with Dr. ___ from
outside hospital for pneumothorax. Patient reports in onset
left-sided chest pain 1 day prior to admission. Felt similar to
previous pneumothoraces ___ and ___. Associated
shortness of breath. Went outside hospital today and was found
to have pneumothorax on the left side. Transferred here for
further management. Denies fever, chills, nausea, vomiting,
cough, lower extremity swelling.
In the ED, initial VS were 99.3, 66, 126/71, 20 at 96% on Nasal
Cannula. Exam notable for No acute respiratory distress, though
the patient did have diminished lung sounds bilaterally. Labs
were unimpressive with K+ 4.2, BUN/Cr ___ and WBC 9.9 Hgb/hct
10.8/35.0. CXR showed small left pneumothorax without signs of
tension. Mild left basal atelectasis and severe background
emphysema. Follow up CT chest without contrast showed a small
anterior left pneumothorax with collapse of the left upper lobe.
Transfer VS were 98.1, 81, 103/58, 18, 96% Nasal Cannula.
Received morphine 4mg x2. IP was consulted and given difficulty
seeing the PTX on CXR, planned for ___ placed chest tube on ___.
On arrival to the floor, patient reports she has ___ pain on
her left anterior chest. Feels exactly like her prior PTX and
worsens with inspiration. She denies shortness of breath, cough,
and other symptoms.
Past Medical History:
- COPD/emphysema on 3L ___ s/p endobrachial valve placement LUL
x 5
- Pneumothorax s/p chest tube ___
- GERD
- Adrenal insufficiency- ? steroid induced
- Osteoporosis
- History of pneumonia
Social History:
___
Family History:
Father: ___, died of pancreatic CA
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.8 116/46 82 18 97%/3L
General: NAD, resting comfortably in bed
HEENT: PEERL, non-icteric sclera, pink conjunctiva, dry mucous
membranes
Neck: no LAD, no JVD, neck supple
CV: distant heart sounds
Lungs: decreased air movement on left, no
wheezes/rhonchi/rales, not using accessory muscles of
respiration
Abdomen: normoactive bowel sounds, soft, non-tender,
non-distended, no hepatosplenomegaly observed
GU: no foley
Ext: no cyanosis or clubbing, 2+ DP pulses
Neuro: CNII-XII grossly intact
Skin: warm and moist, no excoriations or rashes
DISCHARGE PHYSICAL EXAM:
VS - 98.1, 116/49, 67, 18, 99% on 3L via NC
General: NAD, resting comfortably in bed
HEENT: PEERL, non-icteric sclera, pink conjunctiva, dry mucous
membranes
Neck: no LAD, no JVD, neck supple
CV: RRR, S1/S2 heard, no murmurs/rubs/gallops
Lungs: decreased breath sounds diffusely, no
wheezes/rhonchi/rales, not using accessory muscles of
respiration; no tracheal deviation, L Chest tube in place,
clamped, incision C/D/I with no evidence of erythema
Abdomen: normoactive bowel sounds, soft, non-tender,
non-distended, no hepatosplenomegaly observed
GU: no foley
Ext: no cyanosis or clubbing, 2+ DP pulses
Neuro: CNII-XII grossly intact
Skin: warm and moist, no excoriations or rashes
Pertinent Results:
ADMISSION LABS:
================
___ 10:15AM BLOOD WBC-9.9 RBC-3.64* Hgb-10.8* Hct-35.0
MCV-96 MCH-29.7 MCHC-30.9* RDW-15.3 RDWSD-53.8* Plt ___
___ 10:15AM BLOOD Neuts-88.1* Lymphs-6.1* Monos-4.4*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-8.71* AbsLymp-0.60*
AbsMono-0.44 AbsEos-0.01* AbsBaso-0.02
___ 06:20AM BLOOD ___ PTT-25.9 ___
___ 10:15AM BLOOD Glucose-107* UreaN-13 Creat-0.7 Na-138
K-4.2 Cl-102 HCO3-25 AnGap-15
___ 06:20AM BLOOD Calcium-8.8 Phos-4.8* Mg-2.4
DISCHARGE LABS:
================
___ 07:07AM BLOOD WBC-7.7 RBC-3.21* Hgb-9.6* Hct-31.0*
MCV-97 MCH-29.9 MCHC-31.0* RDW-15.4 RDWSD-53.5* Plt ___
___ 07:07AM BLOOD ___ PTT-27.6 ___
___ 07:07AM BLOOD Glucose-86 UreaN-9 Creat-0.7 Na-141 K-4.0
Cl-105 HCO3-28 AnGap-12
___ 07:07AM BLOOD Calcium-8.7 Phos-4.5 Mg-2.2
PERTINENT FINDINGS:
====================
IMAGING
----------
CXR ___:
Small left pneumothorax without signs of tension. Mild left
basal
atelectasis. Severe background emphysema.
CT Chest w/o Contrast ___
Severe emphysema with small left pneumothorax, anterior in
position without signs of tension. Collapse of the left upper
lobe.
CT Chest ___:
IMPRESSION:
Uneventful CT-guided insertion of a 10 ___ catheter into the
left pleural cavity, with catheter placed under low
suction.Re-inflation of the majority of the left upper lobe.
CXR ___:
Compared to chest radiographs since it did ___, most
recently ___ through ___ at 08:22.
Only the apical component of the previous left pneumothorax was
diagnosable on conventional chest radiographs and that has
resolved. Because of the left upper lobe collapse due to the
indwelling bronchial valves, the anterior mediastinum is shifted
to the left of midline and on the lateral view simulates
pneumothorax. Left lower lobe and the right lung are clear of
any focal abnormality. There is no pleural effusion.
CXR ___:
Comparison to ___. The left chest tube is removed.
No pulmonary edema. No pneumonia. No pneumothorax.
Brief Hospital Course:
Ms. ___ is a ___ year old female with history of severe
COPD on 3L ___ s/p endobronchial valve placement (EMPROVE trial)
and recurrent pneumothorax who presents with new L sided
pneumothorax.
#Pneumothorax: Patient presented with new onset left sided chest
pain similar to previous episodes of pneumothorax, and
associated with acute onset of shortness of breath. Likely due
to ruptured bleb in setting of exertion. CXR and CT confirmed L
sided pneumothorax. Per IP will plan for ___ chest tube
placement on ___ and CT showed appropriate lung re-expansion.
Serial chest x-rays showed no new or recurrent pneumothoraces
and the chest tube was transitioned to water seal, and closed.
The patient had significant discomfort from the chest tube and
was requiring IV diluadid intermittently. The patient was
counseled on pleurodesis to prevent further pneumothoraces
before the chest tube was pulled, however, after an extended
discussion, she ultimately declined the procedure. On ___ the
chest tube was pulled, and follow up CXR showed no signs of
recurrent pneumothorax. She was discharged home on her regular
medications with plans to follow up with her pulmonologists.
# COPD: Severe, on 2L-3L home O2 and s/p stent placements as
part of pulmonary stent trial (EMPROVE) for lung volume
reduction. Continued home on tiotropium and albuterol nebs prn.
Continued home beclomethasone dipropionate and
mometasone-formoterol and O2 supplementation, stable at ___
liters.
# GERD: Stable, continued home omeprazole.
# Osteoporosis: Stable, continued home vitamin D and Ca.
# HTN: Normotensive, continued home diltiazem.
# Adrenal insufficiency: Possibly steroid-induced per pulm
notes, pressure stable. Was continued on home prednisone 10mg
daily.
# Chronic nausea: Known history of chronic nausea, etiology
remains unclear. Was maintained on Zofran PRN, with minimal
nausea during this admission. No prolonged QTc.
TRANSITIONAL ISSUUES:
=======================
[] Please make sure patient follows up with her pulmonologists,
Dr. ___ and Dr. ___
[] Patient has intermittent, poorly understood nausea, requiring
Zofran, will require ongoing monitoring
CODE: Full (confirmed)
CONTACT: Husband ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Azithromycin 250 mg PO Q24H
2. calcium carbonate 600 mg (1,500 mg) oral BID
3. Diltiazem Extended-Release 120 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. Vitamin D 400 UNIT PO QID
7. Ondansetron 4 mg PO Q8H:PRN nausea
8. albuterol sulfate 2 puffs INHALATION Q4H:PRN SOB
9. beclomethasone dipropionate 80 mcg/actuation inhalation BID
10. mometasone-formoterol 200-5 mcg/actuation inhalation BID
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. PredniSONE 10 mg PO DAILY
Discharge Medications:
1. albuterol sulfate 2 puffs INHALATION Q4H:PRN SOB
2. Azithromycin 250 mg PO Q24H
3. beclomethasone dipropionate 80 mcg/actuation inhalation BID
4. calcium carbonate 600 mg (1,500 mg) oral BID
5. Diltiazem Extended-Release 120 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. PredniSONE 10 mg PO DAILY
9. Vitamin D 400 UNIT PO QID
10. mometasone-formoterol 200-5 mcg/actuation inhalation BID
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Recurrent pneumothorax
Secondary diagnoses:
Severe COPD
Persistent nausea, etiology unknown
GERD
Adrenal insufficiency
Osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure to care for you at ___. You were admitted
for a recurrent pneumothorax on ___.
What was done?
==============
-A chest tube was placed under imaging guidance in your left
chest to drain the pneumothorax, your lung re-expanded
appropriately.
-We managed your pain after the procedure with IV and oral pain
meds
-We spoke with your lung doctors ___, Dr. ___ about
the pros/cons of pleurodesis, a procedure to decrease recurrence
of pneumothoraces, and ultimately you decided against
pleurodesis.
- Your chest tube was removed, no evidence of pneumothorax on
x-rays and your were discharged home.
What should I do next?
======================
-Continue to take your medications as prescribed
-Please follow-up with your primary care doctor and lung doctor
___ was a pleasure taking care of you. We wish you the best of
health moving forward.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10286603-DS-17 | 10,286,603 | 27,971,172 | DS | 17 | 2164-10-10 00:00:00 | 2164-10-11 15:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ibuprofen
Attending: ___
Chief Complaint:
Abdominal pain, bloody diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with history of DVT s/p amputation of
right leg presenting with acute onset of abdominal pain,
diarrhea, nausea and vomiting with CT findings consistent with
colitis.
Patient was reportedly doing well until the day of admission
when she woke up with bloody diarrhea and generalized abdominal
pain which "felt like labor cramps". She reported associated
chills without fevers, emesis and nausea. Noted nonbloody,
nonbilious emesis. Had single episode of chest pain lasting
seconds. Has had intermittent mild SOB at home with heat, no
cough, dysuria, palpitations. Had headache 2 days ago, now
resolved. Denies leg swelling.
In the ED, initial vitals were: 8 97.6 101 175/99 18 100% RA
Exam notable for: obese female, uncomfortable appearing with
rhonchi in RLL, ttp in RUQ and epigastric area without rebound.
Heme positive, no e/o skin breakdown.
Labs notable for: WBC 19.0 with 92% polys, H/H ___ plt 398. K
5.3, Cl 112, bicarb 17, Cr 0.7, AP 126, lipase 37, lactate 3.9
improved to 2.4 with 1L NS and 4mg IV morphine.
Imaging notable for:
- CTA Abd/pelvis: wall thickening and hyperemia involving the
transverse and descending colon concerning for colitis, not in
distribution concerning for ischemic colitis. Patent
vasculature.
- CXR PA/Lateral: No focal consolidation c/f pneumonia,
prominence of the right paratracheal region could be lipomatosis
or lymphadenopathy of dilated aorta.
Patient was given: 2L NS, Morphine (4mg IV) x2, ciprofloxacin
IV and Zofran 4mg IV.
Vitals prior to transfer: 98.7 95 144/88 18 99% RA
On the floor, patient is nauseated with single episode of
reddish brown liquid emesis (approximately 400cc) without
associated abdominal pain.
Past Medical History:
Arterial thromboembolism
Right BKA in the setting of DVT untreated for prolonged period
HTN
HLD
Social History:
___
Family History:
Mother with ___, HTN.
Physical Exam:
ON ADMISSION:
Vital Signs: 98.8 PO 149/96 99 20 99 RA
General: Obese female, alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur heard best at ___
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Obese, hypoactive bowel sounds, soft, non-tender,
non-distended, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 1+ DP pulse on left without edema,
well healed BKA on right without e/o skin breakdown
Neuro: CNII-XII intact, moving all extremities
ON DISCHARGE:
Vital Signs: 98.5 ___ 95-98% RA
General: Obese female, alert, oriented, laying comfortably in
no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm. ___ SEM heard best on the ___
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Obese. +BS. Soft, nontender, nondistended. No rebound,
guarding, or rigidity
GU: No foley
Ext: Warm, well perfused, 1+ DP pulse on left without edema,
well healed BKA on right without e/o skin breakdown
Neuro: CNII-XII intact, moving all extremities
Pertinent Results:
ON ADMISSION:
___ 03:00PM ___-19.0* RBC-4.67 HGB-14.1 HCT-42.4 MCV-91
MCH-30.2 MCHC-33.3 RDW-15.5 RDWSD-50.7*
___ 03:00PM NEUTS-92.8* LYMPHS-4.0* MONOS-2.4* EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-17.69* AbsLymp-0.76* AbsMono-0.45
AbsEos-0.00* AbsBaso-0.05
___ 03:00PM ALBUMIN-4.4
___ 03:00PM LIPASE-37
___ 03:00PM ALT(SGPT)-20 AST(SGOT)-30 ALK PHOS-126* TOT
BILI-0.2
___ 03:00PM GLUCOSE-263* UREA N-16 CREAT-0.7 SODIUM-135
POTASSIUM-5.3* CHLORIDE-112* TOTAL CO2-17* ANION GAP-11
___ 03:33PM ___
___ 04:20PM LACTATE-3.9* K+-5.4*
___ 06:32PM LACTATE-2.4*
___ 07:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 07:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:00AM cTropnT-<0.01
ON DISCHARGE:
___ 07:55AM BLOOD WBC-12.5* RBC-4.62 Hgb-13.7 Hct-40.3
MCV-87 MCH-29.7 MCHC-34.0 RDW-15.2 RDWSD-48.5* Plt ___
___ 12:30AM BLOOD Neuts-83.9* Lymphs-10.8* Monos-4.6*
Eos-0.0* Baso-0.3 Im ___ AbsNeut-13.11* AbsLymp-1.68
AbsMono-0.71 AbsEos-0.00* AbsBaso-0.04
___ 07:55AM BLOOD Plt ___
___ 07:55AM BLOOD Glucose-161* UreaN-11 Creat-0.6 Na-136
K-3.4 Cl-99 HCO3-24 AnGap-16
___ 12:30AM BLOOD ALT-15 AST-21 AlkPhos-119* TotBili-0.3
___ 07:55AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.0
___ 12:49AM BLOOD Lactate-2.1* K-3.6
MICRO:
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.
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.
IMAGING:
CT ABD/PELVIS (___):
Wall thickening and hyperemia involving the transverse and
descending colons,
concerning for colitis. This is not in a specific a vascular
distribution.
The sigmoid colon is collapsed, and the celiac, SMA, and ___ are
patent.
Differential diagnosis for colitis includes infectious,
inflammatory, and
ischemic etiologies.
CXR Portable (___):
1. No focal consolidation concerning for pneumonia.
2. Prominence of the right paratracheal region is nonspecific,
but could
represent mediastinal lipomatosis or lymphadenopathy or possibly
mild
dilatation of the ascending aorta.. Consider comparison with
outside hospital
films, if they can be obtained, or nonemergent chest CT for
further
evaluation.
Brief Hospital Course:
Ms. ___ is a ___ woman with history of DVT s/p amputation of
right leg presenting with acute onset of abdominal pain, bloody
diarrhea, nausea and vomiting found to have leukocytosis and CT
findings consistent with colitis, likely infectious in etiology
although no clear precipitant. Patient was made NPO, started on
cipro/flagyl, and her pain was controlled with IV medications.
As her pain and diarrhea improved, patient's diet was advanced
and she was tolerating solid food at the time of discharge.
# Colitis
Patient presenting with acute abdominal pain w/ associated N/V,
bloody diarrhea w/ leukocytosis and CT findings c/w colitis.
Different includes infectious vs inflammatory vs ischemic
process. Most likely is infectious even though pt did not
endorse any hx of sick contacts, new ingestion. IBD has a
bi-modal distribution and can present in this age range, but
usually presents insidiously and is therefore unlikely given
acute onset. Mesenteric ischemia also on differential given pain
out of proportion to exam although CT scan reveals findings not
in vascular distribution.
Patient was made NPO, started on IV cipro/flagyl, and IV pain
medications. GI was consulted and believed GI symptoms likely to
be infectious in nature. Colonoscopy was attempted while
inpatient as patient never had screening colonoscopy, but
patient was unable to tolerate the bowel prep and therefore was
cancelled. Patient's pain/diarrhea resolved with bowel
rest/antibiotics and her diet was advanced and antibiotics were
transitioned to PO. Patient to complete a 7 day course of
cipro/flagyl (last day: ___ and schedule a colonoscopy in
___ weeks.
# Hematemesis: Patient presented with an episode of pink watery
emesis concerning for possible bloody emesis with repeat episode
showing specks of blood. Likely ___ tear given
clinical picture of later onset hematemesis after multiple
episodes of vomiting. Patient H/H was trended and she was
hemodynamically stable without any further episodes of
hematemesis.
# H/o thromboembolism s/p R BKA
Patient's xarelto was held on admission due to concern for GI
bleed and was restarted on discharge.
# Hypertension: Stable. Continued home amlodipine 10mg
# HLD: Continued home pravastatin once patient could tolerate
PO
# Hematuria: Small blood in urine may be related to
anticoagulation. Patient denying any symptoms of dysuria,
urgency. Recommend repeat UA as outpatient, consider need for
cystoscopy if persistent microscopic hematuria
# Right paratracheal prominence:
Initial CXR revealed right paratracheal prominence. Prominence
of the right paratracheal region is nonspecific, but could
represent mediastinal lipomatosis or lymphadenopathy or possibly
mild
dilatation of the ascending aorta. Consider comparison with
outside hospital films, if they can be obtained, or nonemergent
chest CT for further evaluation.
TRANSITIONAL ISSUES
=======================
[]follow up abdominal pain/diarrhea
[]patient should have a colonoscopy in ___ weeks
[]consider hematology/vascular follow up given history of
arterial thromboembolism if not fully worked up
[]repeat UA, patient's UA on admission positive for hematuria.
Consider cystoscopy if persistent hematuria
[] Initial CXR revealed right paratracheal prominence.
Prominence of the right paratracheal region is nonspecific, but
could
represent mediastinal lipomatosis or lymphadenopathy or possibly
mild
dilatation of the ascending aorta. Consider comparison with
outside hospital films, if they can be obtained, or nonemergent
chest CT for further evaluation.
# CODE: Full (confirmed)
# CONTACT: Daughter # ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 80 mg PO QPM
2. Rivaroxaban 20 mg PO QHS
3. amLODIPine 10 mg PO HS
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*9 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*13 Tablet Refills:*0
3. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*6 Tablet Refills:*0
4. amLODIPine 10 mg PO HS
5. Pravastatin 80 mg PO QPM
6. Rivaroxaban 20 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Colitis
Hematemesis
SECONDARY:
History of arterial thrombus
Hypertension
Hyperlipiedemia
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.
Why you were here?
-You were admitted because you had severe abdominal pain and
bloody diarrhea. A CT scan showed that you had colitis, an
inflammation of your colon.
What we did for you?
-We started you on antibiotics, controlled your pain with
medications, and gave your bowels some rest by having you start
taking liquids and foods slowly. This led to improvement in your
pain and diarrhea
What you should do when you leave the hospital?
-Continue taking ciprofloxacin and metronidazole to complete a 7
day course (last day: ___
-Take your medications and follow up with your primary care
doctor.
-___ should schedule a colonoscopy in ___ weeks
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10286708-DS-18 | 10,286,708 | 22,103,819 | DS | 18 | 2151-10-01 00:00:00 | 2151-10-01 17:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Motorcycle collision with injuries, open right tibial and
fibular fracture.
Major Surgical or Invasive Procedure:
On ___
1. OR debridement and irrigation down to and inclusive of
bone of open tibia and fibula fracture.
2. Intramedullary nailing of tibia shaft fracture with
Synthes nail, 11 x ___ mm.
3. Plating fibula fracture.
.
On ___:
1. Four-compartment fasciotomy.
2. Placement of vacuum sponges, medial and lateral
incisions, extending over 20 x 10 cm, for 200 cm each.
3. Evacuation of knee hematoma.
.
On ___:
Right leg I+D, medial closure, lateral VAC
.
On ___:
Right leg I+D, VAC change
.
On ___:
STSG R leg
History of Present Illness:
___ s/p motorcycle collision ___ at ___ when the car in
front of him came to abrupt stop resulting in R open tib/fib
fracture. Found lying on ground. + helmet, +head strike, no LOC,
remembers all events. HD stable at scene, GCS 15. Had
dopplerable but not palpable pulses TP/DP on RLE. Was taken
toOSH where he was found to have R open tib/fib fx, was
medflighted to ___. Got Ancef 2g. +tetanus ppx.
Past Medical History:
denies
Social History:
___
Family History:
Non-contributory
Physical Exam:
on admission:
AVSS, in pain but NAD, A&Ox3
CV: RRR
R: CTAB
Ab: S/NT/ND
RLE: 2-3cm open wound on lateral calf, exposed bone, actively
bleeding base. Moderate edema of ankle. No gross contamination.
Multiple superficial abrasions great toe, right thigh and hip.
SILT s/s/sp/t/pt. ___. Biphasic DP, ___ dopplerable pulses
(vs. 1+ palpable DP/PTon LLE); foot and toes warm, well-perfused
with capillary refill < 12 seconds. Compartments full but not
firm. Minimal pain to passive stretch of toes
Pertinent Results:
___ 06:35PM ___ 06:35PM ___ PTT-25.6 ___
___ 06:35PM PLT COUNT-377
___ 06:35PM WBC-19.1* RBC-4.92 HGB-14.5 HCT-41.2 MCV-84
MCH-29.5 MCHC-35.2* RDW-12.3
___ 06:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 06:35PM LIPASE-29
___ 06:35PM estGFR-Using this
___ 06:35PM UREA N-19 CREAT-0.9
___ 06:39PM GLUCOSE-137* LACTATE-3.1* NA+-142 K+-3.5
CL--105 TCO2-23
___ 05:27AM BLOOD WBC-6.8 RBC-3.01* Hgb-7.9* Hct-25.1*
MCV-83 MCH-26.3* MCHC-31.6 RDW-14.0 Plt ___
___ 05:27AM BLOOD Neuts-64.0 ___ Monos-5.9 Eos-2.1
Baso-0.5
___ 05:27AM BLOOD ESR-50*
___ 05:27AM BLOOD ALT-10 AST-14 AlkPhos-91 TotBili-0.3
___ 05:27AM BLOOD CRP-PND
.
RADIOLOGY:
Radiology Report CTA LOWER EXT W/&W/O C & RECONS RIGHT Study
Date of ___ 7:07 ___
IMPRESSION:
1. Open, comminuted tibial and fibular fracture.
2. Attenuation and non-visualization of the mid anterior and
posterior
tibial, and peroneal arteries, with pseudoaneurysm formation in
the region of the tibial and fibular fractures, compatible with
vascular injury and likely vasospasm. Extrinsic vascular
compression or thrombus formation resulting in vascular
occlusion is not excluded. There is no evidence for active
arterial extravasation. There does appear to be weak
reconstitution of flow in both the dorsalis pedis and posterior
tibial arteries of the foot.
.
KNEE (2 VIEWS) RIGHT; TIB/FIB (AP & LAT) RIGHT; ANKLE (AP,
MORTISE & LAT) RIGH
IMPRESSION: Comminuted displaced complete fractures of the
distal fibula and tibia.
.
Radiology Report LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN
O.R. Study Date of ___ 9:22 ___
FINDINGS AND IMPRESSION: ___ images are provided from an
intraoperative examination with fluoroscopic spot views. An
intramedullary
rod has been placed across the tibial fracture which is in near
anatomic
alignment. A lateral plate and screw fixation has been placed
across the
fibular fracture; alignment of the fibular plate is not well
evaluated on
these views, but is grossly anatomic. A skin defect at the
lateral aspect of the distal calf is identified. For further
details, please see the operative note.
.
Radiology Report BILAT LOWER EXT VEINS Study Date of ___
3:06 ___
IMPRESSION: No evidence of deep vein thrombosis in either leg.
Note is made that the right calf veins could not be visualized
due to the open surgical wound.
.
Radiology Report TIB/FIB (AP & LAT) RIGHT Study Date of ___
2:22 ___
FINDINGS: In comparison with the operative study, there is again
an
intramedullary rod transfixing a fracture of the lower shaft of
the tibia. No evidence of hardware-related complication.
.
MICROBIOLOGY:
___ 8:30 am SWAB Site: LEG RIGHT MEDIAL.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___:
ORGANISM. SPARSE GROWTH.
POSSIBLE MYCOPLASMA SPECIES. UNABLE TO RULE OUT
CONTAMINATION.
Reported to and read back by ___. ___ ___
14:30.
.
___ 8:40 am SWAB Site: LEG RIGHT LATERAL TIBIAL.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___:
ORGANISM. SPARSE GROWTH.
POSSIBLE MYCOPLASMA SPECIES. UNABLE TO RULE OUT
CONTAMINATION.
Reported to and read back by ___. ___ ___
14:30.
.
___ 3:49 pm SWAB TIB/FIB WOUND-RT.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___:
ORGANISM. SPARSE GROWTH. POSSIBLE MYCOPLASMA.
UNABLE TO RULE OUT CONTAMINATION.
Brief Hospital Course:
Mr. ___ was admitted to the Orthopedic service on ___
for left open tibial and fibular fracture after being evaluated
and treated with attempted closed reduction, wound lavage and
splinting in the emergency room. CTA of RLE revealed apparent
vascular injury of each of the anterior and posterior tibialis,
and peroneal arteries, with pseudoaneurysm. He underwent open
reduction internal fixation of the right tibia nad fibula
without complication on ___. Please see operative report
for full details. He subsequently underwent intraoperative
angiography by vascular surgery. Please see the operative report
for full details.
.
He was extubated without difficulty and transferred to the ICU
for vascular monitoring. On hospital day 1 he developed
increasing compartmental tightness and pain with passive stretch
of toes. His compartment pressures were found to be elevated and
he was taken to the OR for emergent 4-compartment fasciotomy.
Due to RLE swelling there was not enough skin coverage and wound
was left open with VAC dressing in place. He was undergoing
serial VAC changes and I&D prior to final closure with STSG by
PRS on ___. Please see OR reports for details.
.
He had adequate pain management and worked with physical therapy
while in the hospital. On ___, Infectious Disease paged
___ team to report that 3 out of 3 OR cultures from two
separate dates ___ and ___ were all growing question
of mycoplasma. ID Consult was requested. ID recommendations
included; urinalysis and urine culture for mycoplasma, baseline
blood work, doxicycline 100 mg po BID for at least 4 weeks with
ID follow up in ___ weeks. He is being discharged to home on
___ in stable condition.
Medications on Admission:
none
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*20 Tablet(s)* Refills:*2*
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours): Do not exceed 4000mgs/4gms of tylenol per day.
Disp:*50 Tablet(s)* Refills:*2*
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*150 Tablet(s)* Refills:*0*
7. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 4 weeks.
Disp:*56 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Open right tibia and fibula shaft 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:
Wound Care:
- You should keep your right lower extremity dry and do not get
wet or submerge in water.
- If you would like to shower, you may wrap your right thigh
donor site and your right skin graft site with plastic wrap to
keep the areas dry while you shower.
- Your right thigh donor site should be left open to air to dry
out.
- Your right skin graft site will need daily dressing changes
with the following:
* Apply xeroform dressing directly to skin graft site
* Cover xeroform with 'fluffed' gauzes
* wrap fluffed gauze with kerlix and then apply Ace wrap.
- You should elevate your right lower extremity while in bed and
wear your multipodus boot while in bed.
.
- Activity:
- Continue to be TOUCH DOWN weight bearing on your right leg.
- Elevate right leg to reduce swelling and pain.
.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- You have also been given additional medications to control
your pain. You have been given a two week supply. You should
wean yourself down by lengthening time between doses and
continuing your tylenol, as prescribed. We cannot 'call in'
narcotic prescriptions. If you think you may need additional
pain medication then you should address this at your follow up
appointment. We may only prescribe pain medications for 90 days
from the date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If you have questions, concerns or experience any of the below
danger signs then please call Dr. ___ at ___ or
go to your local emergency room.
.
NEW MEDICATION/DIAGNOSIS:
- You had high blood pressure (hypertension) during your
hospitalization. You were placed on a new medication for you,
Metoprolol Tartrate 25 mg twice per day. You should discuss
this with your PCP so that your blood pressure may be monitored
after discharge home and the need for this medication reviewed.
-Infectious Disease has recommended you take your antibiotic,
Doxicycline, for AT LEAST 4 weeks. The pharmacy would only give
you two weeks supply based on your temporary free care status.
You will need at least another 2 week supply beyond what was
given to you. You will either need to pay for this or it will
be covered under whatever health care plan you end up signing up
with. You will need to follow up Infectious Disease for your
scheduled appointment (see below).
Followup Instructions:
___
|
10286998-DS-4 | 10,286,998 | 24,652,312 | DS | 4 | 2174-09-30 00:00:00 | 2174-10-01 14:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ gentleman PMHx of CAD post CABG in ___ complicated
by complete heart block requiring dual chamber pacemaker with
BiV upgrade, A-fib with recent cardioversion in ___, and
infarct-related cardiomyopathy EF ___, who presents with SOB
and cough. Pt states that his symptoms started 2 weeks ago with
nausea/vomiting and diarrhea; of note multiple, family members
had similar symptoms. He went to his PCP who subsequently gave
him Tamiflu with some relief. Three days ago, patient developed
worsening SOB and wheezing for which he went to the ___ and was
diagnosed with bronchitis and sent home with a Z-pack. He also
endorses right sided substernal chest pressure for the past two
nights. No fevers or chills. Today, the patient awoke in mild
respiratory distress, worsened while dressing. EMS was called to
the house and O2sat at that time was 88% on RA.
In the ED initial vitals were: 98.1 162/84 62 18 94% 6L
Labs/studies notable for: WBC to 10.2, H/H 13.1/39.7. Trops x1
negative, lactate NL. CXR showing extensive pulmonary edema and
small bilateral pleural effusions.
Patient was given: IV Lasix 40 mg
Vitals on transfer: 97.8 140/71 58 20 96% 4L
On the floor, the patient reports two episodes of hemoptysis
while in the ED (coughing up blood tinged sputum the size of a
quarter). At present, he continues to have a dry cough but does
not feel SOB. He denies CP or palpitations. He denies ___
swelling or pain. He denies abdominal pain, nausea, vomiting. He
denies lightheadedness or dizziness. Wife states that appetite
has decreased recently.
REVIEW OF SYSTEMS:
Negative per HPI.
Past Medical History:
CAD s/p CABG in ___ c/b CHB
CHB s/p ___ Sigma DDD PPM, upgrade to biventricular
pacemaker ___
Ischemic cardiomyopathy (EF ___
Hypertension
Atrial fibrillation on Eliquis
Dyslipidemia
Anxiety
Sleep apnea: does not tolerate CPAP
Social History:
___
Family History:
Multiple family members with MIs in ___
Physical Exam:
ADMISSION EXAM:
VS: T 98 BP 153/77 HR 66 RR 22 O2SAT 93 on 3L Weight 224 lbs
(___)
GENERAL: Well developed, in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No exudates or erythema in oral mucosa
NECK: Supple. JVP > 10 cm
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. BS+
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes. Has arm tattoo
DISCHARGE EXAM:
VS: T 98.2 BP 133/71 HR 63-64 RR 22 O2SAT ___ on RA Weight
95.6->95 kg
GENERAL: Well developed, in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No exudates or erythema in oral mucosa
NECK: Supple. No JVD
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. BS+
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes. Has arm tattoo
Pertinent Results:
=================
ADMISSION LABS
=================
___ 11:05AM BLOOD WBC-10.2* RBC-4.30* Hgb-13.1* Hct-39.7*
MCV-92 MCH-30.5 MCHC-33.0 RDW-15.1 RDWSD-50.4* Plt ___
___ 11:05AM BLOOD Neuts-81.7* Lymphs-9.6* Monos-7.1
Eos-0.7* Baso-0.3 Im ___ AbsNeut-8.37* AbsLymp-0.98*
AbsMono-0.73 AbsEos-0.07 AbsBaso-0.03
___ 11:05AM BLOOD ___ PTT-37.0* ___
___ 11:05AM BLOOD Glucose-125* UreaN-13 Creat-1.0 Na-143
K-3.9 Cl-105 HCO3-19* AnGap-23*
___ 11:05AM BLOOD proBNP-4110*
___ 11:05AM BLOOD cTropnT-<0.01
___ 09:35PM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:05AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.2
___ 11:12AM BLOOD Lactate-1.1
===============
DISCHARGE LABS
===============
___ 10:05AM BLOOD WBC-10.7* RBC-4.35* Hgb-13.2* Hct-40.0
MCV-92 MCH-30.3 MCHC-33.0 RDW-15.1 RDWSD-50.7* Plt ___
___ 10:05AM BLOOD Plt ___
___ 10:05AM BLOOD Glucose-134* UreaN-17 Creat-1.0 Na-139
K-4.0 Cl-102 HCO3-21* AnGap-20
___ 10:05AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.1
=============
MICROBIOLOGY
==============
___ 11:05 am BLOOD CULTURE
Blood Culture, Routine (Pending):
====================
IMAGING & STUDIES
=====================
CXR ___: There is a right-sided pacemaker. Mediastinal
wires are seen. There is
cardiomegaly. There is extensive pulmonary edema and small
bilateral pleural
effusions. There are no pneumothoraces.
CXR ___: Resolution of extensive pulmonary edema with
remaining pulmonary vascular
congestion. Small right-sided pleural effusion. No focal
consolidation
identified.
Brief Hospital Course:
SUMMARY: ___ M with PMHx of CAD post CABG in ___
complicated by complete heart block requiring dual chamber
pacemaker with BiV upgrade, A-fib with recent cardioversion in
___, and ischemic cardiomyopathy EF ___, who presents
with acute on chronic systolic heart failure, likely exacerbated
by viral illness. He was diuresed initially with IV furosemide
with good response and transitioned to PO furosemide 20mg daily.
He was also noted to consistently be desaturating with
ambulation to O2 sat 84-87%, concerning for undiagnosed COPD
given smoking history and wheezes on exam. He was set up with a
home oxygen unit and will use 2L O2 when ambulating at home. He
was set up with a followup with a pulmonologist and will get
further workup including PFTs as outpatient.
ACUTE ISSUES:
# Acute on chronic HFrEF (___): Presented with acute
exacerbation likely triggered by recent viral gastroenteritis
and current viral bronchitis. He was initially short of breath
with BNP 4110, CXR significant for extensive pulmonary edema. He
diuresed well to boluses of furosemide 40mg daily quickly
reached euvolemia, with transition to 20mg furosemide daily. He
had previously been on this dose but had since been reduced to
10mg daily. He was also continued on carvedilol 25mg BID,
spironolactone 25mg daily, entresto BID (dose was uptitrated).
# Ambulatory desaturation: As above, noted to be consistently
desturating on exam. This was concerning for undiagnosed COPD
given smoking history and wheezes on exam, vs acute bronchospasm
due to viral illness. Per wife had been wheezing at home for
months, more concerning for chronic condition. He was given
duonebs with improvement in wheezing. He was set up with a home
oxygen unit and will use 2L O2 when ambulating at home. He will
f/u with a pulmonologist and will get further workup including
PFTs as outpatient.
CHRONIC ISSUES:
# Atrial Fibrillation: Underwent cardioversion in ___.
Continued Apixaban 5 mg BID and will f/u with outpatient
cardiologist.
# CAD s/p CABG: Continued ASA 81mg, atorvastatin 40mg.
# Depression: Continued Sertraline 100 mg daily.
# PTSD: Continued Xanax 1 mg ___ times per day PRN.
TRANSITIONAL ISSUES:
- Patient should get pulmonary function testing including DLCOs
as outpatient
- Patient will follow up in clinic with new pulmonologist and
his cardiologist
- Discharged on increased dose of furosemide 20mg daily and
increased dose of entresto (49 mg-51) mg tablet. The patient
would require a Chem7 in 1 week.
- Discharged on home oxygen 2L to be used when ambulating or
with activity. Please measure ambulatory sats on the next visit
and wean off O2 as tolerated.
- The patient has mild normocytic anemia on admission with Hb=
13.1 and 13.2 on discharge.
- a small right-sided pleural effusion was noted on his CXR on
___. Would recommend a follow up CXR to confirm resolution.
# Code: full
# EMERGENCY CONTACT: Ms. ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 1 mg PO TID:PRN anxiety
2. Apixaban 5 mg PO BID
3. Atorvastatin 40 mg PO QPM
4. Carvedilol 25 mg PO BID
5. Furosemide 10 mg PO 3X/WEEK (___)
6. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
7. Sertraline 100 mg PO DAILY
8. Spironolactone 25 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg 1 puff INh q4h:prn
Disp #*1 Inhaler Refills:*0
2. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Sacubitril-Valsartan (24mg-26mg) 2 TAB PO BID
RX *sacubitril-valsartan [Entresto] 49 mg-51 mg 1 tablet(s) by
mouth twice a day Disp #*60 Tablet Refills:*0
4. ALPRAZolam 1 mg PO TID:PRN anxiety
5. Apixaban 5 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Carvedilol 25 mg PO BID
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Sertraline 100 mg PO DAILY
11. Spironolactone 25 mg PO DAILY
12.Home oxygen
Home oxygen therapy 2 liters nasal cannula
please provide extension cord
ICD10 ___ Chronic obstructive pulmonary disease
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Upper respiratory infection
Systolic heart failure, acute on chronic
Ambulatory desaturation
Secondary diagnosis:
Coronary artery disease
Atrial fibrillation s/p cardioversion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ because of shortness of breath. This
was thought to be an exacerbation of your congestive heart
failure, likely due to a viral infection that you have. We gave
you Lasix with good results and you improved to the point where
you could be discharged home.
However, we also noticed that your oxygen was decreasing when
you walked around. We gave you a home oxygen unit that you will
wear when you are doing activities.
Please make sure to do the following:
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Go back to taking Lasix 20mg every day. We also increased your
entresto to two tablets, twice a day
- Wear your home oxygen when you are walking around and doing
activities.
- Please make sure to follow up with your primary care doctor,
your cardiologist Dr. ___, as well as a new lung doctor
___ appointments below)
It was a pleasure taking care of you!
- Your ___ care team
Followup Instructions:
___
|
10286998-DS-6 | 10,286,998 | 22,652,815 | DS | 6 | 2175-05-30 00:00:00 | 2175-05-30 16:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male w/ h/o CAD s/p remote CABG,
HFrEF ___ infarct-mediated CMP, persistent atrial fibrillation
admitted for acute hypoxic respiratory failure, requiring BiPAP.
Patient was in usual state of health until ___ when he
developed constellation of chills, malaise, myalgias, nasal
congestion, and shortness of breath. Patient also noted to have
non-bloody diarrhea. He presented to his PCP the following day,
at which time was found to have minor leukocytosis with
unremarkable CXR. Non-specific symptomatology was attributed to
a viral illness. Patient initially improved, but worsened
thereafter. Called PCP ___ with progressive malaise, congestion,
and shortness of breath as well as home O2 saturation 90%,
prompting presentation.
In the ED initial vitals were: T 98.3 HR 67 BP 146/61 RR 18 92%
3LNC
Desaturations to mid-80s, requiring home CPAP with 8L O2 ->
BiPAP.
EKG: AV paced at 60.
Labs/studies notable for:
WBC 10.7
Trop <0.01, <0.01
NTproBNP 4840
VBG pH 7.44, pCO2 41, pO2 28
CXR with mild pulmonary edema with small bilateral pleural
effusions and bibasilar atelectasis, new since the previous
exam.
Patient was given:
Duoneb
Lasix 40 mg IV, 80 mg IV; 2800 UOP
Nitro gtt
Vitals on transfer: T 99.0 HR 60 BP 115/57 RR 30 O2 92% on BiPAP
___
Patient arrived on BiPAP, which was weaned to 5LNC. Reports
marked improvement in shortness of breath and wakefulness.
Patient corroborates above history and adds that he has been
eating shellfish among other sodium-rich foods (e.g., potato
chips). Estimates 5-pound weight gain. His wife thinks their
granddaughter had a viral illness recently. Daughter works in
___. Denies fevers/chills, LH/dizziness, chest pain,
palpitations, N/V/D/C.
Of note, patient is scheduled for elective right hemicolectomy
on ___ in the setting of 4-cm IC/ascending colon tubulovillous
adenoma. He is quite anxious in that regard.
Past Medical History:
-1. CARDIAC RISK FACTORS
-Hypertension
-Dyslipidemia
2. CARDIAC HISTORY
-Coronaries: 3-vessel CABG (RIMA to LAD; LIMA sequential OM1,
OM2; SVG to PDA, PLB)
-Chronic systolic heart failure (LVEF = 41% on nuclear stress
___ infarct-mediated cardiomyopathy
-Persistent atrial fibrillation s/p DCCV ___
-Dual chamber pacemaker post-CABG -> CRT-P (___)
3. OTHER PAST MEDICAL HISTORY
-PNA (___)
-Tubulovillous adenoma (IC/ascending colon)
-OSA on CPAP
apnea: does not tolerate CPAP
Social History:
___
Family History:
Multiple family members with MIs in ___
Physical Exam:
ADMISSION EXAM
===============
VS: T 97.2 axillary, HR 60 (paced), BP 133/65 (MAP 81), RR
mid-high ___, 93% on 5LNC
GENERAL: NAD, sitting upright, conversational dyspnea
HEENT: PERRL/EOMI, MMM, no conjunctival pallor, anicteric
sclerae, no oropharyngeal lesions, no xanthelasma
NECK: supple, JVD mandibular angle, hepatojugular reflux
CV: RRR, S1/S2, no m/r/g, heart sounds distant
PULM: nasal flaring, otherwise unlabored, decreased bibasilar
breath sounds, diffuse inspiratory wheezes
GI: obese, soft, mild distention, non-tender, normoactive BS, no
organomegaly
EXT: warm, well perfused, without edema
NEURO: non-focal
DISCHARGE EXAM
===============
VS: T 98.3, BP 100/58, HR 60, RR 20, O2 97% on RA
GENERAL: NAD, sitting upright, conversational dyspnea
HEENT: PERRL/EOMI, MMM, no conjunctival pallor, anicteric
sclerae, no oropharyngeal lesions, no xanthelasma
NECK: supple, JVD mandibular angle, hepatojugular reflux
CV: RRR, S1/S2, no m/r/g, heart sounds distant
PULM: CTAB
GI: obese, soft, mild distention, non-tender, normoactive BS, no
organamegaly
EXT: warm, well perfused, without edema
NEURO: non-focal
Pertinent Results:
ADMISSION LABS
===============
___ 05:07PM WBC-10.7* RBC-3.56* HGB-11.3* HCT-33.2*
MCV-93 MCH-31.7 MCHC-34.0 RDW-14.7 RDWSD-49.9*
___ 05:07PM NEUTS-81.0* LYMPHS-9.0* MONOS-8.8 EOS-0.4*
BASOS-0.4 IM ___ AbsNeut-8.67* AbsLymp-0.96* AbsMono-0.94*
AbsEos-0.04 AbsBaso-0.04
___ 05:07PM PLT COUNT-159
___ 05:07PM GLUCOSE-120* UREA N-14 CREAT-0.9 SODIUM-142
POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-23 ANION GAP-14
___ 05:07PM cTropnT-<0.01
___ 12:56AM cTropnT-<0.01
___ 05:07PM proBNP-___*
STUDIES/IMAGING
=================
CXR ___
Mild pulmonary edema with small bilateral pleural effusions and
bibasilar
atelectasis, new since the previous exam.
TTE ___
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is moderate regional left ventricular
systolic dysfunction with inferoposterior akinesis and focal
akinesis of the distal septum/apex (multivessel CAD). There is
mild hypokinesis of the remaining segments (LVEF = 30%). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are mildly thickened.
Mild (1+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction, c/w multivessel CAD. Mild mitral regurgitation.
Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
additional distal LAD-territory LV dysfunction is seen, although
might have been previously present (both studies were
technically difficult, but contrast was used for the current
study).
TTE ___ (focused)
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast at rest.
MICROBIOLOGY
=============
U/A ___: small blood, negative for infection
DISCHARGE LABS
===============
___ 07:40AM BLOOD WBC-10.3* RBC-4.32* Hgb-13.1* Hct-40.1
MCV-93 MCH-30.3 MCHC-32.7 RDW-14.2 RDWSD-48.5* Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-147* UreaN-25* Creat-1.2 Na-140
K-3.2* Cl-101 HCO3-22 AnGap-17*
___ 07:40AM BLOOD Calcium-9.2 Phos-4.7* Mg-2.1
Brief Hospital Course:
Mr. ___ is a ___ male w/ h/o CAB s/p remote CABG,
HFrEF ___ infarct-mediated CMP, persistent atrial fibrillation
admitted for acute hypoxic respiratory failure, requiring NIPPV,
in the context of acute on chronic systolic heart failure.
#) CORONARIES: 3-vessel CABG (RIMA to LAD; LIMA sequential OM1,
OM2; SVG to PDA, PLB)
#) PUMP: LVEF = 41%, inferior/inferolateral wall hypokinesis
#) RHYTHM: paced
#) Acute on chronic systolic heart failure: without cardiogenic
shock. Provocation was felt to be likely related to viral
respiratory illness vs dietary indiscretion. There was no
historical or laboratory evidence of ischemia. The patient was
diuresed with IV Lasix and able to be weaned to room air. He
still remained mildly hypoxic to high ___ low ___ on RA
(particularly in the morning and while laying down), despite pt
appearing euvolemic. The low sats were likely secondary to due
to underlying pulmonary disease as discussed below (OSA not
fully compliant w/ CPAP, restrictive/obstructive disease by
PFTs). The patient was transitioned to oral dose of Torsemide
20mg as a maintenance diuretic. He was continued on home
sacubitril/valsartan ___ mg BID as well as carvediol 6.25mg
BID and spironolactone 25mg QD. His weight was 93.7 kg on day of
discharge.
#) Acute hypoxic respiratory failure: On admission suspected
that respiratory distress was due to cardiogenic pulmonary
edema. He had a minor leukocytosis, but remained afebrile
without hemodynamic instability or consolidation to suggest
pneumonia and furthermore improved without antibiotics. He
continued to be slightly hypoxic despite successful diuresis,
likely secondary to underlying pulmary disease. His outpatient
pulmonology notes/ PFTs were reviewed and notable for PFTs w/
restrictive defect and diffusion abnormalities suggestive of
interstitial process, however CT chest w/o evidence of
interstitial lung disease. He also has a history of OSA and
probable component of obesity hypoventilation syndrome. He was
diuresed as above and continued on CPAP at night. He was weaned
to room air by the time of discharge.
#) Atrial fibrillation, persistent: s/p DCCV ___
with recurrence. The patient was continued on home amiodarone
and apixaban. He was noted to be AV paced throughout admission.
Recommend consideration of cardioversion as an outpatient after
colon surgery.
#) 3-vessel CAD s/p remote CABG complicated by complete heart
block requiring pacer. ___ CRT-P upgrade in ___. Grafts
were noted to be patent in ___. A recent nuclear stress test
was unchanged, as above. There was no evidence of ischemia on
admission. OF note, the patient was not on ASA at home. He was
continued on home atorvastatin.
#) OSA: formally diagnosed on recent PSG. Uses CPAP and 2L O2 in
evening at home. He was continued on nocturnal CPAP. Patient may
benefit from changing CPAP mask for comfort to improve
compliance.
#) Mood-anxiety disorder: The patient was very anxious
throughout admission, attributed to impending colorectal surgery
and current health problems. Wife also w/ significant anxiety,
and both appeared to have had difficulty coping w/ current
health issues. The patient was continued on home sertraline and
alprazolam. Social work was consulted to assist in patient and
family coping.
#) Tubulovillous adenoma, ascending colon: Patient was recently
found to have a tubulovillous adenoma and had an elective
laparoscopic right hemicolectomy scheduled for ___. The mass is
not amenable to endoscopic resection Surgery was deferred to
later date pending discharge of this admission. He is in stable
condition from a cardiac perspective and should have surgery
rescheduled for earliest possible date.
TRANSITIONAL ISSUES
=====================
[ ] Pt w/ history of coronary artery disease s/p CABG, however
not on ASA. Consider restarting after colorectal surgery
[ ] Plans for cardioversion for Afib after colorectal surgery
[ ] Uptitrate coreg as able
[ ] Pt started Torsemide 20mg qday
[ ] Recommend adjusting CPAP mask to improve compliance
[ ] Weight on discharge 93.7 kg. Creatinine 1.2.
[ ] Asymptomatic hematuria noted this admission after foley
removal. Please repeat UA.
# CONTACT/HCP: ___, wife (___)
# CODE: FULL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Apixaban 5 mg PO BID
3. Atorvastatin 40 mg PO QPM
4. Carvedilol 12.5 mg PO BID
5. Furosemide 20 mg PO DAILY
6. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
7. Sertraline 200 mg PO DAILY
8. Spironolactone 25 mg PO DAILY
9. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
10. ALPRAZolam 1 mg PO TID:PRN anxiety
Discharge Medications:
1. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Carvedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
4. ALPRAZolam 1 mg PO TID:PRN anxiety
5. Amiodarone 200 mg PO DAILY
6. Apixaban 5 mg PO BID
7. Atorvastatin 40 mg PO QPM
8. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
9. Sertraline 200 mg PO DAILY
10. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
#Acute on Chronic Systolic Heart Failure
#Coronary Arterial Disease
#Obstructive Sleep Apnea
#Acute Hypoxic Respiratory Failure
Secondary Diagonosis:
#Atrial Fibrillation
#Tubulovillous adenoma in ascending colon
#Mood anxiety disorder
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 on this hospital stay at
___.
Why was I admitted?
- You were admitted to the hospital for a heart failure
exacerbation.
What happened while I was admitted?
- You were treated with medications to take fluids off
(diuretics)
- You were started on a new medication, Torsemide, to continue
taking instead of Furosemide
- Your carvedilol dose was decreased
What should I do after I am discharged?
- Your discharge weight was 93.7 kg Weigh yourself every
morning, call MD if weight goes up more than 3 lbs.
- Please take your medications as directed
- Please try to use your sleep machine (CPAP) every night when
you are sleeping. If you find that you are not able to adjust to
the mask, please talk to your pulmonologist or primary doctor
about trying different masks.
Wishing you the best!
Your ___ Care Team
Followup Instructions:
___
|
10287015-DS-6 | 10,287,015 | 27,614,346 | DS | 6 | 2170-02-12 00:00:00 | 2170-02-12 18:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
adhesive tape
Attending: ___
Chief Complaint:
aphasia
Major Surgical or Invasive Procedure:
tPA
Mechanical ventilation
History of Present Illness:
___ is a ___ year-old right handed male with a
PMHx of possible HTN (wife says he may only be on
antihypertensives due to heart disease), HL, DM c/b retinopathy,
CAD s/p triple bypass, and AAA who presents with acute onset
expressive aphasia (only able to say "okay") and is now s/p tPA.
His last known normal time was 5:30pm on ___ at which time his
wife spoke to him while he was sitting on the couch and watching
TV. At 6pm, she noted that he was only saying, "Ok." He was only
able to tell her her name after ___ 10 minute delay. He was unable
to say his own name or the date. He has never had similar
symptoms before. She did not notice a facial droop or any
weakness. His wife suggested that she take him to the ED, but he
was very resistant, saying "No, no, no." At 6:30pm, she called
EMS. Per his wife, he was initially following more commands than
at the time of interview (could initially name ___ "cup" and could
walk around/ambulate to command). He presented to ___,
and he was noted to have an NIHSS of 4 (R facial, LOC qs,
aphasia, complex commands). Per his wife, he was intermittently
belligerent at the OSH. After a telestroke was initiated, tPA
was
started at 20:01. He began vomiting before tPA was initiated. En
route to ___, EMS noted that the patient only received
55mg/62mg of tPA due to a line problem.
At baseline, he performs all iADLs and ADLS (except wife helps
him with medications). He drove without difficulty prior to
symptom onset on ___.
Past Medical History:
DM
CAD s/p triple bypass (___)
R femoral/R popliteal surgery x2
?HTN (per wife, he is only on antihypertensives due to his
heart)
HL
DM retinopathy
AAA
Social History:
___
Family History:
Father with CAD and stroke (age ___. Mother with kidney cancer.
Physical Exam:
===ADMISSION EXAM===
General: Awake, eyes open to voice, regards, intermittently
agitated (trying to get off CT scanner), vomiting
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, No nuchal rigidity
Pulmonary: no work of breathing
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Neurologic:
Please see top of note for NIHSS.
-Mental Status: Alert, eyes open to voice, regards,
intermittently agitated, saying "okay" repeatedly when asked a
question. Unable to answer any other questions. Does follow
midline commands. Also mimics (e.g., lift up arm). Does not
consistently do appendicular or cross-body commands. Does not
answer orientation questions or participate in language,
attention, or memory testing..
-Cranial Nerves:
II, III, IV, VI: PERRL 4 to 2mm and brisk. Does not cooperate
with EOM testing but eyes move in all directions with VORs. +BTT
bilaterally.
V: +corneals.
VII: +corneals. R NLFF.
XII: Tongue protrudes in midline.
-Motor: Normal bulk and tone. No pronation, no drift. Moving all
limbs antigravity without apparent asymmetry. Does not cooperate
with formal manual motor testing.
-Sensory: Withdraws briskly to light stim in lower extremities,
localizes in uppers
-DTRs: diffusely brisk, toes down
-Coordination and gait: deferred
===DISCHARGE EXAM===
Vitals within normal limits
Gen: awake, alert, comfortable, in no acute distress
HEENT: normocephalic atraumatic, no oropharyngeal lesions
CV: warm, well perfused
Pulm: breathing non labored on room air
Extremities: no cyanosis/clubbing or edema
Neurologic:
-MS: Awake, alert, oriented to self, place, time and situation.
He is somewhat inattentive; able to say months of the year
backwards with difficulty. Naming intact to high and low
frequency objects. Can follow simple and cross body commands,
but struggles with complex commands. Unable to explain who
survived in "the lion was eaten by the tiger" phrase. Speech
fluent, no dysarthria. No evidence of hemineglect.
-CN: Gaze congjugate, ___, EOMI no nystagmus, face symmetric,
palate elevates symmetrically, tongue midline
-Motor: normal bulk and tone. Muscle strength ___ in bilateral
upper and lower extremities. No tremor or asterixis.
-Sensory: intact to LT and proprioception in bilateral UE and ___
-Coordination: finger nose finger intact, no dysmetria
-Gait: narrow based, no ataxia or sway
Pertinent Results:
===ADMISSION LABS===
___ 09:45PM BLOOD WBC-12.9* RBC-3.30* Hgb-10.7* Hct-31.8*
MCV-96 MCH-32.4* MCHC-33.6 RDW-12.9 RDWSD-45.1 Plt ___
___ 11:58PM BLOOD Neuts-85.1* Lymphs-9.2* Monos-4.7*
Eos-0.2* Baso-0.3 Im ___ AbsNeut-9.32* AbsLymp-1.01*
AbsMono-0.52 AbsEos-0.02* AbsBaso-0.03
___ 11:21PM BLOOD ___ PTT-22.5* ___
___ 09:45PM BLOOD Glucose-154* UreaN-29* Creat-1.4* Na-137
K-6.2* Cl-97 HCO3-18* AnGap-28*
___ 11:58PM BLOOD ALT-19 AST-20 AlkPhos-42 TotBili-0.4
___ 11:58PM BLOOD Lipase-27
___ 11:58PM BLOOD cTropnT-<0.01
___ 09:45PM BLOOD Calcium-9.4 Phos-4.9* Mg-1.4*
___ 11:58PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:02AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-100 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:02AM URINE RBC-<1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
___ 05:30AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
===RELEVANT IMAGING===
___ CTA
1. No evidence of hemorrhage or infarction. Please note that
MRI is more sensitive for detection of acute ischemia if there
is high clinical concern.
2. Heavy atherosclerotic calcifications moderately narrowing the
proximal V1 segment of the left vertebral artery. The vertebral
arteries are patent.
3. Heavy atherosclerotic calcifications at the carotid
bifurcations extending into the proximal internal carotid
arteries result in less than 20% luminal narrowing by NASCET
criteria.
4. Unremarkable head CTA aside from confluent calcified
atherosclerotic plaque along the cavernous and paraclinoid
segments of the internal carotid arteries.
5. Partially imaged lung apices is notable for moderate
centrilobular
emphysema.
6. Left maxillary sinus disease in association with periapical
lucency of the proximal left maxillary molar. Correlation with
dental examination is recommended to assess for active
infection.
___ CXR
Median sternotomy wires are intact. There is mild cardiomegaly.
There is no pneumothorax or pleural effusion. There is no
focal lung consolidation. There is a lobulated calcific density
projecting in the region of the posterior left seventh rib, on
subsequent chest radiographs from the same day, this represents
irregularity of the distal scapula, possibly from prior injury.
___ MRI
1. There is no evidence of acute intracranial process or
hemorrhage.
2. Scattered foci of high signal intensity detected on FLAIR
and T2 weighted images, distributed in the subcortical and
periventricular white matter, are nonspecific and may reflect
changes due to small vessel disease.
3. There is no evidence of abnormal enhancement after contrast
administration.
Brief Hospital Course:
Mr. ___ was transported to ___ after tPA
administration at an outside hospital after an episode of
expressive aphasia. While in the Emergency Department, the
patient had several episodes of emesis, with progressive
somnolence. He was intubated in the ED for airway protection. He
was noted to be febrile to 104, with lactate of 3.1. Given
concern for CNS infection, he was started on broad spectrum
antibiotics. He was quickly weaned to spontaneous breathing
modes. An MRI was obtained while he was intubated which did not
show infarcts, or evidence of a CNS infection. An echocardiogram
was similarly unremarkable. He was extubated to room air on
hospital day 2. His clinical history and essentially normal exam
s/p extubation suggested low likelihood of a CNS infection;
antibiotics were subsequently discontinued with no subsequent
evidence of worsening infection. The most likely cause of his
presenting symptoms was felt to be due to either a TIA or a
seizure. He was monitored on cvEEG which showed generalized
slowing indicative of encephalopathy. Of note, his CTA did show
a significant amount of intracranial atherosclerosis. Given his
risk factors, aspirin was switched to Plavix. We attempted to
contact the patient's cardiologist to discuss whether aspirin
was recommended in addition to Plavix in the setting of his
coronary artery disease. However, the Cardiologist was out of
the office for the week. Given that the patient strongly
preferred to be discharged from the hospital and would want to
discuss this with his cardiologist, we discharged him on Plavix
and Cardiology follow up at the earliest availability.
Decision made to hold standing anti epileptic drug at this time.
Patient was recommended for Neurology follow up, but preferred
to follow up with ___ Neurology. He was given the contact
information for ___ Neurology and informed that he would need a
referral from PCP.
___ (likely in setting of CKD)
___ noted with peak creatinine 1.6. Improved with fluid
administration.
#HTN
Home lisinopril briefly held for rising creatinine, as above.
Atenolol also held due to transient soft blood pressures. These
were restarted prior to transfer out of the ICU and continued on
the floor.
#IDDM
Continued on reduced dose glargine while admitted, with sliding
scale. His hemoglobin A1c was 7.6.
#Disposition: Patient was cleared for discharge home by ___
with services.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done
2. DVT Prophylaxis administered? (x) Yes - >24 hours after tPA
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes
4. LDL documented? (x) Yes (LDL = 42)
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes
6. Smoking cessation counseling given? (x) No [reason (x)
non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes
8. Assessment for rehabilitation or rehab services considered?
(x) Yes
9. Discharged on statin therapy? (x) Yes
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN XR (Glucophage XR) 1500 mg PO QAM
2. MetFORMIN XR (Glucophage XR) 750 mg PO QPM
3. Lisinopril 20 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Atenolol 25 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Aspirin 81 mg PO DAILY
8. Calcium Carbonate 500 mg PO DAILY
9. Glargine 22 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Glargine 22 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
3. Atenolol 25 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Calcium Carbonate 500 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
8. MetFORMIN XR (Glucophage XR) 1500 mg PO QAM
9. MetFORMIN XR (Glucophage XR) 750 mg PO QPM
Do Not Crush
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Transient Ischemic Attack (TIA)
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of difficulty speaking
resulting from a TRANSIENT ISCHEMIC ATTACK, a condition where a
blood vessel providing oxygen and nutrients to the brain is
transiently blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
We assessed you for medical conditions that might raise your
risk of having a transient ischemic attack or stroke. In order
to prevent future strokes, we plan to modify those risk factors.
Your risk factors are:
-heart disease
-diabetes
-high blood pressure
-high cholesterol
We are changing your medications as follows:
-Changed your aspirin to Plavix
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10287049-DS-8 | 10,287,049 | 29,973,929 | DS | 8 | 2163-10-07 00:00:00 | 2163-10-07 16:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
___ Cardiac Catheterization: 3v CAD. Successful placement
of PCI of Left circumflex with DES
attach
Pertinent Results:
ADMISSION LABS:
==============
___ 11:20PM BLOOD WBC-5.8 RBC-4.43* Hgb-15.0 Hct-43.7
MCV-99* MCH-33.9* MCHC-34.3 RDW-12.9 RDWSD-46.3 Plt ___
___ 11:20PM BLOOD Neuts-63.1 ___ Monos-10.0 Eos-2.4
Baso-0.5 Im ___ AbsNeut-3.66 AbsLymp-1.35 AbsMono-0.58
AbsEos-0.14 AbsBaso-0.03
___ 11:20PM BLOOD Glucose-130* UreaN-15 Creat-0.9 Na-141
K-4.4 Cl-106 HCO3-21* AnGap-14
___ 11:20PM BLOOD cTropnT-0.16*
PERTINENT LABS:
===============
___ 02:30AM BLOOD cTropnT-0.18*
___ 08:20AM BLOOD cTropnT-0.25*
___ 07:00AM BLOOD cTropnT-0.51*
MICROBIOLOGY:
=============
___ 07:56AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 07:56AM URINE Blood-MOD* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 07:56AM URINE RBC->182* WBC-13* Bacteri-FEW* Yeast-NONE
Epi-0
___ 7:56 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
========
CXR, ___:
IMPRESSION:
Mild cardiomegaly with pulmonary vascular congestion.
Cardiac Catheterization, ___:
Three vessel coronary artery disease.
Successful target lesion PCI of the left circumflex
TTE, ___:
IMPRESSION: Biatrial dilatation. Normal biventricular wall
thickness, cavity size, and regional/
global systolic function. Echocardiographic evidence for
diastolic dysfunction with elevated
PCWP. Mild mitral regurgitation. Mild pulmonary hypertension.
DISCHARGE LABS:
===============
___ 07:00AM BLOOD WBC-6.2 RBC-4.23* Hgb-14.2 Hct-41.9
MCV-99* MCH-33.6* MCHC-33.9 RDW-13.0 RDWSD-47.2* Plt ___
___ 07:00AM BLOOD Glucose-96 UreaN-11 Creat-0.8 Na-141
K-4.4 Cl-108 HCO3-22 AnGap-11
___ 07:00AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.9
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[]Follow up with cardiology regarding recent NSTEMI s/p DES to
proximal L circumflex. Patient found with 3v disease and may
benefit from CABG ultimately.
[]Consider switching amlodipine to ___, or adding on if
pressures tolerate. Of note, patient has tried lisinopril in the
past but did not tolerate due to side effects.
[]Follow up HRs. During this admission HRs between 40-60s and
asymptomatic. For this reason, beta blockade was deferred.
BRIEF HOSPITAL COURSE:
======================
___ with a Hx of HTN and CAD presented with CP that was
exertional, described as a substernal pressure, and improved
with rest. In the emergency department he had an EKG revealing
for sinus rhythm, ST depressions in V4-6 with TWI in III, AVF as
well as RBBB (unclear if new) with rising troponin from 0.16 to
0.25. He was given atorvastatin, ASA, and started on a heparin
gtt prior to arrival to cath lab. Patient underwent cath with R
radial access and was found to have 50% ostial L main stenosis,
90% stenosis of L circumflex, and CTO of RCA. Patient elected to
receive PCI to L circumflex. He had a DES placed at this lesion
and he received loading dose of Plavix. The following day the
patient was continued on aspirin 81 mg, Plavix 75 mg, and
atorvastatin 80 mg. He was free of chest pain and shortness of
breath.
DISCHARGE WEIGHT: 186 lbs
DISCHARGE Cr: 0.8
CODE: Full
CONTACT: ___ (___)
Relationship: wife
Phone number: ___
ACTIVE ISSUES:
==============
#NSTEMI s/p DES to pLCx:
#CAD
Patient presented with a few months history of CP and associated
DOE. Per the patient, he had experienced two episodes the week
prior of substernal chest pressure without associated radiating
symptoms that was provoked by walking ___ blocks and resolved
with rest after 5 minutes. The day of admission he had
experienced a similar chest pain that was greater in intensity
and persisted for 15 minutes even after lying down. In the ED he
was found to be stable with an EKG revealing for sinus rhythm,
ST depressions in leads V4-6, TWI in leads III and aVF and a
RBBB (unclear if new). Patient was found to have a rising
troponin, from 0.16 to 0.25. He was started on heparin gtt and
given full dose ASA with a statin. He then underwent cardiac
catheterization with R radial access. He was found to have 50%
ostial L main stenosis, 90% stenosis of L circumflex, and CTO of
RCA. Patient elected to receive PCI to L circumflex. He had a
DES placed at this lesion and he received loading dose of
Plavix. The following day patient was free of chest pain and
without shortness of breath. He was continued on 81 mg ASA, 80
mg atorvastatin, and 75 mg Plavix. He had a TTE which revealed
normal biventricular systolic function. Given bradycardia in
40-60s throughout admission, beta blockade was not given. In
addition given normotension deferred starting ___ on this
admission; of note, in the past patient had tried lisinopril,
but this was discontinued due to side effects.
#HTN
Patient's blood pressures within normal range throughout
admission. He was continued on 5 mg amlodipine daily.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*0
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain
Please take 1 tab every 5 minutes as needed for chest pain
RX *nitroglycerin 0.3 mg 1 tablet(s) sublingually q5min PRN Disp
#*30 Tablet Refills:*0
5. amLODIPine 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
NSTEMI
CAD
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
=====================================
- You were admitted to the hospital because you had chest pain
that was found to be due to a heart attack.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
============================================
- You were given several medications for your heart attack and
you underwent a procedure to place a stent in a blocked artery
within your heart.
WHAT SHOULD I DO WHEN I GO HOME?
==================================
- You should continue to take your medications as prescribed.
- If you are experiencing new or concerning chest pain that is
coming and going you should call the heartline at ___.
If you are experiencing persistent chest pain that isnt getting
better with rest or nitroglycerine you should call ___.
- You should also call the heartline if you develop swelling in
your legs, abdominal distention, or shortness of breath at
night.
- You should attend the appointments listed below.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10287060-DS-10 | 10,287,060 | 23,334,511 | DS | 10 | 2173-01-29 00:00:00 | 2173-01-29 18:31:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Fever, cough, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a pleasant ___ year old male with a past medical
history of seasonal allergies, eczema, asthma and a right sided
pneumothorax secondary to rib fractures (___) presenting with a
productive cough, fever, dyspnea and n/v x ___ days.
Approximately 1 month ago the patient noticed a dry cough
associated with intermittent SOB. He attributed these symptoms
to allergies, asthma and post-nasal drip. His symptoms continued
for an additional 3 weeks at which time he had a bad "asthma
attack" and went to the ___ ED. He was administered
a nebulizer treatment and prescribed Combivent. Over the last 4
days his symptoms have worsened and he developed fevers, chills,
fatigue and a cough productive of yellow/green, non-bloody
sputum. Prior to the onset of fevers his phlegm was clear. He
reports SOB, worsened by exertion, no pleuritic pain and no sore
throat. He also developed nausea/vomiting 3 days PTA and the
inability to tolerate PO the day PTA. He vomited once 2 days
PTA, and once in-house. He denies abdominal pain, diarrhea and
constipation. He has been voiding well. He states his
temperature 3 days PTA was ~100, 1 day PTA 103. He was evaluated
at the ___ clinic on ___ and found to have a temp of 101.9,
O2sat 91% on RA, HR of 124 and BP of 137/87. He was noted to
have coarse breath sounds bilaterally and rhonchi L>R. He states
nothing this serious has happened to him before and he denies a
history of pneumonia. He reports his asthma symptoms worsen with
mowing the lawn, raking leaves. He reports he has mold in his
house. He reports occasional sinus headaches improved with a
Neti pot. He suffered a motorcycle accident one year ago in
which he fractured six ribs and suffered a pneumothorax on the
right.
-In the ED, initial VS were 102.4 115 130/74 20 88%. Labs were
significant for serum sodium 132, WBC 12.5 (no bands), BUN/Cr
___ and lactate 1.6. Imaging significant for a CXR with acute
parenchymal infiltrates in LUL lingula and RLL posterior
segment, and multiple healed right sided rib fractures.
-Received Levofloxacin 750mg Premix Bag and IVFs. Blood cultures
drawn.
-Transfer VS 99.2 95 137/75 22 97%.
REVIEW OF SYSTEMS:
(+) As above
(-) Denies night sweats, vision changes, syncope, dizziness,
rhinorrhea, congestion, sore throat, chest pain, palpitations,
abdominal pain, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria, myalgias, arthralgias, pallor
Past Medical History:
-Asthma
-Seasonal allergies
-Eczema
-S/p multiple right sided rib fractures (___, ___
-S/p right sided pneumothorax require CT placement (___, ___
-Depression
-Lichen planus
-Balanoposthitis, s/p adult circumscision
-H/o of hernias
-Constipation
-Spinal stenosis
-GERD
-Sleep-disordered breathing
Social History:
___
Family History:
Mother- tobacco abuse, died of lung cancer, age ___
Father- tobacco abuse, died from COPD, age ___, "melanoma" upper
lip
Bother- progressive supranuclear palsy (lives in ___, age
___
Sister- carpal tunnel syndrome, age ___
Children- none
Denies family history of asthma, HTN, HLD, DM, hypothyroidism,
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS T101 BP 148/86 HR 107 RR20 O2sat 94%RA
GEN: Alert, oriented, no acute distress
HEENT: NCAT MMM EOMI sclera anicteric, OP with ___ .5-1 cm
erythematous patches in the posterior oropharynx
NECK: supple, no JVD, no LAD
PULM: Ronchi worse in RLL, coarse breath sounds throughout
CV: RRR normal S1/S2, No MRG
ABD: soft NT ND normoactive bowel sounds, no palpable
hepatosplenomegaly, no rebound or guarding
EXT: WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: no ulcers or lesions
DISCHARGE PHYSICAL EXAM:
VS Tmax100 T 98.5 BP 114/77 (108-131/61-82) HR 74 (70-86) RR18
(18) O2sat 97%2L (95-98%RA)
GEN: Alert, oriented, no acute distress, two episodes of
coughing
HEENT: NCAT MMM sclera anicteric, OP with ~3 .5-1 cm mildly
erythematous patches in the posterior oropharynx
NECK: supple, no JVD, no LAD
PULM: Coarse expiratory sounds bilaterally, no wheezes
CV: RRR normal S1/S2, No MRG
ABD: soft, non-tender, non-distended, no palpable
hepatosplenomegaly, no rebound or guarding, +BS
EXT: WWP 2+ pulses palpable bilaterally, no c/c/e
SKIN: no ulcers or lesions
Pertinent Results:
Admission labs:
___ 02:00PM BLOOD WBC-12.5*# RBC-5.15 Hgb-15.6 Hct-45.1
MCV-88 MCH-30.3 MCHC-34.6 RDW-13.7 Plt ___
___ 02:00PM BLOOD ___ PTT-34.8 ___
___ 02:00PM BLOOD Glucose-121* UreaN-13 Creat-0.8 Na-132*
K-4.4 Cl-97 HCO3-23 AnGap-16
___ 02:00PM BLOOD ALT-40 AST-63* AlkPhos-101 TotBili-0.7
___ 08:00AM BLOOD Albumin-3.3* Calcium-7.6* Phos-2.0*
Mg-1.7
___ 08:00AM BLOOD %HbA1c-5.7 eAG-117
___ 02:19PM BLOOD Lactate-1.6
Discharge labs:
___ 08:00AM BLOOD WBC-11.4* RBC-4.10* Hgb-12.3* Hct-36.7*
MCV-89 MCH-29.9 MCHC-33.5 RDW-13.5 Plt ___
___ 08:00AM BLOOD UreaN-10 Creat-0.6 Na-137 K-3.7 Cl-102
HCO3-26 AnGap-13
___ 08:00AM BLOOD ALT-43* AST-36 AlkPhos-95 TotBili-0.5
___ 08:00AM BLOOD GGT-59
CXR
___
FINDINGS: PA and lateral chest views were obtained with patient
in upright
position. Analysis is performed in direct comparison with the
next preceding PA and lateral chest examination of ___. The heart size is normal. No configurational abnormality
exists. Mild widening and elongation of the thoracic aorta, but
unchanged in comparison with previous study. Remarkable overall
changes since the previous study is mild degree of volume loss
of the upper half right-sided hemithorax, apparently related to
multiple rib fractures ( ___ 4, 5, 6, 7 and possibly 8) now
already demonstrating some increased callus formation and mild
degree of a shortening. There are no new pulmonary
abnormalities in this area, although some decrease in volume be
note, following this, apparently significant chest trauma.
Assuming that the trauma did not involve the left hemithorax,
there are some new changes on the left side in the form of
poorly delineated parenchymal densities overlying the fourth rib
anteriorly , partially obliterating the cardiac left lateral
contour suggestive of a pulmonary parenchymal infiltrate in the
lingula. Comparison with the old study also suggests some new
densities on the right lung base resulting in a minor
parenchymal infiltrate in the right lower lobe posterior
segment. These densities show matching findings on the lateral
view.
IMPRESSION: Significant chest trauma in right side. Observe
that next
previous examination of ___ did not show similar
changes. Does patient have history of severe thorax trauma
during that time? Acute
parenchymal infiltrates in left upper lobe lingula as well as
right lower lobe posterior segment are probably new.. Followup
chest examination of the described new acute parenchymal
infiltrates is recommended after treatment.
Brief Hospital Course:
___ year old male with a past medical history of seasonal
allergies, eczema, asthma and a right sided pneumothorax
secondary to rib fractures (___) presenting with a
productive cough, fever, dyspnea and n/v x ___ days.
#FEVER,HYPOXEMIA
The patient has no known history of chronic lung disease, but
symptoms were considered within the context of his long standing
history of seasonal allergies and eczema, and reported asthma
(no official diagnosis). He had not been hospitalized in the
past 6 months. He was admitted on ___ and CXR that day
showed acute parenchymal infiltrates in the left upper lobe
lingula as well as right lower lobe posterior segment. Treatment
with levofloxacin 750mg IV Q24 was initiated for community
acquired pneumonia. Legionella was considered given coexisting
nausea and vomiting, however, urine antigen was negative. Sputum
and blood cultures were obtained on admission and were pending
at discharge. On ___ he reported improvement in his
cough, which was less frequent, drier, and less productive of
sputum. Levofloxacin was changed to PO on the second day of
admission. On ___ he continued to be afebrile and was
saturating in the high ___ on room air. His cough was
well-controlled with Guaifenesin-codeine phosphate 15 mL PO.
Throughout his hospitalization he reported bouts of chest
tightness improved with PRN nebulizers. A follow up CXR will be
performed at ___ weeks post-discharge.
#ELECTROLYTE ABNORMALITIES:
His electrolytes were monitored and repleted as necessary during
his hospitalization. On presentation he was hyponatremic with a
serum sodium of 132. We considered this most likely to be
hypovolemic hyponatremia, however, we also considered legionella
infection given it can present with pneumonia, GI symptoms, and
hyponatremia, but urine antigen was negative. We also considered
that pneumonia and other pulmonary processes by themselves may
stimulate ADH release. He received a 1L NS bolus on admission
and was continued on 125mL/hr NS overnight. On ___ 8:00
sodium 138, ___ 8:00 137. Urine electrolytes were wnl. His
calcium was low on ___ at 7.6, albumin was low at 3.3,
corrected Ca2+ 8.2. He received calcium carbonate 500mg PO/TID,
and ___ 8:00 it was 8.3. He also had hypophosphatemia
___ 8:00 2.0 and received Neutra-Phos 2 PKT PO/NG ONCE
and on ___ 8:00 phosphate was 2.1. His low phosphorus and
calcium levels may be secondary to a vitamin D deficiency which
should be evaluated as an outpatient.
#HEMATOCRIT DROP:
Mr. ___ has a history of mild anemia in ___, with HCTs
38-39. Hematocrit on admission ___ 14:00 was
___ 8:00 37.3--> ___ 13:30
___ 17:48 ___ 8:00 36.7. He was given
a 1L NS bolus ___ night, followed by 125mL NS/hr
overnight, and changed to 75mL NS/hr ___ morning. His
hematocrit drop was felt to be secondary to hemodilution. We
considered GI bleeding such as ___ tear given nausea,
vomiting, retching, and mild GI discomfort but he was guaiac
negative. Given his previous chest trauma one year ago with
broken ribs and his violent cough, we considered parenchymal
injury and hemothorax, as well as a hemorrhagic pneumonia. These
were considered unlikely when his hemotocrit stabilized and he
did not develop hemoptysis. He never showed overt signs of
hypovolemia.
#NAUSEA/VOMITING
He reported not tolerating POs since 2 days PTA. He reported
vomiting once on ___ and again ___ in house after
having jello. On ___ morning he had a normal breakfast
and sandwich for lunch and did not vomit but reported mild
nausea. On ___ he was changed to PO levofloxacin which he
tolerated well. On ___ he continued tolerating a regular
diet. Throughout his hospitalization he received Ondansetron 4
mg IV Q8H:PRN n/v. We considered his nausea and vomiting to
likely be constitutional symptoms related to pneumonia, but
obtained enzymes to evaluate for a hepatobiliary etiology.
Lactate was normal at 1.6, alkaline phosphate and total
bilirubin were wnl daily, LFTs were mildly elevated and trended
down ALT: 40-->46-->43, AST: 63-->53-->36 on ___ and
___ respectively. Given AST>ALT and in the context of
reportedly drinking a glass of wine a night we considered he
might be drinking more than reported. We obtained a GGT level to
evaluate for alcohol induced LFT elevation, which was normal at
59 (range ___. We also began a multivitamin.
#DEPRESSION: He has a history of depression for which he sees a
therapist and takes an antidepressant. He reported feeling sad
when he lost his job last year, and after being unable to find
another job. However, he reported he had received a good
severance package and was living well and not struggling
economically. He is considering finding work teaching ___ as
a Second Language. We continued his celexa 20mg PO daily
throughout his time in house. Throughout his hospitalization,
his depression appeared to be well controlled, he did not report
any suicidal ideations, and reported no vegetative symptoms. He
will continue to follow up with his outpatient therapist.
TRANSITIONAL ISSUES
*******************
-repeat CXR in ___ weeks
-follow up pending blood cultures
-follow up pending sputum cultures
-evaluate vitamin D status as outpatient
-consider PFTs and chronic therapy for asthma
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN sob/wheezing
Discharge Medications:
1. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN sob/wheezing
No need to take when using albuterol nebulizer.
RX *ipratropium-albuterol [Combivent] 18 mcg-103 mcg (90
mcg)/actuation ___ puffs inh Q6hr:prn Disp #*1 Unit Refills:*0
2. Citalopram 20 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth
once daily Disp #*30 Tablet Refills:*0
5. Guaifenesin-CODEINE Phosphate 15 mL PO Q6H:PRN cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL 5 mL by mouth Q6H:PRN
Disp ___ Milliliter Refills:*0
6. Levofloxacin 750 mg PO DAILY Duration: 4 Days
continue for 4 doses after discharge (___)
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth once
daily Disp #*4 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted for fever, cough and shortness
of breath. We diagnosed you with pneumonia and prescribed
antibiotics. Your fever and oxygen level improved. If you have
any questions regarding your hospitalization feel free to
contact your ___ providers.
Please take your medications as prescribed and follow up with
the appointments listed below.
The following changes were made to your medications:
STARTED levofloxacin
STARTED multivitamin
STARTED Guaifenesin-CODEINE cough syrup
Followup Instructions:
___
|
10287102-DS-20 | 10,287,102 | 29,226,433 | DS | 20 | 2150-11-08 00:00:00 | 2150-11-11 18:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending: ___
___ Complaint:
Stumbling for 3 days
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Ms. ___ is a ___ RH woman with recently diagnosed
right
lung mass (thought to be c/w malignancy; path pending), and
right
acoustic neuroma s/p XRT in ___ who presents with a three day
history of "stumbling". She had been in her USOH until three
days ago, when she noted that she was "stumbling" a bit more
than
usual. She states that she would note objects on her right
side,
but would be unable to manuever her body away from the object
and
would run into the object with the right side of her body. She
denies any weakness, inability to see the object or sensory
changes on her right side. No alteration of her sensorium. No
falls or any injuries. No slurring of her speech, difficulty
with comprehending verbal commands. She had a HA prior to her
lung biopsy three days prior to presentation (described as a
bitemporal "pressure" HA, that subsequently resolved). No N/V.
Concerned, she spoke with her PCP, who recommended that she come
to the ED for evaluation considering an MRI in ___ (routine
surveillance for acoustic neuroma) that was concerning for a new
left parietal lobe T2 hyperintensity (per atrius report; not
available to be viewed here).
In the ED, a NCHCT was performed and revealed a significant
hypodensity in the left parietal region ___, concerning for
edema.
Neurology was then invited to consult given these findings.
Past Medical History:
1. acoustic neuroma s/p XRT in ___ at the ___. Originally
p/w hearing loss and tinnitus. Has persistent right sided
tinnitus.
2. right rotator cuff surgery -- originally in ___ and revised
earlier this year.
3. osteopenia
Social History:
___
Family History:
No neurological dz. Father with bone cancer.
Physical Exam:
VS: 97.4 74 117/65 16 98%
Genl: Awake, alert, NAD
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally, no wheezes, rhonchi, rales
Abd: NABS, soft, NTND abdomen
Ext: No lower extremity edema bilaterally
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says ___
backwards. Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. Reading intact.
Registers ___, recalls ___ in 5 minutes. No evidence of apraxia
or neglect. Calculation intact with serial 7s and $1.75 = 7
quarters.
Cranial Nerves: Pupils equally round and reactive to light, 3 to
2 mm bilaterally. No RAPD. Visual fields are full to
confrontation. Extraocular movements intact bilaterally without
nystagmus. Sensation intact V1-V3. Facial movement symmetric.
Hearing intact to finger rub bilaterally. Palate elevation
symmetric. Sternocleidomastoid and trapezius full strength
bilaterally. Tongue midline, movements intact.
Motor: Normal bulk and tone bilaterally. No observed myoclonus,
asterixis, or tremor. No pronator drift.
Del Tri Bi WE FE FF IP H Q DF PF TE
R ___ ___ ___ ___
L ___ ___ ___ ___
Sensation: Intact to light touch and position sense. No
extinction to DSS.
Reflexes: 2+ and symmetric throughout. Toe downgoing on left and
mute on right.
Coordination: finger-nose-finger, finger-to-nose, fine finger
movements, and RAM normal.
Gait: Narrow based, steady. Able to tandem. Romberg negative.
Pertinent Results:
Admission Labs:
___ 04:55PM BLOOD WBC-7.9 RBC-4.27 Hgb-13.5 Hct-40.1 MCV-94
MCH-31.5 MCHC-33.5 RDW-12.9 Plt ___
___ 04:55PM BLOOD Neuts-76.0* Lymphs-16.3* Monos-5.3
Eos-2.0 Baso-0.4
___ 07:55PM BLOOD ___ PTT-36.9* ___
___ 04:55PM BLOOD Glucose-101* UreaN-14 Creat-0.6 Na-133
K-3.8 Cl-100 HCO3-24 AnGap-13
Imaging:
___
FINDINGS: A 10 x 9mm isodense mass in the left parasaggital
cerebral
hemisphere (2, 25) is noted with surrounding hypodensity
consistent with
vasogenic edema. There is no shift of normally midline
structures. The
ventricles and sulci are mildly prominent, consistent with
age-related
involutional changes. Bilateral mastoid air cells are clear.
Opacification is noted within the left sphenoid sinus.
Bilateral maxillary sinuses are clear. The globes are intact.
IMPRESSION:
1. A 10 x 9mm isodense mass in the left parasaggital cerebral
hemisphere (2, 25) is noted with surrounding vasogenic edema
suspicious for metastatic disease which should be further
evaluated with MRI.
2. Mucosal thickening within the right portion of the sphenoid
sinus.
MRI brain w/ and w/o contrast
FINDINGS: There is a 1.2-cm enhancing left parietal region with
surrounding vasogenic edema. The location at the gray-white
matter junction is suggestive of metastatic disease. In
addition, there is an approximately 1.5 x 7 mm enhancing lesion
in the right internal auditory canal extending to the
cerebellopontine angle. Given the location and the appearance
of the lesion, it is suggestive of a vestibular schwannoma more
likely than a metastatic lesion. There is no leptomeningeal
enhancement seen. There is no midline shift or hydrocephalus.
No acute infarcts are seen.
Tiny artifacts within the left frontal bone and both parietal
bones appear to be due to small metallic densities as seen in
the left frontal both parietal regions could be related to prior
trauma. Clinical correlation recommended.
IMPRESSION:
1. 1.2-cm enhancing mass in the left parietal lobe at the
gray-white matter junction suggestive of metastatic disease.
2. Right vestibular schwannoma.
3. Incidental right parietal developmental venous anomaly.
4. Small artifacts in the left frontal and both parietal bones
could be
related to prior trauma and correlate with the small metallic
densities seen on the CT.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a recently diagnosed lung
mass, presenting with complaints of running into objects on the
right side. She underwent a CT scan in the emergency
department, which showed a hypodense lesion with surrounding
edema concerning for metastasis. She underwent an MRI of the
brain with and without contrast which showed a solitary
enhancing mass in the left occipital lobe. She was seen by
Neuro-oncology, and the possiblity of SRS to the lesion.
Arrangements were made for her to be followed in the
multi-disciplinary brain tumor clinic the following day for
further discussion of treatment plans. Examination was notable
only for a very subtle right sided field cut, and she was
otherwise asymptomatic. She was discharged home, with plans for
PET scan, Neuro-oncology follow-up and Oncology follow-up during
the following week for further treatment.
Medications on Admission:
1. albuterol ___ puffs q4-6hrs prn wheezing
2. alendronate 70mg qweek
3. calcium-D3 500-200 1tab BID
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
2. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
3. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic brain tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted with concerns of running into
objects on your right side. You had an MRI of your brain which
showed a tumor in the part of your brain that controls vision on
the right. This is likely a metastasis from your lung mass. We
have arranged follow-up for you in the ___
___ clinic tomorrow where they will discuss further
treatment options.
If you notice any of the concerning symptoms listed below,
please return to the ED for further evaluation.
Followup Instructions:
___
|
10287348-DS-20 | 10,287,348 | 23,806,152 | DS | 20 | 2191-07-31 00:00:00 | 2191-08-02 05:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Egg
Attending: ___.
Chief Complaint:
BRBPR/Dark Stools
.
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ yo M h/o NASH cirrhosis with varices/GAVE (just banded last
week), multiple admissions for GI bleeds in setting of
asa/plavix for CAD who presents with BRBPR and dark stools x one
day. States he had four bowel movements yesterday and four more
this AM. He states he normally has ___ bowel movements daily and
this is not more than his normal pattern. He noted some dyspnea
and chest tightness yesterday evening, but has not had any
since. He denies abdominal pain/vomiting/nausea/hematemasis.
___ also notes a 12-lb weight gain in the past few days. He
does note increased abdominal distension. No changes in his
appetite. Denies dietary indiscretion and states he takes all of
his medications.
.
Of note the ___ had an EGD ___ and 2 cords of grade II
varices were seen in the GE junction. The varices were not
bleeding. 2 bands were successfully placed. 2 cords of grade I
varices were seen in the Mid-esophagus. The varices were not
bleeding at that time.
.
In the ED, initial VS were: 97.4 70 140/47 18 100%. Rectal exam
showed maroon guaiac positive stool. NG lavage was negative. Hct
23.0 (from 28.9 ___. Cr stable at 1.2. Started on
octreotide and pantoprazole gtts and given a dose of
ceftriaxone. Liver was contacted in the ED. EKG: NSR rate of 74,
no ischemic changes. Has 18G PIVs x 3, VS prior to transfer: 66
18 109/51 99% RA.
.
On arrival to the MICU, ___ feels well without complaints.
Past Medical History:
- CAD: CABG ___, stenting in ___ DES, cath in ___ all
grafts and stents patent. Cards Dr ___, ___. Recently
discontinue Plavix due to multiple GI bleeds.
- ___ cirrhosis: followed by Dr ___ distant h/o
ascites, encephalopathy, Grade 2 esophogeal varices, s/p banding
___.
- H/O obscure GI Bleed: gastric antral vascular ectasia (GAVE)
noted on EGD and AVMs noted on capsule, varices, diverticulosis,
and rectal varices
- DM II on insulin with frequent episodes of hypoglycemia in the
past
- TIA ___ followed by Dr ___
- Squamous cell carcinoma
- HTN
- HL
Social History:
___
Family History:
Brother with asthma. Mom with diabetes and breast cancer, sister
who had a heart attack in stroke in her ___ and father who died
of stomach cancer at age ___.
Physical Exam:
ADMISSION EXAM
Vitals: T:98.6 BP:111/49 P: 65 R: 16 O2: 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace edema in BLE.
Rectal: Guaiac positive brown stool
Neuro: NO focal deficits
DISCHARGE EXAM
VS: 98.2,67, 116/49 (116/49-129/61), 100 % RA
GENERAL: Well appearing M who appears stated age. Comfortable,
appropriate and in good humor
HEENT: Sclera icteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, S1 S2 clear and of good quality without murmurs, rubs
or gallops. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Distended but Soft, non-tender to palpation. Dullness
to percussion.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. no
peripheral edema
NEURO: CN II-XII intact, strength ___ bilaterally, sensation in
tact to light touch.
Pertinent Results:
Admission Labs:
___ 03:00PM BLOOD WBC-5.8 RBC-2.36* Hgb-7.2*# Hct-23.0*
MCV-98 MCH-30.6 MCHC-31.3 RDW-16.3* Plt ___
___ 03:00PM BLOOD Neuts-69.2 Lymphs-14.4* Monos-6.8
Eos-9.1* Baso-0.6
___ 03:00PM BLOOD ___ PTT-25.8 ___
___ 03:00PM BLOOD Glucose-139* UreaN-23* Creat-1.2 Na-131*
K-4.7 Cl-103 HCO3-21* AnGap-12
___ 03:00PM BLOOD ALT-37 AST-46* CK(CPK)-103 AlkPhos-82
TotBili-0.5
___ 04:42AM BLOOD Albumin-2.6* Calcium-7.4* Phos-4.0 Mg-2.2
.
Discharge Labs
___ 06:20AM BLOOD WBC-3.9* RBC-2.77* Hgb-8.5* Hct-26.1*
MCV-94 MCH-30.6 MCHC-32.5 RDW-16.2* Plt ___
___:20AM BLOOD Glucose-186* UreaN-14 Creat-1.0 Na-134
K-4.3 Cl-107 HCO3-20* AnGap-11
___ 06:20AM BLOOD ALT-28 AST-36 AlkPhos-66 TotBili-0.5
___ 03:00PM BLOOD CK-MB-3 cTropnT-<0.01
___ 11:11PM BLOOD CK-MB-3 cTropnT-<0.01
___ 04:42AM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:20AM BLOOD ___ PTT-27.6 ___
EGD:
Varices at the middle third of the esophagus and lower third of
the esophagus Two sites of recent banding visualized at the GE
junction, with one band still in place. Small overlying ulcer
seen without active bleeding. Erythema, and petechiae noted in
the antrum consistent with known GAVE. in the stomach Otherwise
normal EGD to second part of the duodenum
RUQ US
1. Known non-occlusive thrombus in the main portal vein within
the hepatic hilum is not visualized, possibly due to technical
factors. Intrahepatic portal veins, hepatic veins, and hepatic
arterial system are patent.
2. Shrunken nodular liver consistent with cirrhosis. No focal
hepatic lesions.
3. Mild gallbladder wall thickening likely related to chronic
liver disease. Known gallstones are not well seen, however,
there are no signs of acute cholecystitis.
4. Unchanged splenomegaly measuring 14 cm.
5. No intra- or extra-hepatic biliary dilatation.
6. Stable moderate ascites.
Brief Hospital Course:
Assessment and Plan: ___ yo M h/o NASH cirrhosis, recurrent GI
bleeds, CAD presenting with BRBPR and dark stools and a six
point Hct drop in 11 days.
.
ACTIVE ISSUES
.
# GI bleed: Given patients recent esophageal banding
presentation was most concerning for misplacement of the bands
or an ulcer around the recent bands. Differential also included
bleeding from AVMs, GAVE, esophageal varices (all seen on recent
EGD) as well as lower sources including diverticulosis and
rectal varices. ___ had a negative NG lavage. HCT was noted
to be 23 on admission from a baseline of around 30. The ___
was transfused 2 units PRBCs with appropriate increase in his
HCT. He underwent EGD which demonstrated an small ulcer at the
site of recent variceal banding in addition to extensive
gastropathy. It was ultimately felt that bleeding was likely
resultant from the ___ GAVE. ___ may require laser
ablation at a later date. Octreotide was discontinued and the
___ was transitioned to PO protonix. The patients HCT
remained stable and he was transferred to the floor where he was
noted to have a brown non bloody stool. The ___ was able to
tolerate a regular diet. HCT was 26.1 at the time of discharge.
.
# Weight Gain: ___ notes weight gain in past few days.
Weight on admission 211.4 lbs and was noted to be 201 on
___. Differential includes worsening portal
hypertension/cirrhosis, Congestive heart failure or renal
failure. Synthetic function and LFTs were stable. Normal
biventricular function in echo in ___ and Cr was at baseline.
RUQ US showed patent intrahepatic portal veins, hepatic veins,
and hepatic arteries. ___ be reflective of increased ascites
burden. The ___ was restarted on his home diuretics at the
time of discharge. He will follow-up with Dr. ___
up-titration of these medications.
.
# NASH Cirrhosis: ___ is followed by Dr. ___ in the
outpatient. Not on transplant list at present. As above home
furosemide/spironolactone/nadolol was held in the acute setting
and restarted at the time of discharge.
.
# Hyponatremia: Patients sodium was 131 on admission. This was
felt to likely be secondary to hypervolemic hyponatremia. Sodium
normalized and was 134 at the time of discharge.
.
STABLE ISSUES
.
# CAD: The ___ was chest pain free throughout admission. He
does have a significant history of coronary artery disease
requiring a CABG and stenting. The ___ recently stopped
plavix in early ___ due to recurrent GI bleeds. His home ASA
81 mg was held on admission. ___ will restart this
medication 2 days after discharge. He was continued on his home
atorvastatin and zetia.
.
# Hyperlipidemia: ___ was continued on his home atorvastatin
and zetia.
.
# Hypertension: Patients home lisinopril was held in the setting
of a GI bleed. This medications was restarted at the time of
discharge.
.
TRANSITIONAL ISSUES
- ___ will follow-up with Dr. ___
- ___ was full code throughout this admission
Medications on Admission:
1. rifaximin 550 mg Tablet PO BID
2. atorvastatin 20 mg PO DAILY
3. ezetimibe 10 mg Tablet PO DAILY
4. folic acid 1 mg PO DAILY
5. furosemide 20 mg PO once a day.
6. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day) as needed for < 3BMs per day: titrate to ___ BMs
daily.
7. nitroglycerin 0.1 mg/hr Patch 24 hr Sig: One Patch 24 hr
Transdermal Q24H
8. Protonix 40 mg Tablet PO twice a day.
9. spironolactone 50 mg Tablet PO DAILY
10. aspirin 81 mg One PO DAILY
11. coenzyme Q10 50 mg Capsule Sig: One (1) Capsule PO once a
day.
12. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. nadolol 20 mg PO DAILY
15. Lisinopril 2.5 mg daily
16. Lantus 35 units qhs
17. Novolog sliding scale
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Upper GI bleed
Gastric antral vascular ectasia (GAVE)
Esophageal Ulcer
Secondary Diagnosis
Non alcoholic steatohepatitis
Diabetes
Hyperlipidemia
Coronary Artery diease
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 while you were
admitted to ___. As you know you were
admitted because you had blood in your stool that was concerning
for a GI bleed. You blood counts were noted to be low and you
were given a blood transfusion. An endoscopy was performed that
showed a small ulcer where one of your varices had been banded
in addition to dilated vessels in your stomach which were likely
the source of the bleed. You blood counts were monitored closely
and remained stable. You were also started on antibiotics to
prevent infection. You will need to continue these for 3 more
days.
We made the following changes to your medications
1. START ciprofloxacin 500 mg daily for 3 more days
2. START Sucralfate 1 gram three times a day
3. STOP you aspirin for the next 2 days. You can restart this
medication on ___
You should continue to take all other medications as instructed.
Please feel free to call with any questions or concerns.
Followup Instructions:
___
|
10287348-DS-22 | 10,287,348 | 21,404,400 | DS | 22 | 2191-08-25 00:00:00 | 2191-08-25 20:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Egg / Latex / mayonaise
Attending: ___.
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
Small bowel enteroscopy
History of Present Illness:
___ male history of coronary disease status post
CABG/stents, insulin-dependent diabetes, cirrhosis with ascites
and varices, status post recent failed TIPS procedure,
transferred from outside hospital for evaluation of dizziness.
He reports that he has felt lightheaded for at least 1 week,
worse with positional changes but also occurring without
position changes. Denies sensation of room spinning. Reports
episodes of lightheadedness usually last minutes and resolve
spontaneously. He had worsening lightheadedness on day of
admission, lasting longer. Denies syncope. Has never had these
symptoms previously, although per last discharge summary he had
lightheadedness when diuretics were increased. He has been on
lasix 20mg daily and spironolactone 50mg daily. He was told by
outpatient hepatologist office to increase to lasix 40mg and
spironolactone 100mg yesterday but he did not do so given his
symptoms. He has been checking BPs during episodes of
lightheadedness and they have been systolic 110s. Blood sugars
range 75-100 during these episodes. He does have associated
nausea but no CP, SOB, headache, vision changes, neck stiffness.
Denies decrease in po intake; no vomiting or diarrhea to suggest
volume loss. He does have history of GI bleeding but has not had
hematemesis, melena, or hematochezia recently. Continues to have
3BMs daily despite not being on lactulose. He was seen at ___'s
office ___ for these symptoms; CBC was checked and Hct was
at baseline at 27. Orthostatic vital signs were not positive at
that time.
.
He was initially brought to ___ where labs were
largely unremarkable (Hct 25). He received 400-500cc normal
saline and ativan and was reportedly guaiac positive on rectal
exam. Per report, CXR, EKG, and U/A were unremarkable. At ___
ED, initial VS: 98 70 126/60 18 100%. Labs were not repeated.
.
Pt has had several recent hospitalizations. He was admitted to
___ ___ ___s ___ with GI bleeding that was
thought to be due to GAVE. EGD on ___ revealed grade 2
varices at ___ junction that were banded and grade 1 varices at
mid esophagus. He was also hospitalized ___ for
worsening abdominal distention and underwent paracentesis with
3L fluid removed. He also underwent TIPS procedure that was
unsuccessful. Uptitration of diuretics was attempted but pt
became lightheaded and pt was discharged with plans for
outpatient uptitration of diuretics.
Past Medical History:
- CAD: CABG ___, stenting in ___ DES, cath in ___ all
grafts and stents patent. Cards Dr ___, ___. Recently
discontinue Plavix due to multiple GI bleeds.
- ___ cirrhosis: followed by Dr ___ distant h/o
ascites, encephalopathy, Grade 2 esophogeal varices, s/p banding
___.
- H/O obscure GI Bleed: gastric antral vascular ectasia (GAVE)
noted on EGD and AVMs noted on capsule, varices, diverticulosis,
and rectal varices
- DM II on insulin with frequent episodes of hypoglycemia in the
past
- TIA ___ followed by Dr ___
- Squamous cell carcinoma
- HTN
- HL
Social History:
___
Family History:
Brother with asthma. Mom with diabetes and breast cancer, sister
who had a heart attack in stroke in her ___ and father who died
of stomach cancer at age ___.
Physical Exam:
VS - 98.2 139/61 66 18 100%RA ___ 202
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRL, 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, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT, mild-moderate abdominal distension ___
ascites, no masses or HSM
EXTREMITIES - WWP, trace ___ edema, 2+ peripheral pulses
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, cerebellar exam intact, no asterixis
Unchanged upon discharge
Pertinent Results:
Admission Labs:
___ 04:15AM BLOOD WBC-3.5* RBC-2.61* Hgb-8.1* Hct-24.2*
MCV-93 MCH-31.1 MCHC-33.6 RDW-16.2* Plt ___
___ 04:15AM BLOOD ___ PTT-27.8 ___
___ 04:15AM BLOOD Glucose-101* UreaN-18 Creat-1.0 Na-133
K-4.0 Cl-105 HCO3-22 AnGap-10
___ 04:15AM BLOOD ALT-28 AST-34 AlkPhos-74 TotBili-0.4
___ 04:15AM BLOOD Albumin-3.0* Calcium-7.9* Phos-3.3 Mg-2.1
Discharge Labs:
___ 04:20AM BLOOD WBC-3.5* RBC-2.63* Hgb-8.2* Hct-25.1*
MCV-95 MCH-31.2 MCHC-32.7 RDW-15.9* Plt ___
___ 04:20AM BLOOD Plt ___
___ 04:20AM BLOOD Glucose-116* UreaN-17 Creat-0.9 Na-134
K-4.1 Cl-104 HCO3-22 AnGap-12
___ 04:20AM BLOOD ALT-28 AST-36 LD(LDH)-210 AlkPhos-76
TotBili-0.4
___ 04:20AM BLOOD Albumin-3.1* Calcium-7.9* Phos-3.6 Mg-2.0
Pertinent Studies:
Small Bowel Enteroscopy
Impression: Varices at the mid esophagus
Esophageal ring
Streaking erythema and petechiae in the Antrum and prepylorus
compatible with GAVE
Mild erythema in the duodenum compatible with mild duodenitis
Erythema in the proximal jejunum compatible with mild jejunitis
Otherwise normal small bowel enteroscopy to mid jejunum
Recommendations: There was no cause found for the patient's
melena on this EGD
While there was GAVE noted in the antrum, it was only
mild-moderate with no stigmata of bleeding.
Consider capsule endoscopy for further evaluation
Additional notes: FINAL DIAGNOSES are listed in the impression
section above. Estimated blood loss = zero. No specimens were
taken for pathology. Patient's home medication list was
reconciled The patient's reconciled home medication list is
appended to this report. The attending was present for the
entire procedure
Brief Hospital Course:
Mr. ___ is a ___ male history of coronary disease
status post CABG/stents, ?TIA, insulin-dependent diabetes,
cirrhosis with ascites and varices, status post recent failed
TIPS procedure, transferred from outside hospital for evaluation
of dizziness.
.
# Lightheadedness: Potential causes of lightheadedness on
admission initially included orthostatic hypotension either due
to volume depletion (though no recent GI losses, reduced po
intake, or hypotension and orthostatic VS were normal), anemia
(though Hcts have been relatively stable in mid-high ___,
arrhythmia (no events on tele), episodes of hypo or
hyperglycemia (BS were WNL), or most likely vestibular
dysfunction. Given positive ___ with nystagmus likely
BPPV. Furthermore, dizziness occurs with motion while supine as
well as with orthostasis. A central process cannot be excluded,
however and vascular disease involving the posterior circulation
is possible. ___ was consulted for teaching regarding BPPV, and
he was referred to outpatient ___ rehab at ___. He was
referred to neurology on discharge.
.
# Melena/Hct Drop: Mr. ___ has slowly been losing blood per
rectum in the form of melena over the last several months. Given
his recurrent melena, an enteroscopy was performed which
re-demonstrated GAVE but did not discover a discreet lesion
causing his melena and hct drops. He will need a capsule
endoscopy as an outpatient.
.
# Cirrhosis: Pt with NASH cirrhosis complicatated by varices,
hepatic encephalopathy, and ascites. Rifaximin, nadolol,
pantoprazole, and lasix/spironolactone were continued.
.
# CAD: ASA, Ace inhibitor and statin were continued.
.
# Type II DM: Lantus 33units qhs with novolog sliding scale was
continued.
==============================
Transitional Issues:
Mr. ___ will require a capsule endoscopy as an outpatient.
Medications on Admission:
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tablet(s) by mouth po
daily
EZETIMIBE [ZETIA] - 10 mg Tablet - 1 Tablet(s) by mouth daily
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth daily
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth daily
INSULIN SLIDING SCALE - NOVOLOG
LANTUS - 33 units qHS
LISINOPRIL - 2.5 mg Tablet - 1 Tablet(s) by mouth dailiy
LOPERAMIDE - 2 mg Capsule - 1 Capsule(s) by mouth every four (4)
hours as needed for diarrhea
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - one
Tablet(s) by mouth twice a day
RIFAXIMIN [XIFAXAN] - (Prescribed by Other Provider) - 550 mg
Tablet - Tablet(s) by mouth twice a day
SPIRONOLACTONE - 50 mg Tablet - One Tablet(s) by mouth daily
ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth daily
COENZYME Q10 - (Prescribed by Other Provider) - 50 mg Capsule -
1 Capsule(s) by mouth once a day
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - (OTC) - 500 mcg
Tablet - 1 Tablet(s) by mouth daily
FERROUS SULFATE [IRON (FERROUS SULFATE)] - (OTC) - 325 mg (65 mg
iron) Tablet - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
11. nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. coenzyme Q10 50 mg Capsule Sig: One (1) Capsule PO once a
day.
14. Lantus 100 unit/mL Solution Sig: ___ (33) units
Subcutaneous at bedtime.
15. Physical Therapy Sig: One (1) session ___ times weekly as
needed for BPPV: OUTPATIENT ___ REHABILITATION.
Disp:*1 referral* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Benign paroxysmal positional vertigo (BPPV), mild
melena likely due to ___ cirrhosis
Secondary: Coronary artery disease s/p stenting, type 2 diabetes
mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
- You were admitted with dizziness, which you described as the
room spinning. On physical exam and working with physical
therapy, you were found to have benign paroxysmal positional
vertigo (BPPV), a condition where small stones in the fluid in
your ear make you dizzy when you change positions.
.
Because your hematocrit was lower than normal and you had dark
stools, we were concerned you could be bleeding from your GI
tract again. You underwent an endoscopy to evaluate this and
everything was stable - you still have mild varices and GAVE
(dilated small blood vessels). You should follow-up with a
capsule endoscopy as an outpatient - a pill with a camera in it
that you swallow, to more fully evaluate your small intestines.
.
-It is important that you continue to take your medications as
directed. We made no changes to your medications during this
admission.
.
** You should, however, set yourself up with outpatient physical
therapy specifically for ___. We also made you an
appointment to be seen in Neurology. **
.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.
Followup Instructions:
___
|
10287348-DS-24 | 10,287,348 | 28,908,079 | DS | 24 | 2191-12-21 00:00:00 | 2191-12-22 09:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Egg / Latex / mayonaise
Attending: ___
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo male with h/o cirrhosis with ascites and varices ___ NASH,
prior episode of hepatic encephalopathy, GAVE, status post
failed TIPS procedure, s/p thermal therapy in ___ for GAVE,
coronary disease status post CABG/stents, insulin-dependent
diabetes, presents to the ED with confusion and forgetfulness.
This morning he reports waking up and feeling confused, telling
his wife ___ things such as "where's the toothpick". He
also reports difficulties walking. Because he was confused the
also stays that he took a double dose of his medications this
morning including his lasix and spiranolactone. He initially
presented to an OSH where it was noted that his ammonia level
was 160 and his sodium was 129.
.
Of note, he reports that he has no taken lactulose since
___ since he is able to have have ___ BMs/day without this.
He has had increasing sleep over the past week and reports that
his walking has slowed. He does say that over the past week he's
had some cold-like symptoms including a dry cough. He states
that for the last day he's had some trouble initiating urination
which he's never had before and denies dysuria or fevers. He
also has had some some chronic episodic pain over the anterior
part of his right foot when he stands on it. He denies any
fevers
.
In the ED, initial vitals: 97.4 70 115/78 15 99%
His labs were notable for sodium = 124, K = 5.4. EKG NSR 69
NA/NI no peaked T-waves. RUQ U/S: not enough ascites to tap. UA
and UC was sent and he was admitted for managment of likely
hepatic encephalopathy.
Vitals prior to transfer: 97.6 73 128/61 20 100%
.
Currently, he feels much less confused and reports BM 2x since
come to to hospital. He denies any pain, nausea or vomiting. He
does feel that his abdomen is slightly more distended then his
baseline.
Past Medical History:
- CAD: CABG ___, stenting in ___ DES, cath in ___ all
grafts and stents patent. Cards Dr ___, ___. Recently
discontinue Plavix due to multiple GI bleeds.
- ___ cirrhosis: followed by Dr ___ distant h/o
ascites, encephalopathy, Grade 2 esophogeal varices, s/p banding
___.
- H/O obscure GI Bleed: gastric antral vascular ectasia (GAVE)
noted on EGD and AVMs noted on capsule, varices, diverticulosis,
and rectal varices
- DM II on insulin with frequent episodes of hypoglycemia in the
past
- TIA ___ followed by Dr ___
- ___ cell carcinoma
- HTN
- HL
Social History:
___
Family History:
- Father died at ___ of gastic cancer
- Mother had breast cancer in her ___
- Sister with a history of CAD
Physical Exam:
On Admission:
VS - Temp 97.8 F, BP 140/62 , HR 72, RR 18, O2-sat 100% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVP just above clavicles at 30
degress. neg hepatojugular reflex.
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use.
ABDOMEN - NABS, mildly bulging flanks, +fluid wave ,soft, NT, no
masses or HSM, no rebound/guarding.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions. No jaundice.
NEURO - awake, A&Ox3, able to recite days of week backwards,
+asterixis bilaterally, CNs II-XII intact, muscle strength ___
throughout, sensation to light touch intact throughout.
On Discharge:
PHYSICAL EXAM:
VS - Temp 98.1 F, BP 100-126/60-64, HR 66-77, RR 18, O2-sat
95-98% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM.
NECK - supple, no thyromegaly, JVP low
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use.
ABDOMEN - NABS, no fluid wave, soft, NT, no masses or HSM, no
rebound/guarding.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions. No jaundice.
NEURO - awake, A&Ox3, able to recite days of the week backwards,
no asterixis bilaterally.
Pertinent Results:
___ 06:15AM WBC-9.6 RBC-2.90* HGB-9.6* HCT-29.0* MCV-100*
MCH-33.2* MCHC-33.2 RDW-14.7
___ 06:15AM NEUTS-64.6 LYMPHS-9.9* MONOS-7.1 EOS-17.9*
BASOS-0.5
___ 05:50AM BLOOD WBC-6.8 RBC-2.64* Hgb-9.1* Hct-27.1*
MCV-103* MCH-34.4* MCHC-33.4 RDW-14.8 Plt Ct-92*
___ 07:35AM BLOOD WBC-5.6 RBC-2.55* Hgb-8.7* Hct-26.4*
MCV-104* MCH-34.3* MCHC-33.1 RDW-14.8 Plt Ct-76*
___ 06:58AM BLOOD WBC-7.1 RBC-2.77* Hgb-9.4* Hct-28.3*
MCV-102* MCH-33.9* MCHC-33.1 RDW-14.9 Plt ___
___ 07:35AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL
___ 06:15AM ___ PTT-26.5 ___
___ 05:50AM BLOOD ___ PTT-26.6 ___
___ 05:50AM BLOOD Plt Ct-92*
___ 07:35AM BLOOD ___
___ 07:35AM BLOOD Plt Ct-76*
___ 06:58AM BLOOD ___
___ 06:58AM BLOOD Plt ___
___ 01:30PM UREA N-27* CREAT-1.1 SODIUM-127*
POTASSIUM-4.8 CHLORIDE-99
___ 06:15AM GLUCOSE-185* UREA N-28* CREAT-1.1 SODIUM-124*
POTASSIUM-5.2* CHLORIDE-97 TOTAL CO2-17* ANION GAP-15
___ 05:50AM BLOOD Glucose-116* UreaN-23* Creat-1.1 Na-132*
K-4.8 Cl-103 HCO3-21* AnGap-13
___ 07:35AM BLOOD Glucose-101* UreaN-20 Creat-1.0 Na-133
K-4.8 Cl-103 HCO3-22 AnGap-13
___ 06:58AM BLOOD Glucose-96 UreaN-20 Creat-1.0 Na-129*
K-4.8 Cl-99 HCO3-20* AnGap-15
___ 05:50AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.0
___ 06:58AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.9
___ 06:15AM ALT(SGPT)-27 AST(SGOT)-44* ALK PHOS-73 TOT
BILI-0.4
___ 05:50AM BLOOD ALT-25 AST-28 AlkPhos-72 TotBili-0.5
___ 07:35AM BLOOD ALT-28 AST-30 AlkPhos-69 TotBili-0.3
___ 06:58AM BLOOD ALT-37 AST-41* AlkPhos-78 TotBili-0.3
___ 06:15AM ALBUMIN-3.5
___ 06:15AM AMMONIA-145*
___ 06:34AM LACTATE-1.3
___ 06:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 11:18AM URINE HOURS-RANDOM UREA N-868 CREAT-70
SODIUM-53 POTASSIUM-25 CHLORIDE-36
___ 07:45AM URINE HOURS-RANDOM UREA N-427 CREAT-37
SODIUM-94 POTASSIUM-28 CHLORIDE-84
___ 07:45AM URINE OSMOLAL-401
___ 07:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 07:45AM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 07:45AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 07:45AM URINE RBC-0 WBC->182* BACTERIA-MOD YEAST-NONE
EPI-0
MICRO:
___ 7:45 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML..
___ MORPHOLOGY.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- =>8 R =>8 R
NITROFURANTOIN-------- <=16 S <=16 S
OXACILLIN------------- 0.5 S =>4 R
TETRACYCLINE---------- <=1 S <=1 S
VANCOMYCIN------------ <=0.5 S 1 S
___ 6:11 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
CXR PA + Lat (___)
CHEST, PA AND LATERAL: There is chronic biapical pleural
parenchymal
scarring, right greater than left. No focal consolidation.
Changes of CABG,
with median sternotomy wires and mediastinal clips. Heart size
is normal.
There are no pleural effusions or pneumothorax.
IMPRESSION: No acute cardiopulmonary process.
RUQ US (___)
FINDINGS: This study is extremely limited due to lack of
patient cooperation
and lack of a good acoustic window. Within this limitation the
imaged liver
is nodular and heterogeneous in echotexture. No biliary
dilatation is seen.
The common bile duct is normal, measuring 5 mm. The gallbladder
wall edema
relates to third spacing. There is a small-to-moderate amount
of perihepatic
ascites. The main portal vein has normal hepatopetal flow. The
spleen is
enlarged measuring 14.4 cm. Limited views of the right and left
kidneys are
unremarkable.
IMPRESSION:
1. Cirrhotic liver.
2. Small-to-moderate amount of upper abdominal ascites.
3. Mild splenomegaly.
4. Patent portal vein.
Brief Hospital Course:
___ yo male with h/o cirrhosis with ascites and varices ___ NASH,
GAVE, status post failed TIPS procedure, s/p thermal therapy in
___ for GAVE, coronary disease status post CABG/stents,
insulin-dependent diabetes, presents to the ED with confusion
and forgetfulness in the setting of not taking lactulose and UA
___ UTI.
.
# Encephalopathy - Initial UA ___ UTI (>182 wbc, mod bacteria,
large leuks, 0 epi) and not taking lactulose (though has 3BM per
day). RUQ US showed small amount of ascites, and did not show
PVT. Bedside US revealed scant ascites and so paracentesis was
not performed. CXR did not show pna. Confusion largely resolved
on admission with restarting lactulose (patient had ~11 BM
daily) and initiating treatment w/ CFTX. He was continued on
home rifaximin and his home diuretics were held in the setting
of hyponatremia. His UTI was treated as below.
.
# UTI - UTI was suspected on admission as his UA has large
leuks, >182 whites, and moderate bacteria. He also had some new
urinary hesitancy, no dysuria. Prostate exam was normal, with
no sign of prostatitis. He did not have clinical signs of
pyelonephritis during his hospitalization. He was started on
empiric therapy with ceftriaxone on HD1. Urine culture revealed
coagulase negative Staph; repeat culture from ___ returned
with no growth. The coagulase negative Staph was felt to been a
contaminant as the patient was transferred from the ED w/ a
foley; however, given the number of leuks and bacteria in his
urine, his course of antibiotics will be completed. He was
transitioned to Cefpodoxime Proxetil 200 mg PO Q12H on
discharge, to complete a 10 day course.
.
# Hyponatremia - Likely hypovolemic (at OSH Cr 1.3, and patient
taking increased lasix dose). He did not appear volume
overloaded (small amount of ascites, edema). He was started on
albumen on HD1 and his hyponatremia improved with this and
fluids. His diuretics were restarted (furosemide 40 mg and
spironolactone 100 mg) the day before discharge, and his Na
dropped back to 129. His diuretics were held the day of
discharge, and he was restarted on a lower outpatient dose of
furosemide 20 mg and spironolactone 50 mg.
.
# ___ cirrhosis: In the past complicated by ascites, hepatic
encephalopathy, and varices. His abdominal exam was benign
throughout admission. LFTs close to baseline. On SBP ppx for low
protein in ascites. He was continued on lactulose/rifaximin for
HE, on nadolol for h/o varices. On HD1 diuretics were held given
hyponatremia, but are to be restarted outpatient. Unable to tap
ascites due to inadequate fluid amount.
.
# T2DM: insulin dependent. Stable during admission. He was
continued on home lantus 35u in ___ and on a humalog sliding
scale.
.
# Macrocytic anemia: HCT = 29 on admission, stable from priors.
Likely componenet of his liver disease adding to anemia. Also
known to be on ferrous sulfate supplementation for ___. He was
continued on his home iron, b12, folate.
.
# CAD - s/p CABG in ___. Stable during admission. He was
continued on home atorvastatin. Home lisinopril was initially
held (elevated Cr 1.3 at OSH) and was restarted on HD2.
.
#Transitions:
-Follow up appointments:
1. ___, ___ at 2:00 ___, ___
___ ___
___ BUILDING ___ Floor
2. HEALTHCARE ASSOCIATES, ___ at 1 ___, Dr. ___
___, ___ POST
DISCHARGE CLINIC ___, ___ Ctr ___ Floor
Central ___. Provider: ___, DPM ___
___ 1:20
4. Provider: PULMONARY FUNCTION LAB ___
___ 3:10
5. Provider: ___ NO CHECK-IN PFT INTEPRETATION
BILLING ___ 3:30
6. ___, ___ at 11:00 AM, ___
___, ___ BUILDING ___ Floor
7. PODIATRY, ___ at 8:40 AM, ___, DPM
___, ___) ___ Floor
- Abx: Cefpodoxime Proxetil 200 mg PO Q12H until ___
- Labs: Please check electrolytes, particularly Na, at next
appointment now that diuretics have been restarted. Please
repeat UA at next liver appointment.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Pantoprazole 40 mg PO Q24H
2. Atorvastatin 20 mg PO DAILY
3. Nadolol 20 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Spironolactone 50 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Cyanocobalamin 500 mcg PO DAILY
10. coenzyme Q10 *NF* 50 mg Oral daily
11. Rifaximin 550 mg PO BID
12. Ferrous Sulfate 300 mg PO DAILY
13. Ezetimibe 10 mg PO DAILY
14. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
15. Ciprofloxacin HCl 250 mg PO Q24H
16. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
17. Lactulose 15 mL PO DAILY
Please titrate to 3 BM/day
18. Acetaminophen 325 mg PO Q6H:PRN pain
19. Meclizine 25 mg PO Q8H:PRN vertigio
Discharge Medications:
1. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Lactulose 15 mL PO DAILY
Please titrate to 3 BM/day
RX *lactulose 10 gram/15 mL ___ cc by mouth every 6hours Disp
#*946 Milliliter Refills:*0
3. FoLIC Acid 1 mg PO DAILY
4. Ferrous Sulfate 300 mg PO DAILY
___ tablest daily
5. Ezetimibe 10 mg PO DAILY
6. Cyanocobalamin 500 mcg PO DAILY
7. Atorvastatin 20 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Meclizine 25 mg PO Q8H:PRN vertigio
10. Nadolol 20 mg PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. Rifaximin 550 mg PO BID
13. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
14. coenzyme Q10 *NF* 50 mg Oral daily
15. Lisinopril 2.5 mg PO DAILY
16. Spironolactone 50 mg PO DAILY
17. Acetaminophen 325 mg PO Q6H:PRN pain
Because of your liver disease you should not take more than the
suggested amount
18. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 Tablet(s) by mouth daily Disp #*30
Capsule Refills:*0
19. Ciprofloxacin HCl 250 mg PO Q24H
20. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 6 Days
RX *cefpodoxime 200 mg 1 Tablet(s) by mouth twice a day Disp
#*12 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatic Encephalopathy, Urinary Tract Infection, Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you in the hospital. You were
admitted because of confusion, due to a urinary tract infection
and not taking lactulose. We performed an abdominal ultrasound
which showed a small amount of ascites fluid in your abdomen.
Your sodium level was also low, which we believe was due to
dehydration and the extra lasix you took at home; this improved
with albumin and holding your lasix and spironolactone.
We have made the following changes to your medications:
1. REDUCE your lasix dose from 40mg to 20mg daily
2. TAKE lactulose to have ___ bowel movements per day
3. TAKE cefpodoxime, this is an antibiotic to treat you urinary
tract infection. You should take this for 6 more days.
Followup Instructions:
___
|
10287348-DS-25 | 10,287,348 | 27,641,682 | DS | 25 | 2192-05-28 00:00:00 | 2192-07-02 22:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Egg / Latex / mayonaise / Codeine
Attending: ___
Chief Complaint:
confusino
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH of NASH cirrhosis c/b grade 1 varices and portal
hypertensive gastropathy on EGD in ___ and banding for
esophageal varice grade ___ on ___ and recent episode of hep
encephalopathy p/w fever to 100.4 and confusion x 12 hrs. Wife
noted pt to be confused and lethargic this AM. He had difficulty
performing his BG measurement and seemed lethargic. He was
recently seen in the ED for hep encephalopathy. At that time,
his lactulose was uptitrated. He has since been having ___ BMs
per day. Today, he had 5 BMs (nonbloody, nonmelenic), and his
wife notes that he has cleared somewhat throughout the day.
At this time, he denies belly distention, n/v, diarrhea, melena,
cough, sob, f/c, abdominal pain, dysuria. He does note some mild
blood on the toilet paper. Patient reports being told in the
past he has hemorrhoids.
Initial Vitals were: 100.4 81 167/58 18 100%. On exam, his
vitals are stable. Febrile to 100.4. Asterixis is present. No
scleral icterus. Spiders present on chest, skin no jaundiced.
RRR no m/r/g, Lungs CTAB. Abdomen soft without
hepatosplenomegaly, normoactive bowel sounds. Rectal shows
significant blood. No stool present. No e/o hemorrhoidal
bleeding. No lower extremity edema.
Bedside US shows trace ascites, no pocket to tap. Given 2G CTX
in the ED and 80mg IV pantoprazole. IV octreotide was initially
ordered then discontinued. Typed and screened. IV access
obtained b/l. CBC show HCT up from last check (?
hemoconcentration). LFTs show isolated AST elevation. INR 1.2.
Lipase elevation of unclear significance. There is a mild gap
acidosis of 14 and acute on chronic kidney injury presumably
from volume depletion. 1L NS started in ED. UA pending. EKG with
borderline ST depression in V4-V6 with Trop negative x1. CXR
shows no acute process (per my read) Spoke with hepatology who
recommended admission to ET. Blood Cx x 2 sent. Per ED nursing
note, patient was alert and responds slowly but appropriately to
questions. He reports noted blood on toilet tissue this
afternoon. In the ED he denied abdominal pain or nausea. He has
Prior history of GIB requiring ICU admission and blood
transfusion.
Vitals prior to transfer were: 99.7 78 121/60 16 97%.
On arrival to the floor, patient denies CP,SOb,cough, melena,
BRBPR, hematemesis.
REVIEW OF SYSTEMS:
(+) as in HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- CAD: CABG ___, stenting in ___ DES, cath in ___ all
grafts and stents patent. Cards Dr ___, ___. Recently
discontinue Plavix due to multiple GI bleeds.
- ___ cirrhosis: followed by Dr ___ distant h/o
ascites, encephalopathy, Grade 2 esophogeal varices, s/p banding
___.
- H/O obscure GI Bleed: gastric antral vascular ectasia (GAVE)
noted on EGD and AVMs noted on capsule, varices, diverticulosis,
and rectal varices
- DM II on insulin with frequent episodes of hypoglycemia in the
past
- TIA ___ followed by Dr ___
- ___ cell carcinoma
- HTN
- HL
Social History:
___
Family History:
- Father died at ___ of gastic cancer
- Mother had breast cancer in her ___
- Sister with a history of CAD
Physical Exam:
VS - Temp 98.4F, BP 136/85 , HR 82 , R 11 , O2-sat 100% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MM relatively
moist, OP clear
NECK - supple, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no rub or gallop, very faint
systolic murmur, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no cyanosis or edema, has clubbing, 2+
peripheral pulses (radials, DPs). no asterixis bilaterally
SKIN - spider nevi
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, gait defered
Pertinent Results:
___ 08:30PM WBC-7.4 RBC-3.90* HGB-12.8* HCT-38.3* MCV-98
MCH-32.9* MCHC-33.4 RDW-14.4
___ 08:30PM NEUTS-70.0 LYMPHS-8.3* MONOS-6.8 EOS-14.5*
BASOS-0.5
___ 08:30PM PLT COUNT-105*
___ 08:28PM AMMONIA-95*
___ 08:19PM ___ TOP
___ 08:19PM LACTATE-1.8
___ 08:00PM GLUCOSE-161* UREA N-21* CREAT-1.5* SODIUM-136
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-19* ANION GAP-20
___ 08:00PM estGFR-Using this
___ 08:00PM ALT(SGPT)-28 AST(SGOT)-45* ALK PHOS-73 TOT
BILI-1.0
___ 08:00PM LIPASE-138*
___ 08:00PM cTropnT-<0.01
___ 08:00PM ALBUMIN-4.1 CALCIUM-8.9 PHOSPHATE-4.0
MAGNESIUM-2.0
___ 08:00PM ___ PTT-31.7 ___
CXR ___
The patient is status post median sternotomy and CABG. Right
upper lobe
scarring is again seen; 9 mm right lung apex nodule seen on
prior chest CT from ___ was better seen on that study
and followup recommendations per that study remain.
Reticulonodular opacities at the lung bases are again seen and
stable, chronic. No new focal consolidation is seen. There is
no pleural effusion or pneumothorax. The cardiac and
mediastinal silhouettes are stable.
ECG ___
Sinus rhythm with ventricular premature beats. Since the
previous tracing no significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
78 174 92 384/415 25 55 37
ECG ___
Normal sinus rhythm. There are two ventricular premature
contractions present which are monomorphic. Otherwise, the
tracing is within normal limits.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 176 92 384/413 27 65 48
RUQ Ultrasound ___
1. Extremely limited study. Patent main portal vein with
normal hepatopetal flow.
2. Cholelithiasis without evidence of cholecystitis.
3. Cirrhosis with splenomegaly. No ascites.
Brief Hospital Course:
___ with NASH cirrhosis c/b grade ___ esophageal varices, portal
hypertensive gastropathy and hepatic encephalopathy, CAD s/p 3
vessel CABG ___, DM2 who presented to ED ___ with confusion,
asterixis consistent with hepatic encephalopathy.
# Hepatic Encephalopathy: Exact trigger unclear. Pt reported
compliance with lactulose, rifaximin and cipro at home, denies
melena, hematemesis, BRBPR. HCT stable. Low grade temp on
admission but subsequently afebrile, no localizing infectious
symptoms. CXR negative for acute process. Blood and urine
cultures negative. RUQ u/s showed no ascites, patent portal
vein. Treated with IV ceftriaxone, octreotide x 3 days.
Lactulose, rifaximin continued and mental status gradually
improved.
# ___: Recent Cr baseline ___ 1.5 on admission. Creatinine
slightly improved to 1.4 after receiving albumin. Possibly
prerenal given low grade fever, potential decrease in PO intake
in the setting of confusion. Received IVF, lisinopril,
spironolactone, lasix initially held. Cr at discharge was 1.2.
# Thrombocytopenia: Plt 63 from 10. Pt did not receive heparin
this admission, making HIT unlikely. Possible dilutional
component given IVF. No active signs of bleeding. Plt at
discharge 77.
# NASH cirrhosis: In the past complicated by ascites, hepatic
encephalopathy, and varices. His abdominal exam was benign on
admission. LFTs close to baseline. INR 1.2. He is On SBP ppx at
home with daily cipro. Continued lactulose, rifaximin, nadolol.
# Macrocytic anemia: H/H stable and actually slightly higher
than prior with same level of WBC and plt despite DRE heme
positive. Likely component of his liver disease adding to his
anemia. Also he was known to be on ferrous sulfate
supplementation for ___ in the past. ___ variceal banding
with current DRE heme positivity is concerning. Also has rectal
varices which could be the source of blood on DRE and toilet
paper. HCT noted to drop overnight 34.6->28.7, but suspect
dilution as all cell lines decreased. Repeat CBC showed HCT
stable at 33.2
# CAD: s/p CABG in ___. Denied CP or SOB. Per ED report V4-v6
borderline ST depression which was not seen on repeat EKG.
Cardiac enzymes negative x 3, making ACS unlikely. Multiple PVCs
on telemetry but no red alarms. Continued home lipitor and
Zetia.
# Lung Nodule: 9 mm right lung apex nodule noted on CXR was
known from prior chest CT from ___. Repeat CT in 6
months from that study was recommended.
# Transitional Issues:
- diuretic doses were decreased upon discharge to 20 mg lasix,
50 mg spironolactone. please evaluate volume status at follow
up. doses may need to be increased (weight at discharge 86kg)
- repeat imaging needed for known right lung nodule
- blood cultures pending at time of discharge
- urinalysis showed small blood, this should be repeated to
ensure resolution
Medications on Admission:
Atorvastatin 20 mg PO DAILY
Ciprofloxacin HCl 250 mg PO Q24H
Cyanocobalamin 500 mcg PO DAILY
Ezetimibe 10 mg PO DAILY
FoLIC Acid 1 mg PO DAILY
Furosemide 20 mg PO DAILY
Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Lactulose 30 mL PO TID
Lisinopril 2.5 mg PO DAILY
Meclizine 25 mg PO Q8H:PRN vertigo
Nadolol 20 mg PO DAILY
Rifaximin 550 mg PO BID
Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY
2. coenzyme Q10 *NF* 50 mg Oral daily
3. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Cyanocobalamin 500 mcg PO DAILY
5. Rifaximin 550 mg PO BID
6. Ezetimibe 10 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Lisinopril 2.5 mg PO DAILY
10. Meclizine 25 mg PO Q8H:PRN vertigo
11. Vitamin D ___ UNIT PO DAILY
12. Nadolol 20 mg PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. Ciprofloxacin HCl 250 mg PO Q24H
15. Spironolactone 50 mg PO DAILY
16. Lactulose 30 mL PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: hepatic encephalopathy, acute kidney injury
secondary diagnosis: cirrhosis, history of coronary artery
disease, type 2 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you while you were admitted to
___. You were admitted because you were confused. You had
studies to look for infection which were negative. You were
given medications to help with your confusion and your mental
status improved.
The following changes have been made to your medication regimen.
Please HOLD your lasix and spironolactone until your follow up
appointment with ___ on ___. At that time you can
discuss if it is safe to restart.
Please DECREASE pantoprazole 40 mg twice daily to ONCE DAILY
Please take the rest of your medications as prescribed and
follow up with your doctors as ___.
Please weigh yourself daily and call your doctor if your weight
increases by 3 pounds
Followup Instructions:
___
|
10287348-DS-27 | 10,287,348 | 24,131,252 | DS | 27 | 2193-08-28 00:00:00 | 2193-08-29 16:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Egg / Latex / mayonaise / Codeine
Attending: ___.
Chief Complaint:
Pre-syncope
Major Surgical or Invasive Procedure:
None this hospitalization.
History of Present Illness:
This is a ___ gentleman with a history of NASH cirrhosis
c/b varices s/p banding on ___, GAVE and hepatic
encepholopathy, type 2 diabetes with recent episodes of
hypoglycemia, ___ TIA and CAD status post PCI off of aspirin
secondary to bleed transferred from an OSH for further
evaluation of anemia and lightheadedness. This AM he was in his
usual state of health, brushing his teeth when he felt light
headed and "like the room was spinning". He laid down and felt
better. When he stood up suddenly he felt light headed again,
lost his balance and fell hitting his arm and head. No loss of
consciousness; this was witnessed by his wife. He felt better
when he layed down again except some nausea and one episode of
nbnb emesis. FSG this AM was in ___'s and in ___'s per his report
when EMS came, it had been in the 60's a few days ago. He has
felt this way in the past when he stands up too quickly, but not
this "dizzy" since about a year ago when he thought he had BPPV.
After the episode this AM he took meclizine and tramadol which
didn't seem to make a difference. He denies f/c/s, diarrhea,
CP/SOB, prodrome, melena, hematochezia, change in bowel or
bladder function, weakness, parasthesias or difficulty walking.
He does not feel symptomatic from hepatic encepholopathy, denies
tremor, confusion and his wife corroborates this. He does not
know why he has anemia, but says he was last transfused 1u
pRBC's about 2 weeks ago at ___ prior to transfusion today at
OSH.
Of note he was hospitalized on ___ for an episode of
hepatic encephalopathy. At that time, he had a laboratory
evaluation, chest x-ray and right upper quadrant ultrasound that
did not show any signs of infection or etiology of hepatic
decompensation. He was given a few doses of lactulose and was
discharged home. He was maintained on 40 mg of Lasix and kept
off of his spironolactone during that time and his electrolytes
were stable.
At OSH head CT showed a possible R cerebllar hypodensity, stool
was reportedly guiaic positive. ECG was sinus NANI, Hg: 6.9, CXR
negative, given 1U pRBC, pantoprazole, and then transferred
here.
In our ED initial vitals were Triage 15:35 0 98 72 124/54 18
97%. Normal neuro exam without ataxia, guaic neg brown stool.
Radiology here was not sure if cerebellar hypodensity was
artifact or ___ underlying infarct on lesion, recommended MR.
___ here significant for Hgb 8.1, WBC 3.8, PLT 103, tbili 1.6,
trop <.01.
GI was consulted in the ED, they recommended checking for
ascites; this was negative and so he was admitted to medicine
for further workup. Vitals prior to transfer were: Today ___ 67 120/43 16 96% RA. On the floor he has no complaints,
feels back to baseline.
Past Medical History:
- ___ cirrhosis: followed by Dr ___ ascites,
encephalopathy, Grade 2 esophogeal varices, s/p banding ___.
- CAD: CABG ___, stenting in ___ DES, cath in ___ all
grafts and stents patent. Cards Dr ___. Recently
discontinue Plavix due to multiple GI bleeds.
- ___ obscure GI Bleed: gastric antral vascular ectasia (GAVE)
noted on EGD and AVMs noted on capsule, varices, diverticulosis,
and rectal varices
- DM II on insulin with frequent episodes of hypoglycemia in the
past
- TIA ___ followed by Dr ___
- Squamous cell carcinoma
- HTN
- HL
Social History:
___
Family History:
- Father died at ___ of gastic cancer
- Mother had breast cancer in her ___
- Sister with a history of CAD
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals - T98.2, 809, 130/44, 18, 99%RA
GENERAL: NAD, AOx3, pleasant, wife at bedside
___: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, 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, no fluid wave
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema. Abrasion on L forearm.
NEURO: CN II-XII intact, MAE, no asterixis, ___
negative, no nystagmus, cannot provoke vertigo with maneuvers
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
Vitals: 98.0/97.2 154/53 82 18 100%RA
Stool: Guiac positive brown stool
GENERAL: NAD, AOx3, pleasant, in no acute distress
___: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no JVD
CARDIAC: RRR, S1/S2, ___ systolic murmur best heard at the apex
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, no fluid wave
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema. Abrasion on L forearm.
NEURO: CN II-XII intact, finger-to-nose intact, rapid
alternating movements intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION ___
___ 04:40PM BLOOD WBC-3.8* RBC-3.26* Hgb-8.1* Hct-26.9*
MCV-83 MCH-24.7* MCHC-29.9* RDW-16.7* Plt ___
___ 04:40PM BLOOD Neuts-64.8 Lymphs-17.9* Monos-7.9
Eos-8.8* Baso-0.8
___ 04:40PM BLOOD ___ PTT-29.7 ___
___ 04:40PM BLOOD Glucose-96 UreaN-23* Creat-1.2 Na-137
K-4.1 Cl-107 HCO3-20* AnGap-14
___ 04:40PM BLOOD ALT-22 AST-33 AlkPhos-68 TotBili-1.6*
___ 04:40PM BLOOD Lipase-27
___ 04:40PM BLOOD cTropnT-<0.01
___ 04:40PM BLOOD Albumin-3.3* Calcium-7.9* Phos-4.0 Mg-2.2
___ 04:40PM BLOOD Ferritn-11*
INTERVAL ___
___ 07:05AM BLOOD %HbA1c-6.5* eAG-140*
___ 07:05AM BLOOD Triglyc-56 HDL-44 CHOL/HD-2.3 LDLcalc-45
DISCHARGE ___
___ 07:15AM BLOOD WBC-3.5* RBC-3.27* Hgb-8.0* Hct-26.6*
MCV-81* MCH-24.6* MCHC-30.2* RDW-17.1* Plt ___
___ 07:15AM BLOOD Glucose-119* UreaN-18 Creat-1.1 Na-139
K-4.2 Cl-111* HCO3-20* AnGap-12
___ 07:05AM BLOOD ALT-22 AST-29 AlkPhos-64 TotBili-0.6
MICRO
___ Blood Culture x2 - pending
IMAGING
CT Head ___ OSH
Apparent hypodensity in the right cerebellum is noted without
mass effect, which may be artifactual. However, infarct or
underlying lesion cannot be excluded on this study. MR is
recommended for further evaluation.
MRI Head ___
1. Punctate evolving acute infarct in the left precentral gyrus.
2. No MR correlate for the right cerebellar hypodensity seen on
the preceding CT, which was artifactual.
Carotid Ultrasound ___
1. ___ percent stenosis of the right internal carotid artery
(increased
from 40-59 percent ___ year ago).
2. 60-69 percent stenosis of the left internal carotid artery
(increased from 40-59 percent ___ year ago).
3. Normal antegrade vertebral artery flow.
Brief Hospital Course:
Mr. ___ is a ___ gentleman with a history of NASH
cirrhosis c/b varices s/p banding on ___, GAVE and hepatic
encepholopathy, type 2 diabetes with recent episodes of
hypoglycemia, ___ TIA and CAD status post PCI off of aspirin
secondary to bleed transferred from an OSH for further
evaluation of anemia and pre-syncope.
ACUTE ISSUES
# CVA: Incidental finding on MRI of acute infarct in left
precentral gyrus without neurological findings. Patient is
overall asymptomatic. Discussed risks and benefits of aspirin
therapy given previous history of cirrhosis and bleeding versus
risk of future stroke. Started Aspirin, increased atorvastatin,
and carotid US showed worsening carotid stenosis (70-79% on
right and 60-69% on left). The patient clearly understood the
increased risk of bleeding, especially in the setting of recent
bleeds but clearly favored preventing a future stroke, which is
potentially irreversible. The decision to start aspirin was
discussed with hepatology inpatient team, patient's outpatient
hepatologist, PCP, neurology/stroke team who agreed with
starting cautiously. Also, patient was evaluated by vascular
surgery regarding his increased carotid stenosis, and they will
follow-up as outpatient.
# Pre-syncope: Patient reports light-headedness after standing,
with a "spinning" sensation that resolved after lying down. He
is now s/p 1u pRBC's and IVF at OSH and feels back at baseline.
Not orthostatic by BP. Cardiac cause less likely despite his ___
CAD, given negative trop, no EKG changes, and no events on tele.
Seizure less likely as no report of seizure like activity, neuro
exam is non-focal, and vertigo cannot be provoked on exam.
Anemia may also explain lightheadedness although no
signs/symptoms of acute GI bleed, patient has multiple reasons
for slow GI bleeding including esophageal varices and GAVE.
Likely patient had a small GI bleed causing an acute drop in his
hematocrit leading to dizziness which has since resolved. MRI
head shows no cerebellar infarct but does note punctate infarct
in left precentral gyrus. The area of the stroke was not in a
watershed area per the stroke team.
# Normocytic Anemia: Hgb has been between ___ since last
___, was lower today at OSH at 6.9. Recieved 1 unit
transfusion, appropriate bump and has been stable at during his
hospitalization. Ferritin low and started on PO iron. Continued
home B12 and folate. Patient was hemodynamically stable during
his admission.
CHRONIC ISSUES
# Hepatic encephalopathy: Currently controlled, continued
lactulose.
# NASH cirrhosis: Followed by Dr ___. Complicated by SBP,
ascites, encephalopathy, Grade 2 esophogeal varices s/p banding
___, rectal varices, ___ GI bleed secondary to GAVE, AVMs,
diverticulosis. Tbili is currently 1.6 up from baseline of .___,
normalized during admissin. Creatinine at baseline. Not on
spironolactone ___ hyperkalemia in the past. Continued on
ciprofloxacin for SBP prophylaxis, nadolol, lactulose, and
rifaximin. His lasix was restarted at time of discharge.
# GERD: Continue pantoprazole 40mg BID.
# CAD, ___ TIA: CABG ___, stenting in ___ DES, cath in
___ all grafts and stents patent. Cards Dr ___, ___.
Increased atrovastatin and started aspirin as above. Continued
on lisinopril.
# Insulin-dependent diabetes, type II: Recently complicated by
hypoglycemia requiring aggressive down titration of his Lantus
then hyperglycemic. Repeat HbA1c 6.5% at goal. Continued home
glargine and ISS.
# Chronic Pain: Continued tylenol and tramadol. Counseled
patient to avoid taking tramadol if her feels dizzy or
lightheaded.
# BPPV: Not clear that this was ever an accurate diagnosis, when
last seen by neurology they felt his sx more c/w orthostasis.
Discharged on home meclizine with warning about taking while
feeling dizzy.
Transitional Issues:
- Patient has vascular surgery follow-up in 1 month with repeat
carotid ultrasound.
- Patient started on Aspirin 81mg daily for stroke prevention.
Please monitor for bleeding and check hematocrit at next visit.
- Increased atorvastatin to 80mg given history of carotid
stenosis. Please repeat LFTs at next visit and monitor for side
effects.
- Patient started on oral iron for iron-deficiency anemia.
- Please ensure follow-up with ___ diabetes.
- Consider outpatient TTE to evaluate for cardiac origin of
emboli.
- Please follow-up pending blood cultures from ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY
2. Ciprofloxacin HCl 250 mg PO Q24H
3. Furosemide 40 mg PO DAILY
4. Glargine 18 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Lactulose 30 mL PO Q8H:PRN titrate to ___ BM's day
6. Lisinopril 2.5 mg PO DAILY
7. Meclizine 25 mg PO Q8H:PRN vertigo
8. Nadolol 20 mg PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Rifaximin 550 mg PO BID
11. TraMADOL (Ultram) 25 mg PO BID
12. Vitamin D ___ UNIT PO DAILY
13. coenzyme Q10 50 mg Oral daily
14. Cyanocobalamin 500 mcg PO DAILY
15. FoLIC Acid 1 mg PO DAILY
16. Acetaminophen Dose is Unknown PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg Take 1 tablet by mouth daily Disp #*30
Tablet Refills:*0
3. Ciprofloxacin HCl 250 mg PO Q24H
4. Cyanocobalamin 500 mcg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Glargine 18 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
7. Nadolol 20 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Rifaximin 550 mg PO BID
10. TraMADOL (Ultram) 25 mg PO BID
11. Vitamin D ___ UNIT PO DAILY
12. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg Take 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*0
13. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate 325 mg (65 mg iron) Take 1 tablet by mouth
twice per day Disp #*60 Tablet Refills:*0
14. coenzyme Q10 50 mg Oral daily
15. Furosemide 40 mg PO DAILY
16. Lisinopril 2.5 mg PO DAILY
17. Meclizine 25 mg PO Q8H:PRN vertigo
18. Lactulose 30 mL PO Q8H:PRN titrate to ___ BM's day
19. walker Rolling walker 1 miscellaneous Daily
Diagnosis: CVA, Prognosis: Poor, Length of Use: Lifetime.
RX *walker [Airgo Rolling Walker] Please use walker daily Disp
#*1 Each Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Acute Stroke, Pre-Syncope
Secondary Diagnosis: Type II Diabetes, Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital
because you had a fall at home. You were found to have very low
red blood cells and recieved a transfusion. Your blood counts
have been stable while in the hospital. You also had an MRI of
your brain, which showed you had a small infarct or stroke.
Please avoid taking tramadol or meclizine if you feel dizzy or
lightheaded as this can make these symptoms worse.
The iron you may taking may cause constipation, you may need to
increase your lactulose so you have 3 to 4 bowel movements per
day. Please continue to monitor for blood in your stool.
All the Best,
Your ___ Team
Followup Instructions:
___
|
10287348-DS-29 | 10,287,348 | 27,884,593 | DS | 29 | 2194-03-31 00:00:00 | 2194-03-31 20:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Egg / Latex / mayonaise / Codeine
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ gentleman with a history of NASH cirrhosis c/b
varices s/p banding on ___, GAVE and hepatic encepholopathy,
type 2 diabetes with recent episodes of hypoglycemia, ___ TIA
and CAD status post PCI off of aspirin secondary to bleed
presenting with confusion and BRBPR.
Patient woke up at 430am and was confused prior to similar
episodes of hepatic encephalopathy. His wife became concerned
and gave him lactulose x 4 throughout the morning. She noted
when he stooled there was bright red blood on toilet paper, but
no blood in the toilet. He does report a history of hemorrhoids.
Patient went to sleep and woke up in garage in his car. At which
time she brought him to the ED as wife became concerned for
hepatic encephalopathy. Also reports having BRBPR. His wife
reports he had a large ham steak day prior to admission which
violated his low protein diet. Denies f/c/n/v, chest pain,
shortness of breath, cough, abdominal pain, diarrhea, urinary
symptoms.
Of note, his previous sigmoidoscopy (___) with changes c/w
ischemic colitis. Recent EGD with Grade II varices.
In the ED initial vitals were: 97.0, 77, 172/67, 16, 100% RA
Labs were significant for WBC 6.5 with 61% N, 15.3% E, 15.3%,Hgb
of 11.7, Hct 35 (at baseline), Plt 86, AST 39, Alb 3.3, K 4.3.
Cr was 1.1, and lactate was normal. UA was negative. Blood
cultures were sent. RUQ US with doppler showed cirrhosis,
moderate ascites, and cholelithiasis. No paracentesis was
performed due to inability to find a pocket.CXR showed no acute
process.Liver was consulted, who recommended NPO, infectious
w/u, Liver US, 2 large bore PIVs, T&S, serial Hcts. Patient was
given nothing in the ED. Vitals prior to transfer were: 97.4 66
133/56 17 98% RA.
On the floor he has no complaints, feels back to baseline with
no further confusion.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
1. ___ cirrhosis: followed by Dr ___ ascites,
encephalopathy, Grade 2 esophogeal varices, s/p banding ___.
2. CAD: CABG ___, stenting in ___ DES, cath in ___ all
grafts and stents patent. Cards Dr ___, ___. Recently
discontinue Plavix due to multiple GI bleeds.
3. ___ obscure GI Bleed: gastric antral vascular ectasia (GAVE)
noted on EGD and AVMs noted on capsule, varices, diverticulosis,
and rectal varices
4. DM II on insulin with frequent episodes of hypoglycemia in
the
past
5. TIA ___ followed by Dr ___
6. Squamous cell carcinoma
7. HTN
8. Hyperlipidemia
9. Chronic Eosinophilia
Social History:
___
Family History:
- Father died at ___ of gastic cancer
- Mother had breast cancer in her ___
- Sister with a history of CAD
Physical Exam:
PHYSICAL EXAM ON ADMISSION
Vitals - T: 97.9 BP: 148/67 HR: 67 RR: 18 02 sat: 98% RA
GENERAL: Pleasant male who appears older than stated age in NAD,
AOx3, pleasant and cooperative, wife at bedside
___: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no JVD
CARDIAC: Regular rate, 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, no fluid wave
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema.
NEURO: Speech coherent, Cognition intact. AAOx3, able to perform
serial 3s and days of the week backwards.CN II-XII intact, MAE,
no asterixis.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
PHYSICAL EXAM ON DISCHARGE
Vitals -
GENERAL: NAD, AOx3, thin gentleman
___: AT/NC, anicteric sclera, MMM,
CARDIAC: Regular rate, 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, no fluid wave
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema.
NEURO: Speech coherent, Cognition intact. AAOx3, no asterixis.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes , no jaundice
Pertinent Results:
LABS ON ADMISSION
=============
___ 09:00PM WBC-6.5 RBC-3.46* HGB-11.7* HCT-35.1*
MCV-102* MCH-33.9* MCHC-33.3 RDW-15.0
___ 09:00PM NEUTS-61.5 LYMPHS-13.8* MONOS-8.9 EOS-15.3*
BASOS-0.5
___ 09:00PM PLT COUNT-86*
___ 09:00PM ___ PTT-22.4* ___
___ 09:00PM GLUCOSE-179* UREA N-18 CREAT-1.1 SODIUM-137
POTASSIUM-7.5* CHLORIDE-108 TOTAL CO2-22 ANION GAP-15
___ 09:00PM ALT(SGPT)-33 AST(SGOT)-89* ALK PHOS-58 TOT
BILI-0.8
___ 09:00PM ALBUMIN-3.3*
___ 09:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:15PM LACTATE-1.6
LABS ON DISCHARGE
--------------------
___ 06:30AM BLOOD WBC-4.9 RBC-3.41* Hgb-11.3* Hct-34.6*
MCV-102* MCH-33.2* MCHC-32.7 RDW-14.7 Plt Ct-71*
___ 06:30AM BLOOD Neuts-53.1 Lymphs-16.6* Monos-8.0
Eos-21.5* Baso-0.9
___ 06:30AM BLOOD ___
___ 06:30AM BLOOD Plt Ct-71*
___ 06:30AM BLOOD Glucose-124* UreaN-15 Creat-1.0 Na-142
K-3.8 Cl-112* HCO3-23 AnGap-11
___ 06:30AM BLOOD ALT-27 AST-32 LD(LDH)-236 CK(CPK)-86
AlkPhos-60 TotBili-0.9
___ 06:30AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.9
IMAGING
--------
___ (PA & LAT)
FINDINGS:
The patient is status post median sternotomy and CABG. A
coronary artery
stent is noted. There is biapical scarring with no focal
consolidation,
pleural effusion or pneumothorax. Coarsened lung markings are
compatible
emphysema as noted on prior CT. The cardiac, mediastinal and
hilar contours
are within normal limits.
IMPRESSION:
No acute cardiopulmonary process.
The study and the report were reviewed by the staff radiologist.
___ OR GALLBLADDER US
FINDINGS:
LIVER: The contour of the liver is nodular, consistent with
cirrhosis. There
is no focal liver mass. Main portal vein is patent with
hepatopetal flow.
There is a moderate amount of ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD
measures 1 mm.
GALLBLADDER: Cholelithiasis is again noted, but there is no
gallbladder wall
thickening.
PANCREAS: 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 14.1 cm.
IMPRESSION:
1. Coarsened, nodular liver compatible with clinical history of
cirrhosis.
Signs of portal hypertension including splenomegaly and moderate
amount of
ascites.
2. Cholelithiasis.
The study and the report were reviewed by the staff radiologist.
MICROBIOLOGY
---------------
___ CULTURE-PENDINGINPATIENT
___ VANCOMYCIN RESISTANT
ENTEROCOCCUS-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY WARD
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY WARD
Brief Hospital Course:
Mr. ___ is a ___ gentleman with a history of NASH
cirrhosis c/b varices s/p banding, GAVE and hepatic
encepholopathy, type 2 diabetes presenting with nausea/vomitting
and altered mental status likely ___ to hepatic encephalopathy
due to protein violation and minimal BRBPR.
BRIEF HOSPITAL COURSE
================
ACTIVE ISSUES
# CONFUSION: Patient became confused in setting of had increased
protein and salt intake (ham cold cuts). This resolved after
family increased his lactulose and spontaneously returned to
baseline mentation without further intervention by medical
staff. Diagnostic tap was deferred due to minimal ascites. CXR
negative, UA bland. Patient discharged with lactulose and
rifaximin. Patient discharged with liver follow-up in place.
# BRBPR: Patient with known history of internal hemorrhoids,
mild diverticulosis (last colonoscopy ___, also with evidence
of ischemic colitis on flexible sigmoidoscopy (___).
Patient with complaint of BRBPR when wiping, no complaints of
large bleed. Abdominal exam benign. Hct trended and found to be
stable since ___. Lactate within normal limits. No
recurrence of bleeding on admission. Consider outpatient follow
up.
STABLE CHRONIC ISSUES
# ___ cirrhosis: Complicated by SBP, ascites, encephalopathy,
Grade 2 esophogeal varices s/p banding ___, rectal
varices, ___ GI bleed secondary to GAVE, AVMs, diverticulosis.
Current MELD score 9. Followed by Dr ___. Tbili is currently
0.8 and at baseline. Creatinine at baseline. Not on
spironolactone ___ hyperkalemia in the past. Patient was
continued on home dose ciprofloxacin 500mg DAILY for SBP
prophylaxis, nadolol 20mg daily, lactulose 30mg TID, rifaximin
500 BID, furosemide.
#Chronic Eosinophilia: Notably 15.3% on diff with absolute count
of 995. This has improved from prior admissions. Outpatient work
up significant for +strongyloides antibody. This was noted, but
not an active issue pursed during admission.
# Insulin-dependent diabetes, type II: No episodes of
hypoglycemia during admission. Patient was continued on home
dose glargine and sliding scale.
# GERD: Patient was placed on pantoprazole IV at admission. He
was transitioned to home dose PPI at discharge.
# CAD, ___ TIA: CABG ___, stenting in ___ DES, cath in
___ all grafts and stents patent: Patient was continued on home
dose lisinopril, atorvastatin, aspirin.
# Chronic Pain: patient was continued on home dose tylenol.
Tramadol was restarted upon discharge.
# BPPV: Meclizine was held on admission. This was restarted at
discharge.
TRANSITIONAL ISSUES
[] PCP/Hepatology: Nutrition education
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Atorvastatin 80 mg PO DAILY
3. Ciprofloxacin HCl 250 mg PO Q24H
4. Cyanocobalamin 500 mcg PO DAILY
5. Ferrous Sulfate 325 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Lactulose 30 mL PO Q8H:PRN titrate to ___ BM's day
8. Nadolol 20 mg PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Rifaximin 550 mg PO BID
11. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
12. Vitamin D ___ UNIT PO DAILY
13. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral daily
14. coenzyme Q10 50 mg Oral daily
15. walker 0 1 MISCELLANEOUS DAILY
16. Aspirin 81 mg PO DAILY
17. Furosemide 40 mg PO DAILY
18. Lisinopril 2.5 mg PO DAILY
19. Glargine 18 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Ciprofloxacin HCl 250 mg PO Q24H
5. Cyanocobalamin 500 mcg PO DAILY
6. Ferrous Sulfate 325 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Glargine 18 Units Dinner Insulin SC Sliding Scale using HUM
Insulin
10. Lactulose 30 mL PO Q8H:PRN titrate to ___ BM's day
11. Lisinopril 2.5 mg PO DAILY
12. Nadolol 20 mg PO DAILY
13. Rifaximin 550 mg PO BID
14. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
15. Vitamin D ___ UNIT PO DAILY
16. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral daily
17. coenzyme Q10 50 mg Oral daily
18. Pantoprazole 40 mg PO Q12H
19. walker 0 1 MISCELLANEOUS DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
-------------------
HEPATIC ENCEPHALOPATHY
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for confusion. This was most likely due to
eating increased protein (for example: ham) causing hepatic
encephalopathy. Please avoid eating a very high protein diet and
take your lactulose. Please aim for ___ bowel movements per day
with lactulose.
Please follow up with your primary care provider for follow up
care.
It was a pleasure taking care of you at ___. We wish you well.
Sincerely,
Your Team at ___
Followup Instructions:
___
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