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10287348-DS-32 | 10,287,348 | 22,039,640 | DS | 32 | 2194-08-30 00:00:00 | 2194-09-01 09:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Egg / Latex / mayonaise / Codeine
Attending: ___
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of NASH cirrhosis c/b Hepatic encephalopathy, ascites,
and varices, CAD s/p CABG, DM, HTN, HLD p/w generalized
weakness.
Patient states before a month ago he was able to ambulate
without using a walker but has needed one in the last month. He
has had no recent s/sxs of infection; denies fevers/chills,
nausea/vomiting, diarrhea, abdominal distention or pain, dysuria
or frequency. He endorses a dry cough. No chest pain or
shortness of breath. The day prior to admission he was trying to
put on his pants and fell to his bottom. He had no LOC. No head
strike. He was too weak to get up, so his wife called EMS, who
came and helped him up put patient refused to be taken into the
hospital. On am of admission, his wife then called his PCP , who
advised them to come to the ED.
He also reports lower extremity swelling (which is chronic but
left side seemed a little more so) and reports 4lb weight gain
recently. No pain in legs.
He is able to sleep flat on a bed without dyspnea.
Vitals in the ED: 98.3 75 160/46 16 100% RA
diagnostic paracentesis was negative
trop 0.03, ck 134, ck-mb 3, cr 1.4 proBNP 961
serum tox negative, UA negative
CXR- mild pulomonary edema w/ left pleural effusion
EKG- sinus 68, occasional PVCs
Patient given: 1l Normal saline IVF and ASA 325mg
Vitals prior to transfer: 97.1 68 107/55 16 100% RA
On the floor, he is comfortable at rest. Vitals are: 115/58 p71
rr20 98.6 99%RA 78.8KG BS 252
Past Medical History:
1. ___ cirrhosis with h/o ascites, encephalopathy, Grade 2
esophogeal varices, s/p banding ___.
2. CAD: CABG ___, stenting in ___ DES, cath in ___. Not
on plavix due to multiple GI bleeds.
3. H/O 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
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:
Admission PHYSICAL EXAM:
Vitals - 115/58 p71 rr20 98.6 99%RA 78.8KG BS 252
GENERAL: Alert and oriented x 3 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: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft and non-tender
EXTREMITIES: 1+ right pre-tibial edema, 2+ left pretibial edema.
No calf tenderness bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical Exam
Vitals: 97.8 123/54 64 18 100% on RA
I+O: 24H: ___ 8H: 120/200
Wt: 79.4 (Adm wt: 81.7)
Gen: Alert and oriented, No acute distress
HEENT: PERRL, moist mucosa, no JVD
CV: RRR, no m/r/g, nl s1,s2
Pulm: CTAB, no rhonchi wheezes
Abd: full, nttp, no fluid wave, no megaly
Ext: no pedal edema
Neuro: moves all extremities spontaneously, CN2-12 intact
Pertinent Results:
Admission Labs
___ 02:48PM BLOOD WBC-5.9 RBC-3.00* Hgb-9.9* Hct-30.6*
MCV-102* MCH-33.0* MCHC-32.4 RDW-15.5 Plt ___
___ 04:06PM BLOOD ___ PTT-30.3 ___
___ 02:48PM BLOOD Glucose-190* UreaN-20 Creat-1.4* Na-134
K-3.8 Cl-104 HCO3-20* AnGap-14
___ 02:48PM BLOOD ALT-30 AST-42* CK(CPK)-134 AlkPhos-72
TotBili-0.6
___ 02:48PM BLOOD CK-MB-3 cTropnT-0.03* proBNP-961*
___ 02:48PM BLOOD Albumin-2.7*
___ 04:39PM BLOOD Lactate-1.8
Discharge Labs
___ 07:35AM BLOOD WBC-4.0 RBC-2.63* Hgb-8.4* Hct-26.3*
MCV-100* MCH-31.8 MCHC-31.8 RDW-15.7* Plt Ct-80*
___ 07:35AM BLOOD ___ PTT-33.6 ___
___ 05:55AM BLOOD Glucose-98 UreaN-22* Creat-1.3* Na-140
K-3.8 Cl-106 HCO3-25 AnGap-13
___ 07:35AM BLOOD ALT-24 AST-35 AlkPhos-62 TotBili-0.6
___ 02:48PM BLOOD Lipase-36
___ 07:35AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.0
Pertinent Studies
Echocardiogram ___
The left atrial volume index is normal. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
low normal (LVEF 50-55%). The right ventricular cavity is mildly
dilated with borderline normal free wall function. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate (___)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] Due to the eccentric nature of the regurgitant
jet, its severity may be significantly underestimated (Coanda
effect). The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Normal left ventricular size with borderline left
ventricular systolic function. Mildly dilated ascending aorta.
Mild to moderate mitral regurgitation. Normal pulmonary artery
systolic pressure.
Brief Hospital Course:
___ w/ fall at home due to weakness, unable to get up and EMS
called. Refused transfer to ED, but went next day at ___ of PCP.
#___ Cirrhosis: Admitted to cardiology after CXR w/ effusion,
b/l lower extremity edema. Echo showed low-normal heart function
(EF 50%). Patient was transferred to hepatology service who
adjusted diuresis and liver medications, which was well
tolerated. Spironolactone 50mg was added and lasix dose was
reduced to 20mg. Renal function was monitored and creatinine
improved to baseline.
___: patient had mildly elevated creatinine on admission, which
improved to baseline despite diuresis.
#Weakness: Patient complained of weakness for a few ___.
Appeared fluid up, secondary to liver failure. Improved with
diuresis. ___ consulted and okay to go home.
Transitional Issues
-appointment to be scheduled with hepatology
-labs to be drawn next week with hepatology visit, to be
followed by them but no need to write outpatient lab orders
-weakness likely due to disease, but should be monitored
-low normal EF on echo, should watch closely for signs of heart
failure
-starting spironolactone, should monitor K+
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Ciprofloxacin HCl 500 mg PO/NG DAILY
5. Cyanocobalamin 500 mcg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Lactulose 30 mL PO Q8H:PRN titrate to ___ BM's day
8. Lisinopril 2.5 mg PO DAILY
9. Nadolol 20 mg PO DAILY
10. Pantoprazole 40 mg PO Q12H
11. Rifaximin 550 mg PO BID
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. Furosemide 40 mg PO DAILY
16. Ferrous Sulfate 325 mg PO BID
17. Glargine 18 Units Bedtime
Insulin SC Sliding Scale using Aspart 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 500 mg PO DAILY
5. Glargine 18 Units Bedtime
Insulin SC Sliding Scale using Aspart Insulin
6. Lactulose 30 mL PO Q8H:PRN titrate to ___ BM's day
7. Nadolol 20 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Rifaximin 550 mg PO BID
10. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral daily
11. coenzyme Q10 50 mg Oral daily
12. Cyanocobalamin 500 mcg PO DAILY
13. Ferrous Sulfate 325 mg PO BID
14. FoLIC Acid 1 mg PO DAILY
15. Lisinopril 2.5 mg PO DAILY
16. Vitamin D ___ UNIT PO DAILY
17. Furosemide 20 mg PO DAILY
18. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
___ Cirrhosis
Secondary Diagnoses
Diabetes Mellitus, Type 2
Coronary Artery Disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
You were admitted after you fall and your concern for weakness.
You also had some fluid on your lungs which was concerning for
heart failure. Your echocardiogram showed relatively normal
heart function. Hepatology was consulted and adjusted your
medications to optimize the management of your liver failure.
Physical therapy was consulted and determined you were safe to
go home.
We have made some changes to your medications. You will start
taking spironolactone, a potassium-sparing diuretic to take off
fluid and maintain your potassium levels. We have also cut your
furosemide dose to 20mg daily, so please take a ___ pill daily
starting tomorrow.
Please follow up with the appointment listed below. You will
have blood drawn with your appointment with your liver doctors,
to be scheduled next week.
Please be well.
Your ___ Team
Followup Instructions:
___
|
10287348-DS-37 | 10,287,348 | 29,082,336 | DS | 37 | 2194-12-25 00:00:00 | 2194-12-25 19:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Egg / Latex / mayonaise / Codeine
Attending: ___.
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ PMH of NASH cirrhosis s/p banding, HE, ascites, GAVE, CAD
s/p CABG and PCIx2, DM2 who was referred to the ED after having
a hematocrit of 21 noted on labwork. He was recently discharged
on ___ with a hematocrit of 26. He has known history of GAVE
that has required APC and his hematocrit was checked nearly a
week and found to bepresenting to ED with anemia. Routine
labwork at rehab revealed anemia with hct of 21, down from 26 on
discharge on ___ from here. Patient has PMHx notable for NASH
cirrhosis c/b esophageal varices s/p banding, hepatic
encephalopathy, ascites, GAVE, CAD s/p CABG (___), and PCI,
DMII. Not on anticoagulation. Denies any chest pain, abdominal
pain, N/V, lightheadedness. Pt denies any gross blood in stool.
In the ED, initial vitals: 98.1 72 127/55 18 98% RA
Exam: Rectal with brown +guaiac stool, unremarkable abdominal
exam
Labs were notable for: H/H 7.3/22.9, plateletes of 98,
creatinine of 1.4. UA unremarkable.
Patient was given: 40 IV pantoprazole, and IV ceftriaxone. Had 2
IVs placed, was crossmatched 2U.
Vitals prior to transfer: 98 84 132/61 16 99% RA
Upon arrival to the floor the patient has no complaints.
Past Medical History:
1. NASH cirrhosis with h/o ascites, encephalopathy, no varicies
on most recent EGD. h/o Grade 2 esophogeal varices, s/p banding
___. Last EGD ___ without varicies (evidence of prior
banding), GAVE (tx at the time with thermal therapy).
Otherwise normal EGD to third part of the duodenum
2. CAD: CABG ___, stenting in ___ DES, cath in ___. Not
on plavix due to multiple GI bleeds.
3. H/O occult 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
5. TIA ___ followed by Dr ___
6. Squamous cell carcinoma
7. HTN
8. Hyperlipidemia
9. Chronic Eosinophilia
10.Enterococcus Bacteremia ___ diagnosed at ___
___
11.Portal Venous Thrombus ___ unable to
anticoagulate given portal hypertensive gastropathy s/p APC
___
12.Portal Hypertensive Gastropathy s/p APC.
13. diverticulosis
14. Back Pain and spinal stenosis
Social History:
___
Family History:
- Father died at ___ of gastic cancer
- Mother had breast cancer in her ___
- Sister with a history of CAD/Stroke
- CAD/DM both parents.
Physical Exam:
Admission Physical
===================
VS: T 97.8 HR 89 BP 135/54 RR 18 O2 Sat 96% on RA
General: A&Ox3, appears older than stated age, in NAD.
HEENT: sclera anicteric, PERRL, EOMI, OP clear, pale MM
Neck: supple, no LD
CV: RRR, ___ systolic murmur best heard at lower sternal
border, no gallops, rubs
Lungs: clear to auscultation bilaterally, no wheezes, rales,
rhonchi.
Abdomen: Abdomen diffusely distended, +fluid wave, soft,
nontender
GU: Right inguinal hernia. Non-tender and easily reducible.
Ext: 1+ edema to mid-thigh. Ecchymoses on medial aspect of upper
right arm. Right PICC placement.
Back: No spinal tenderness, no paraspinal tenderness.
Neuro: A&Ox3, CNs grossly intact
Discharge Physical
==================
Vitals: T 97.8 HR 89 BP 135/54 RR 18 SpO2 96% RA
General: A&Ox3, appears older than stated age, in NAD.
HEENT: conjunctival pallor, sclera anicteric, PERRL, EOMI, OP
clear, pale MM
Neck: supple, no LD, JVP at 8cm
CV: RRR, ___ systolic murmur best heard at lower sternal
border, no gallops, rubs
Lungs: clear to auscultation bilaterally, no wheezes, rales,
rhonchi.
Abdomen: Abdomen diffusely distended, +fluid wave, soft,
nontender
GU: Right inguinal hernia. Non-tender and easily reducible.
Ext: 1+ edema to mid-thigh. Ecchymoses on medial aspect of upper
right arm. Right PICC placement.
Back: No spinal tenderness, no paraspinal tenderness.
Neuro: A&Ox3, CNs grossly intact
Pertinent Results:
Admission Labs
================
___ 02:30PM BLOOD WBC-4.5 RBC-2.34* Hgb-7.3* Hct-22.9*
MCV-98 MCH-31.2 MCHC-31.9* RDW-17.1* RDWSD-61.1* Plt Ct-98*
___ 02:30PM BLOOD ___ PTT-27.8 ___
___ 02:30PM BLOOD Glucose-120* UreaN-19 Creat-1.4* Na-137
K-4.3 Cl-106 HCO3-23 AnGap-12
___ 02:30PM BLOOD ALT-55* AST-71* AlkPhos-67 TotBili-0.7
Discharge Labs
==============
___ 05:54AM BLOOD WBC-4.2 RBC-2.36* Hgb-7.3* Hct-22.3*
MCV-95 MCH-30.9 MCHC-32.7 RDW-17.2* RDWSD-59.4* Plt Ct-97*
___ 05:54AM BLOOD ___ PTT-28.2 ___
___ 05:54AM BLOOD Glucose-72 UreaN-18 Creat-1.4* Na-136
K-3.9 Cl-108 HCO3-22 AnGap-10
___ 05:54AM BLOOD ALT-41* AST-49* AlkPhos-58 TotBili-0.6
___ 05:54AM BLOOD Calcium-7.7* Phos-2.7 Mg-1.7
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
Imaging
========
Chest Xray ___
IMPRESSION:
No acute cardiopulmonary process. Right PICC tip in the mid
SVC.
EGD ___
Impression: No evidence of esophageal varices
Angioectasias in the antrum (thermal therapy)
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ with PMHx notable for NASH cirrhosis c/b esophageal varices
s/p banding, hepatic encephalopathy, ascites, GAVE, CAD s/p
CABG, DMII, recent admission in ___ for enterococcus bacteremia
who presents from reahb after notied anemia.
# Bleeding from Gastric antral vascular ectasias: He has
previously noted history of Portal Hypertensive Gastropathy,
diverticulosis, GAVE, AVMs, and esophageal varices s/p banding.
In addition, patient's hemodynamic stability and brown stool
speaks to a slow bleed. Pt was noted to have Hgb of 6.5, Hct of
19.7 on ___, and pt was transfused 1 unit PRBC. Pt's Hgb
increased to 7.4, Hct of 22.6. Pt is now s/p EGD on ___, with
evidence of several sites of angioectasia in the antrum
consistent with GAVE, with one area particularly oozing during
the procedure. Pt was treated with APC and effective hemostasis
was achieved. This is consistent with pt's previous EGD at ___
on ___ also showed "patchy discontinuous erythema and
petechiae of the mucosa with mild oozing noted in the antrum",
and was treated with APC for hemostasis. He was continued on a
PPI and started on carafate.
# Enterococcus Bacteremia: Please refer to previous discharge
summary for full information. Enterococcus had grown at OSH and
was sensitive to vancomycin. He was started on vancomycin which
has been adjusted during his stay at rehab. He had been followed
by OPAT who had decreased his dose to 750mg q24 hours. His plan
was to have at least a four week course of antibiotics with
earliest stop time on ___.
#Portal Venous Thrombus: Based on CT Abdomen/Pelvis at ___
___, at previous admission. As patient is continuuing
to bleed he has not been anticoagulated at this point.
Consideration of systemic anticoagulation for
the portal venous thrombus should occur in ___ weeks following
EGD which occurred on ___ (earliest to consider
anticoagulation ___.
# ___ Cirrhosis c/b esophageal varices s/p banding ___,
hepatic encephalopathy, ascites, GAVE. He is not listed for
transplant due to a low biochemical MELD score. He was continued
on lactulose and rifaxamin. He was briefly on ceftriaxone and
then restarted on ciprofloxacin at discharge. He was not on
nadolol on admission. Given history OF GAVE/portal hypertensive
gastropathy/esophageal varices this should be
considered as an outpatient. At the time of discharge his
diuretic regimen should be restarted at lasix 10mg and
spironolactone 25mg.
# Ascites: Patient has ascites on physical examination. He was
not uncomfortable and did not undergo a large volume
paracentesis.
# Eosinophilia: Chronic. Was previously treated for
strongyloides with ivermectin in ___. He had no
localizing symptoms and per previous plan will require repeat
Strongyloides serology testing in ___ to
assess for conersion to seronegative status of Strongyloides.
# CAD s/p CABG (___), and PCI x2 (___): Continued on
aspirin 81 mg PO daily, Atorvastatin 80 mg PO QPM.
# DM2: Continued glargine 10 units at bedtime.
# HTN: Continued lisionopril 2.5 mg PO daily.
# GERD: Continued pantoprazole 40 mg PO Q12H.
# hypothyroidism: Continued levothyroxine 25 mcg PO daily.
Transitional
-Please continue vancomycin for at least a four week course
which would end at earliest on ___
-Continue carafate for 14 days through ___
-Infectious Disease Weekly Lab Tests: CBC with differential,
BUN, Cr, vancomycin trough. Please obtain WEEKLY. All Lab
results should be sent to: ATTN: ___ CLINIC-FAX:
___.
-Patients diuretics held throughout admission but can be
restarted at half the previous dose. Please check a creatinine
in one week and assess whether doses of diuretics need
adjustment.
-Portal Venous Thrombus: Cannot undergo systemic
anticoagulation, as patient underwent APC for portal
hypertensive gastropathy on ___. Systemic anticoagulation
can start 3 weeks following this procedure (which would be
___ at the earliest).
-Repeat EGD: Requires repeat EGD in ___ (2 months
following previous EGD in which patient underwent APC for portal
hypertensive gastropathy).
-Consider further imaging to assess for portal venous thrombus
-Patient is currently on ciprofloxacin for SBP prophylaxis given
a previous low total protein in ascitic fluid. Please consider
whether patient needs to be on ciprofloxacin for SBP
prophylaxis.
-Consider whether patient needs to be on nadolol given history
of varices/portal hypertensive gastropathy.
-Repeat Strongyloides serology in ___ (as had positive
serology treated with Ivermectin as recently as ___.
-Repeat trans-thoracic echocardiogram in ___ year as patient has
mildly dilated thoracic aorta.
-Consider repeat TSH as outpatient as patient had elevated TSH
in ___.
-Code Status: Full Code (confirmed)
-Contact Information: wife (___) ___
___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Bisacodyl ___AILY:PRN constipation
5. Calcium Carbonate 500 mg PO DAILY
6. Ciprofloxacin HCl 500 mg PO Q24H
7. Ferrous Sulfate 325 mg PO BID
8. FoLIC Acid 1 mg PO DAILY
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Lisinopril 2.5 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Pantoprazole 40 mg PO Q12H
13. Rifaximin 550 mg PO BID
14. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
15. Milk of Magnesia 30 mL PO DAILY:PRN constipation
16. coenzyme Q10 60 mg oral DAILY
17. Cyanocobalamin 500 mcg PO DAILY
18. Vitamin D ___ UNIT PO DAILY
19. Lactulose 30 mL PO TID:PRN Titrate to ___ BMs daily
20. Furosemide 20 mg PO DAILY
21. Spironolactone 75 mg PO DAILY
22. Vancomycin 750 mg IV Q 24H
23. Glargine 10 Units Bedtime
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 QPM
4. Bisacodyl ___AILY:PRN constipation
5. Calcium Carbonate 500 mg PO DAILY
6. coenzyme Q10 60 mg oral DAILY
7. Cyanocobalamin 500 mcg PO DAILY
8. Ferrous Sulfate 325 mg PO BID
9. FoLIC Acid 1 mg PO DAILY
10. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Lactulose 30 mL PO TID:PRN Titrate to ___ BMs daily
12. Levothyroxine Sodium 25 mcg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Rifaximin 550 mg PO BID
15. Vancomycin 750 mg IV Q 24H
16. Vitamin D ___ UNIT PO DAILY
17. Omeprazole 40 mg PO DAILY
18. Sucralfate 1 gm PO QID
19. Ciprofloxacin HCl 500 mg PO Q24H
20. Lisinopril 2.5 mg PO DAILY
21. Milk of Magnesia 30 mL PO DAILY:PRN constipation
22. Furosemide 10 mg PO DAILY
23. Spironolactone 50 mg PO DAILY
24. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Gastrointestinal bleed
Acute kidney injury
Secondary Diagnosis:
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 our pleasure caring for you at ___
___. You were admitted with low blood counts. We did
an EGD, which showed oozing of blood in the stomach. This was
cauterized and the bleeding stopped.
Followup Instructions:
___
|
10287348-DS-38 | 10,287,348 | 20,508,429 | DS | 38 | 2195-01-07 00:00:00 | 2195-01-07 20:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Egg / Latex / mayonaise / Codeine
Attending: ___
Chief Complaint:
Worsening ascites
Major Surgical or Invasive Procedure:
Ultrasound guided paracentesis
History of Present Illness:
Mr. ___ is a ___ year-old man with PMH significant for NASH
cirrhosis s/p banding, HE, ascites, GAVE, CAD s/p CABG and
PCIx2, DM2 p/w abd distention for 2 weeks. Pt. has been at rehab
since last discharge and has overall been progressing with plans
for discharge home on ___. Unfortunately, given the
worsening ascites as well as increasing back pain, the pt. was
instead sent to the ED. Pt. reports that he has had increased
abdominal girth for the past ___ weeks. He denies any fevers,
sweats, chills, abdominal pain. He reports adhering to a low
sodium diet and all of his medications as prescribed. While he
has some ___ edema, he reports that it has improved
significantly. reports that he has had chronic left-sided low
back pain, but over the past ___ weeks as his abdominal
distension has increased, he has had worsening pain with
extension up the left side of his thoracic spine. He denies any
___ weakness, bowel/bladder incontinence.
Of note, the patient was recently admitted to ___ from ___
to ___ for anemia in the setting of known history of portal
hypertensive gastropathy, diverticulosis, GAVE, AVMs, and
esophageal varices s/p banding. He underwent EGD on ___ that
showed several sites of angioectasia in the antrum consistent
with GAVE, with one area particularly oozing during the
procedure for which he was treated with APC. He was otherwise
continued on Vancomycin for prior Enterococcus bacteremia.
Although he was noted to have ascites, no therapeutic
paracentesis was conducted.
In the ED, initial vitals were 98.2 88 115/54 16 100%RA. Labs
notable for Chem-7 with Na 131 and BUN/Cr ___ CBC with H/H
7.3/22.0 (stable from baseline); INR 1.4; UA neg. On arrival to
the floor, pt. reports feeling well with no abdominal pain or
dyspnea and only mild back pain.
ROS: Per HPI. In addition, pt. reports that he has had
significant diarrhea for the past 2 weeks with about 7 loose BM
already today. He denies any black or bloody stools. He has had
no nausea or vomiting. He denies any confusion. No headaches or
blurred vision.
Past Medical History:
1. NASH cirrhosis with h/o ascites, encephalopathy, no varicies
on most recent EGD. h/o Grade 2 esophogeal varices, s/p banding
___. Last EGD ___ without varicies (evidence of prior
banding), GAVE (tx at the time with thermal therapy).
Otherwise normal EGD to third part of the duodenum
2. CAD: CABG ___, stenting in ___ DES, cath in ___. Not
on plavix due to multiple GI bleeds.
3. H/O occult 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
5. TIA ___ followed by Dr ___
6. Squamous cell carcinoma
7. HTN
8. Hyperlipidemia
9. Chronic Eosinophilia
10.Enterococcus Bacteremia ___ diagnosed at ___
___
11.Portal Venous Thrombus ___ unable to
anticoagulate given portal hypertensive gastropathy s/p APC
___
12.Portal Hypertensive Gastropathy s/p APC.
13. diverticulosis
14. Back Pain and spinal stenosis
Social History:
___
Family History:
- Father died at ___ of gastic cancer
- Mother had breast cancer in her ___
- Sister with a history of CAD/Stroke
- CAD/DM both parents.
Physical Exam:
========================
Admission physical exam:
========================
VS: Tm 98.0 Tcurr 97.9 HR 83 (82-86) BP 122/55 RR 18 SpO2 97% on
RA, Wt 86.6kg
General: pleasant, chronically-ill appearing gentleman lying in
bed, in NAD
HEENT: atraumatic, normocephalic head, sclear anicteric, MMM,
EOMI, PERRLA, VF full to confrontation
Neck: supple
CV: ___ systolic murmur at lower sternal border; RRR;
Lungs: decreased breath sounds in LLL field with bibasilar
crackles
Abdomen: soft, distended, (+) fluid wave, nontender, normoactive
bowel sounds
GU: no foley
Rectal: non-bleeding external hemorrhoids; no stool in rectal
vault
Ext: WWP; 3+ edema to thigh. No tenderness to palpation of spine
or paravertebral areas on L or R
Neuro: A&O x3; no asterixis,
Skin: no jaundice or lesions
=======================
Discharge physical exam:
========================
VS: Tm 98.4 Tcurr 98.4 HR 82 (82-87) BP 116/52 (116-152/53-82)
RR 18 SpO2 100% on RA,
General: pleasant, chronically-ill appearing gentleman lying in
bed, in NAD
HEENT: atraumatic, normocephalic head, sclear anicteric, MMM,
EOMI, PERRLA, VF full to confrontation
Neck: supple
CV: ___ systolic murmur at lower sternal border; RRR;
Lungs: mildly diminished breath sounds in LLL improved since
admission, otherwise CTAB, w/ no wheezes or crackles appreciated
Abdomen: soft, nontender, normoactive bowel sounds, no longer
distended, (-) fluid wave
GU: no foley
Ext: WWP; pitting edema to thigh. No tenderness to palpation of
spine or paravertebral areas on L or R
Neuro: A&O x3; no asterixis,
Skin: no jaundice or lesions
Pertinent Results:
========================
Admission labs:
========================
___ 05:35PM GLUCOSE-195* UREA N-19 CREAT-1.3* SODIUM-131*
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-23 ANION GAP-7*
___ 05:35PM estGFR-Using this
___ 05:35PM ALT(SGPT)-34 AST(SGOT)-44* ALK PHOS-73 TOT
BILI-0.4
___ 05:35PM ALBUMIN-2.3*
___ 05:35PM WBC-4.8 RBC-2.30* HGB-7.3* HCT-22.0* MCV-96
MCH-31.7 MCHC-33.2 RDW-15.8* RDWSD-54.3*
___ 05:35PM NEUTS-69.8 LYMPHS-9.2* MONOS-12.8 EOS-6.9
BASOS-0.9 IM ___ AbsNeut-3.26 AbsLymp-0.43* AbsMono-0.60
AbsEos-0.32 AbsBaso-0.04
___ 05:35PM ___ PTT-28.6 ___
___ 06:05PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
=======================
Discharge labs:
========================
___ 06:54AM BLOOD Glucose-112* UreaN-18 Creat-1.3* Na-137
K-3.8 Cl-109* HCO3-20* AnGap-12
___ 06:54AM BLOOD ALT-32 AST-42* AlkPhos-74 TotBili-1.0
___ 06:54AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.8
___ 06:54AM BLOOD WBC-4.8 RBC-3.05*# Hgb-9.5*# Hct-29.1*#
MCV-95 MCH-31.1 MCHC-32.6 RDW-15.8* RDWSD-54.4* Plt ___
___ 06:54AM BLOOD ___ PTT-30.1 ___
___ 08:04AM ASCITES WBC-62* RBC-81* Polys-PND Lymphs-PND
Monos-PND
___ 08:04AM ASCITES TotPro-0.7 Albumin-<1.0
Brief Hospital Course:
Mr. ___ is a ___ y/o M with PMHx notable for NASH cirrhosis c/b
esophageal varices s/p banding, hepatic encephalopathy,
ascites, GAVE, CAD s/p CABG, DMII, recent admissions in ___
for enterococcus bacteremia and ___ for GI bleed (s/p RBC
transfusion and EGD and APC treatment of GAVE ulcers) who
presents from clinic with worsening ascites.
# Ascites: Worsening ascites secondary to NASH cirrhosis (see
below) and possibly exacerbated by untreated PVT. While pt has
significant distension on exam, his abdomen is nontender and he
is not in any acute pain or respiratory distress. Pt further he
has no obvious evidence of SBP, and thus antibiotics were held
while awaiting paracentesis with cell count and cultures.
Patient underwent diagnostic and therapeutic ultrasound guided
paracentesis on ___ AM by ___, with drainage of 5.5L of
fluid. Ascites fluid analysis was notable for PMNS of 10, not
consistent with SBP (<250 PMNs, Total protein=0.7, Albumin 1.0).
However, due to pt's previous history of SBP, pt was continued
on Ciprofloaxacin prophylaxis.
# NASH cirrhosis c/b esophageal varices s/p banding ___, GAVE,
PVT, HE, and ascites. Childs class B. MELD 10: Pt is currently
not on transplant list given his low MELD score. Pt currently
has decompensated with ascites, but no evidence of HE, SBP, or
GI bleed. During this admission, pt was continued on home
regimen of lactulose/rifaximin for hepatic encephalopathy.
However, pt initially had 7 loose BM on day prior to admission,
and lactulose was held. Pt's BM frequency reduced during this
hospital admission, with improvement in consistency of BM, and
pt was counseled on restarting Lactulose with titration of dose
to ___ BM. C diff studies were sent due to recent Antibiotic use
as well as chronic SBP antibiotic prophylaxis. Pt was continued
on Ciprofloxacin 500MG qD for SBP prophylaxis. Pt was volume
overloaded on this admission with increase in ___ edema and
ascites fluid; however, pt's home lasix 10mg/ spironolactone
25mg doses were held due to uptrending Cr and concern for ___.
Pt's Cr downtrended during this admission from Cr of 1.3 to 1.4,
and pt was restarted on his current diuretic regimen (Lasix 10MG
Spironolactone 25MG daily) with close followup with his PCP to
recheck electrolytes and trend his Cr, Na.
# Anemia: Pt has a known history of chronic anemia from
intermittently oozing GAVE. He has previously noted history of
Portal Hypertensive Gastropathy, diverticulosis, GAVE, AVMs, and
esophageal varices s/p banding. On this admission pt had Hgb of
7.0, Hct of 22.1. In setting of pts anemia, low volume status
and requirement for Albumin, pt received 1U PRBC for anemia with
improvement of his Hgb to 9.5 (from 7.0) and Hct of 29.1 (from
22.1) following transfusion. Pt was continued to be monitored
with serial daily H/H with thershold of Hgb<7 or symptomatic for
transfusion. Pt had stable VS throughout this admission.
# ___: Mild ___ and hyponatremia on labs are suggestive of some
component of hypoperfusion. Pt's diuretics were held overnight
given ___ and in anticipation of large volume para. Pt had bland
UA. Pt had paracentesis on ___ AM with drainage of 5.5L of
fluid, and was given 50g Albumin post-paracentesis. Pt's
diuretics were held in the setting of elevated Cr of 1.4. At
time of discharge, Cr improved to 1.3 and pt was restarted on
home diuretics (Furosemide 10MG daily and Spironolactone 25MG
daily) with close followup with his PCP to trend his Cr and
electrolytes to ensure continued improvement.
# Recent enterococcus bacteremia: Recent course of vanc
completed on ___. No evidence of recurrent infection on this
admission, with afebrile temperatures, VSS stable.
# Diarrhea: Pt has reported 7 loose stools on the day of
admission. Pt's stool softening regimen was held, and pt's stool
has been more formed with less frequency. C. diff studies were
negative this admission. Pt's lactulose was held and diarrhea
improved to ___ BM a day, more formed, with plan to continue to
titrate lactulose to ___ BM per day.
Chronic issues:
# CAD s/p CABG (___), and PCI x2 (___): During this
admission, pt was continued on aspirin 81 mg PO daily,
Atorvastatin 80 mg PO QPM.
# DM2: Patient was continued on glargine 10 units at bedtime
everynight. Pt's AM fingersticks were well controlled, with ___
stable at 100-120 during admission.
# HTN: Patient was continued on his home lisinopril 2.5 mg PO
daily.
# GERD: Patient was continued on his home pantoprazole 40 mg PO
Q12H.
# hypothyroidism: Patient was continued on his home
levothyroxine 25 mcg PO daily.
#DVT prophylaxis: pt was maintained on SC heparing during this
admission.
#Pain: pain mgmt was achieved with Tylenol, Lidocaine patch and
hot packs to the affected area.
Transitional
===========
1. Recheck Cr and electrolytes. Pts home diuretics were held on
this admission due to elevated Cr of 1.4. At the time of
discharge, pt's Cr was downtrending to Cr of 1.3 and he was
restarted on his home Lasix 10MG and Sprinolactone 25MG. Please
continue to monitor his Cr and electrolytes
2. Recheck pt's Hemoglobin/Hematocrit. Pt had Hgb of 7.0 and Hct
of 22.1 during this admission and received 1 PRBC. At the time
of discharge pt had Hgb of 9.5, Hct of 29.1.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Bisacodyl ___AILY:PRN constipation
5. Calcium Carbonate 500 mg PO DAILY
6. coenzyme Q10 60 mg oral DAILY
7. Cyanocobalamin 500 mcg PO DAILY
8. Ferrous Sulfate 325 mg PO BID
9. FoLIC Acid 1 mg PO DAILY
10. Lactulose 30 mL PO TID:PRN Titrate to ___ BMs daily
11. Levothyroxine Sodium 25 mcg PO DAILY
12. Rifaximin 550 mg PO BID
13. Vitamin D ___ UNIT PO DAILY
14. Omeprazole 40 mg PO DAILY
15. Sucralfate 1 gm PO QID
16. Ciprofloxacin HCl 500 mg PO Q24H
17. Lisinopril 2.5 mg PO DAILY
18. Milk of Magnesia 30 mL PO DAILY:PRN constipation
19. Furosemide 10 mg PO DAILY
20. Spironolactone 25 mg PO DAILY
21. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
22. Fleet Enema ___AILY:PRN constipation
23. TraMADOL (Ultram) 25 mg PO Q8H:PRN pain
24. Guaifenesin 10 mL PO Q6H:PRN cough
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Ciprofloxacin HCl 500 mg PO Q24H
5. Cyanocobalamin 500 mcg PO DAILY
6. Ferrous Sulfate 325 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Rifaximin 550 mg PO BID
11. Sucralfate 1 gm PO QID
12. Vitamin D ___ UNIT PO DAILY
13. Bisacodyl ___AILY:PRN constipation
14. coenzyme Q10 60 mg oral DAILY
15. Atorvastatin 80 mg PO QPM
16. Lactulose 30 mL PO TID:PRN Titrate to ___ BMs daily
17. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
18. Fleet Enema ___AILY:PRN constipation
19. Furosemide 10 mg PO DAILY
20. Guaifenesin 10 mL PO Q6H:PRN cough
21. Lisinopril 2.5 mg PO DAILY
22. Milk of Magnesia 30 mL PO DAILY:PRN constipation
23. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Ascites
Discharge Condition:
VS Stable.
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
admission at ___. You were
admitted for worsening ascites in your abdomen. During your
hospital admission, you underwent ultrasound guided paracentesis
to drain the fluid from your abdomen, and 5.5L of ascites fluid
was drained from your abdomen. Following your procedure, your
symptoms improved, with less distention of your abdomen and
improvement in your back pain.
Followup Instructions:
___
|
10287475-DS-12 | 10,287,475 | 22,730,947 | DS | 12 | 2116-07-09 00:00:00 | 2116-07-11 08:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Intraparenchymal hemorrhage with intraventricular extension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old right-handed man who presents
with right-sided weakness and dysarthria. He was in his usual
state of health this morning. He awoke at around 4:30 this
morning and went to work (works in ___). At around 7:45
this morning he noticed that his speech became slurred. He
within the next few minutes, he developed weakness in his right
arm and leg and needed to sit down. He could not stand back up.
EMS was called and per report when they arrived he was
hypertensive with SBP in 200s in the field. Pt states that he
has
been hypertensive for a long time, he is taking a single agent
for control to which he is compliant, but he does not remember
the name of the medication. He initially presented to the
___ ED where CT showed a left thalamic intraparenchymal
hemorrhage with intraventricular extension. His blood pressure
there was elevated to the 170's-200's; he was given labetalol
and
transferred to the ___ ED.
In the ___ ED his blood pressure was elevated to the 180s
systolic. He was started on a Chlamydia pain drip with
improvement of his blood pressure to the 130s and 140s systolic.
Review of Systems: Positive for HA. Vision feels "weak" but it's
not blurry or double. Denies language difficulties. Had some
dizziness earlier, but none currently. The pt denies loss of
vision, blurred vision, diplopia, hearing difficulty. Denies
difficulties producing or comprehending speech. Denies cough,
shortness of breath. Denies chest pain or palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
rash.
Past Medical History:
HTN
Social History:
___
Family History:
- father: HTN
- mother: HTN
Physical ___:
==============
ADMISSION EXAM
==============
Vitals: 98.7 70 185/112 16 100% RA
FSBG: 75
General: Awake, cooperative, NAD.
HEENT: NC/AT
Pulmonary: breathing comfortably on RA
Cardiac: RRR on bedside monitor
Abdomen: soft, nondistended
Extremities: no edema, warm
Skin: no rashes or lesions noted.
NEUROLOGIC EXAMINATION
-Mental Status: Awake, alert. Able to relate history though has
some difficulty relating details. Language is fluent with
intact
repetition. He did require repeated prompting to follow some
commands and answer some questions. ___ is his second
language, which may be confounding this exam (patient refused
offer to obtain translator). There were some paraphasic errors.
For example, on the stroke card he called cactus a "captus" and
called hammock a "sleeping place". Otherwise, he was able to
name the items on the stroke card. He had some difficulty
reading phrases on the stroke card (it was slow and effortful)
and the patient says this is worse than his baseline reading.
He
was able to follow the commands of the exam but had some
difficulty with more complex commands - able to show 3 fingers;
unable to touch his left ear with his left thumb. There was no
evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm bilaterally. VFF to confrontation with
finger
wiggling.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch
VII: Right nasolabial fold flattening
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
XI: Shoulder shrug is slower on the right.
XII: Tongue protrudes in midline with full ROM right and left
-Motor: There is a pronator drift on the right. No tremor noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ 4 4+ ___- ___ 4+ 4 4
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
- Toes were downgoing bilaterally.
-Sensory: Decreased light touch and pinprick sensation in the
right arm and leg. Temperature sensation was decreased in the
right arm, intact in the right leg. No extinction to DSS.
-Coordination: No dysmetria on FNF out of proportion to his
weakness.
-Gait: Deferred given risk for fall
___ Stroke Scale - Total [5]
1a. Level of Consciousness -0
1b. LOC Questions -0
1c. LOC Commands -0
2. Best Gaze -0
3. Visual Fields -0
4. Facial Palsy -1
5a. Motor arm, left -0
5b. Motor arm, right -1
6a. Motor leg, left -0
6b. Motor leg, right -0
7. Limb Ataxia -0
8. Sensory -1
9. Language -1
10. Dysarthria -1
11. Extinction and Neglect -0
======================
TRANSFER TO FLOOR ___
======================
Unchanged except:
-Cranial nerves: Shoulder shrug 4- on the right.
-Motor: Right arm drift. No tremor noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 4 4+ 4 4 4
Examination on Discharge is significant for mild right facial
weakness, mild and improved UMN pattern of weakness in right arm
and leg.
Pertinent Results:
=======
IMAGING
=======
- ___ CTA Head
1. Left thalamic intraparenchymal hematoma with slight increase
in surrounding edema exerting mild mass effect on the third
ventricle. No evidence of hydrocephalus or change in size of the
ventricle. No evidence of associated vascular malformation.
2. Small amount of intraventricular hemorrhage similar to the
prior study.
3. Slight prominence of the central vasculature, which may be
related to hypertension. Otherwise, unremarkable CTA of the
head.
- ___ CT Head
1. Stable appearance of left thalamic intraparenchymal
hemorrhage with slightly increased edema since prior exam.
Previously seen trace intraventricular blood within the
posterior horn of the right lateral ventricle has resolved with
stable volume of blood within the body, trigone and occipital
horn of the left lateral ventricle. Unchanged effacement of the
body and trigone left lateral ventricle, as well as the third
ventricle. No midline shift.
2. No new intracranial hemorrhage. No acute large vascular
territorial infarction.
3. Paranasal sinus disease, as described above.
___ CT Head
1. Intraparenchymal hemorrhage in the left thalamus measures 1.5
x 1.2 cm,
decreased in size from CT head ___, previously
measuring 1.9 x 1.7 cm. Degree of edema and effacement the left
lateral ventricle is unchanged.
2. Interval resolution of intraventricular hemorrhage.
3. No new intracranial hemorrhage or acute large territory
infarct.
Brief Hospital Course:
SUMMARY:
Mr. ___ is a ___ man with a history of hypertension,
not compliant with his outpatient treatment regimen, who
presented with acute onset slurred speech and right-sided
weakness. CT at an outside hospital showed left thalamic
intraparenchymal hemorrhage with intraventricular extension. He
had not been taking his home chlorthalidone prior to admission.
He was hypertensive to SBP 170-200 on presentation. He was given
labetalol, transferred to ___, and admitted to the ICU via
the ED. A nicardipine drip was started, bringing his SBP to
130-140s. He subsequently was weaned off of the cardene drip
and blood pressures were well controlled after restarting his
home regimen of chlorthalidone and lisinopril.
HOSPITAL COURSE BY PROBLEM:
# LEFT THALAMIC INTRAPARENCHYMAL HEMORRHAGE WITH
INTRAVENTRICULAR EXTENSION
His initial exam on ___ in the ED was significant for mild
aphasia (slowed speech, occasional paraphasic errors, difficulty
understanding complex commands), and mild right-sided weakness
most prominent in the deltoids (4), wrist/fingers (~4), IP (4-),
hamstrings (4-), and TA (3). Upon transfer to the ICU, his exam
worsened with his deltoids and wrist/fingers becoming barely
anti-gravity (3). Do to this change, he was sent for a repeat CT
which was grossly stable, showing only mildly increased
surrounding edema. He was not started on hyperosmolar therapy.
This weakness improved somewhat the following day. His blood
pressures were well controlled after being restarted on his home
regimen of chlorthalidone 25mg daily and adding lisinopril 10mg
daily. At the time of discharge, his exam was notable for
dysarthria, mild weakness of right instrinsic muscles of hand
(interossei, finger extensors), and unsteady gait requiring a
walker to ambulate. He was evaluate by ___ and recommended for
rehab given his significant decompensation from his functional
baseline.
The etiology of his bleed was likely hypertensive in the setting
of not being compliant with his outpatient regimen. He had not
been taking his home chlorthalidone prior to admission.
# HYPERTENSION
His SBP on presentation to OSH was 170-200, so he was given
labetalol prior to transfer. Upon transfer here, his SBP was
~180 so he was admitted to the ICU for a nicardipine drip with a
goal SBP <150. He was on this drip at a rate of 2mcg/kg/min for
~4 hours until 9PM on ___, whereafter his SBP stablized to the
120s without nicardipine. He was monitored in the ICU for the
next ~18 hours and did not require any antihypertensives. Before
transfer to the floor, his SBP began to climb to 150s, so he was
restarted on his home chlorthalidone 25mg and we added
lisinopril 10mg.
He was transferred to the floor ~9PM on ___. After this
transfer, patient's blood pressures remained stable, SBP<150.
*******************
TRANSITIONAL ISSUES
-Continue Chlorthalidone 25mg daily and Lisinopril 10mg daily
-Once you have obtained insurance, please follow up with a
Neurologist from the Stroke Neurology division at ___. The
number for the office is ___
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes
2. DVT Prophylaxis administered? (x) Yes
3. Smoking cessation counseling given? (x) No [reason (x)
non-smoker
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Chlorthalidone 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain or temp > ___
2. Docusate Sodium 100 mg PO BID
3. Lisinopril 10 mg PO DAILY
4. Chlorthalidone 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left thalamic hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of right sided weakness
and slurred speech resulting from an ACUTE HEMORRHAGIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is impaired due to bleeding. The brain is the part of
your body that controls and directs all the other parts of your
body, so damage to the brain from being deprived of its blood
supply can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
-high blood pressure
We are changing your medications as follows:
Started Lisinopril, a new blood pressure medication
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:
___
|
10287742-DS-11 | 10,287,742 | 27,210,620 | DS | 11 | 2131-08-30 00:00:00 | 2131-09-09 13:23:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o male, + ETOH who was found down and dropped off in
front of the ED at the OSH. A CT of the head was obtained and
showed diffused SAH, mostly in the frontal lobe, and a small
right frontal SDH. He was transferred to ___ for further
management. He was also found to have a rib fx and possible
duodenal or pancreatic bleeding. The patient was non verbal and
intoxicated, unable to obtain history or review of system.
Past Medical History:
unknown
Social History:
___
Family History:
unknown
Physical Exam:
Admission exam:
PHYSICAL EXAM:
Mental status: Lethargic but moving all extremity with
stimulation, opening eyes to verbal stimulus, not following
commands.
Orientation: Nonverbal, ? language barrier.
Language: Non verbal
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2.5
mm bilaterally and sluggish.
Unable to examine other cranial nerves.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. MAE spont, with good strength, no commands.
Discharge Physical Exam:
VS: VSS afebrile
GEN: AA&O x 2 (not to place), NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, non tender to palpation,
non-distended.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
NEURO: Intact.
Pertinent Results:
___ 06:35AM BLOOD WBC-10.7* RBC-4.05* Hgb-14.0 Hct-40.7
MCV-101* MCH-34.6* MCHC-34.4 RDW-12.5 RDWSD-46.6* Plt ___
___ 04:29PM BLOOD WBC-7.5 RBC-3.60* Hgb-12.5* Hct-36.1*
MCV-100* MCH-34.7* MCHC-34.6 RDW-12.5 RDWSD-45.9 Plt ___
___ 12:10AM BLOOD WBC-7.4 RBC-3.47* Hgb-12.2* Hct-35.1*
MCV-101* MCH-35.2* MCHC-34.8 RDW-12.8 RDWSD-47.7* Plt ___
___ 09:06AM BLOOD Hct-35.4*
___ 02:41AM BLOOD WBC-9.1 RBC-3.32* Hgb-11.4* Hct-33.5*
MCV-101* MCH-34.3* MCHC-34.0 RDW-12.2 RDWSD-46.0 Plt Ct-97*
___ 04:51AM BLOOD WBC-9.5 RBC-3.26* Hgb-11.1* Hct-32.5*
MCV-100* MCH-34.0* MCHC-34.2 RDW-11.9 RDWSD-43.8 Plt ___
___ 06:05AM BLOOD WBC-7.4 RBC-3.43* Hgb-11.7* Hct-33.7*
MCV-98 MCH-34.1* MCHC-34.7 RDW-11.7 RDWSD-42.4 Plt ___
___ 05:30AM BLOOD WBC-7.0 RBC-3.55* Hgb-12.0* Hct-34.9*
MCV-98 MCH-33.8* MCHC-34.4 RDW-11.9 RDWSD-42.9 Plt ___
___ 06:35AM BLOOD ___ PTT-25.7 ___
___ 06:35AM BLOOD Plt ___
___ 05:30AM BLOOD Plt ___
___ 06:35AM BLOOD UreaN-17 Creat-0.9
___ 04:29PM BLOOD Glucose-153* UreaN-13 Creat-0.8 Na-142
K-3.8 Cl-103 HCO3-21* AnGap-22*
___ 06:45AM BLOOD Glucose-136* UreaN-7 Creat-0.6 Na-134
K-3.2* Cl-95* HCO3-28 AnGap-14
___ 06:35AM BLOOD ALT-315* AST-694* AlkPhos-109 TotBili-0.5
___ 12:10AM BLOOD Amylase-322*
___ 02:41AM BLOOD Amylase-138*
___ 04:51AM BLOOD ALT-96* AST-88* AlkPhos-100 Amylase-96
___ 06:35AM BLOOD Lipase-486*
___ 12:10AM BLOOD Lipase-622*
___ 02:41AM BLOOD Lipase-138*
___ 04:51AM BLOOD Lipase-107*
___ 06:35AM BLOOD Albumin-4.8
___ 04:29PM BLOOD Calcium-8.4 Phos-2.5* Mg-1.5*
___ 06:45AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.8
___ 06:35AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:43AM BLOOD Glucose-120* Lactate-2.5* Na-148* K-4.5
calHCO3-27
___ 04:40PM BLOOD Lactate-1.9
___ 06:43AM BLOOD Hgb-14.8 calcHCT-44 O2 Sat-65 COHgb-2
MetHgb-0
___
Trauma CXR: IMPRESSION:
1. Tiny right pneumothorax without evidence of mediastinal
shift, better
visualized on the concomitant CT examination.
2. Three contiguous lateral mildly displaced right rib
fractures.
CTA head and neck: 1. Bilateral frontal and left temporal lobe
hemorrhagic contusions have
evolved since the prior outside CT.
2. Multi-focal subdural and subarachnoid hemorrhages are similar
compared to
the prior study. There is no midline shift.
3. The principal arteries of the head and neck are patent,
without focal
stenosis, occlusion, dissection, or aneurysmal formation.
4. Linear calvarial and right third rib fractures are
nondisplaced.
5. Small right apical pneumothorax.
CTA Torso: 1. Periduodenal hematoma in addition to a bulky and
hypodense pancreatic head
and uncinate process are suggestive of a combined
duodenal/pancreatic
contusion.
2. Small right pneumothorax without evidence of mediastinal
shift to suggest
tension pneumothorax.
3. Four contiguous, minimally displaced lateral right rib
fractures.
4. Mild mediastinal stranding, compatible with small hematoma.
5. Hemoperitoneum. Linear hypodensity in spleen may be
artifactual from
streak artifact or phase of bolus timing, though it is difficult
to exclude a
splenic contusion.
6. Hepatic steatosis.
7. Extravasated contrast material throughout the left upper
extremity from
prior administration.
8. 1.4 x 3.4 cm indeterminate hyperdensity in right hip
adductor musculature
is not fully evaluated on post contrast examination and could
represent
calcification, as in heterotopic ossification, versus contrast
enhancement, in
which case extravasation of contrast cannot be excluded.
However, this is
felt unlikely due to lack of surrounding hematoma.
CT head w/o contrast:
1. Progressive and new intraventricular, subarachnoid, subdural
and
intraparenchymal hemorrhage .
MRCP 1. Increased edema involving the posterior aspect of the
pancreatic head and
uncinate process with interval progressed peripancreatic fat
stranding and
fluid, with intraperitoneal and retroperitoneal extension.
These favor
traumatic pancreatitis with associated third-spacing. No
pancreatic ductal
injury or pancreatic laceration/necrosis. No duodenal injuries
are
appreciated.
2. Mild diffuse hepatic steatosis.
CT spine: o evidence of fracture or subluxation. Mild changes
of degenerative disc disease.
Brief Hospital Course:
Mr. ___ was admitted to to the ICU after being found down on
___. His imaging revealed the following injuries: small
right pneumothorax, right somewhat displaced rib fractures,
hemorrhagic products surrounding descending duodenum and
pancreas, Bilateral frontal and left temporal hemorrhagic
contusions and multifocal SDH and SAHs. The patient was
lethargic and not responding to questions. Imaging revealed a
slightly worsening SAH and neurosurgery was consulted. They
decided to get another CT scan, which was stable, and CTA head
and neck did not identify any vascular lesions. He became
agitated and was started on phenobarbital CIWA. Otherwise he
continued to move extremities and mental status was unchanged,
and remained hemodynamically stable. After his mental status
and agitation cleared, he was transitioned to a PO phenobarbital
taper and was transferred to the floor on ___.
CV: His blood pressure was monitored throughout his ICU course,
but he never required pressors and there were no active issues.
His SBP goal was maintained at < 140 throughout his ICU course.
It was monitored closely especially while on the CiWA protocol.
P: No active issues. Pain was well controlled and he was able to
transition to room air rapidly, never required intubation.
GI: Given his duodenal contusion versus possible bleed, he was
originally kept NPO. An MRCP was obtained on ___ that did not
show any pancreatic leak, and he was allowed to start eating.
His abdominal tenderness improved significantly throughout the
first few days and he had no issues tolerating a diet.
H: His CBC's were checked often during the first 2 days but
barely dropped, and he remained hemodynamically stable without
any evidence of ongoing bleeding.
ID: No issues with any signs of infection throughout his ICU
course.
E: no issues.
The patient remained hemodynamically stable on the floor, and
mental status steadily improved. The patient was seen and
evaluated by ___, who cleared him for discharge home with ___
supervision.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with with family
for ___ supervision. The patient and his family received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. He was
scheduled to have follow-up with neurosurgery and would continue
the Keppra until his follow-up. He also had an appointment
scheduled in the ___ clinic.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*84 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Polytrauma:
right frontal subdural hemorrhage
diffuse subarachnoid hemorrhage
right ___ lateral rib fractures
duodenal/pancreatic head contusion
small mediastinal hematoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ after sustaining injuries from an
assault. Your injuries included bleeding in the brain, right
sided rib fractures, a contusion to your abdominal organs, and a
small hematoma to the mediastinum. Your neurological exam was
closely monitored and a repeat head cat scan was stable and did
not show active bleeding. Because of your head injury, it will
take some time for your mental status to clear and for you to be
functioning independently again. You have been working with the
Physical Therapists and Occupational Therapists, who have
recommended you go home with 24-hour supervision. You are
medically cleared for discharge, and will need to follow-up in
the ___ clinic for a repeat head CT in ___ weeks.
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.
* 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.
* 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:
___
|
10287750-DS-18 | 10,287,750 | 27,335,755 | DS | 18 | 2166-10-31 00:00:00 | 2166-11-08 13:18:00 |
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
Injuries:
L rib fx ___
small L PTX, small L pulm contusion
L humerus fx
R radius fx
Major Surgical or Invasive Procedure:
Placement of left chest tube ___, chest tube removed ___
History of Present Illness:
___ in MVC, ejected from vehicle, moving all four extremities,
intubated at ___ for agitation.
Past Medical History:
PMH: Seizure disorder as a child, has not had a seizure since
college. ADD, previously on adderal (not currently taking),
asthma, scoliosis
PSH: none
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION: upon admission ___
Constitutional: intubated and sedated
HEENT: Normocephalic, atraumatic
Chest: chest tube in place, distant breath sounds
Abdominal: Soft
Extr/Back: left upper extremity gross deformity
Neuro: intubated and sedated.
___: No petechiae
Pertinent Results:
___ 06:17AM BLOOD WBC-8.6 RBC-4.04* Hgb-11.7* Hct-33.4*
MCV-83 MCH-29.0 MCHC-35.1* RDW-12.6 Plt ___
___ 05:30AM BLOOD WBC-9.8 RBC-3.92* Hgb-11.5* Hct-32.0*
MCV-82 MCH-29.3 MCHC-35.9* RDW-12.9 Plt ___
___ 04:19AM BLOOD WBC-8.8# RBC-4.24* Hgb-11.8* Hct-35.0*
MCV-83 MCH-27.9 MCHC-33.8 RDW-12.8 Plt ___
___ 06:17AM BLOOD Plt ___
___ 05:30AM BLOOD Plt ___
___ 06:17AM BLOOD Glucose-102* UreaN-9 Creat-1.0 Na-135
K-4.2 Cl-96 HCO3-27 AnGap-16
___ 05:30AM BLOOD Glucose-113* UreaN-7 Creat-1.1 Na-135
K-4.2 Cl-98 HCO3-26 AnGap-15
___ 06:17AM BLOOD Calcium-9.7 Phos-4.1 Mg-2.2
___ 09:18AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___: cat scan of the head:
IMPRESSION:
1. No acute intracranial injury.
2. Air-fluid level in the right maxillary sinus, which may
reflect acute
inflammation, as no fracture is seen on this study.
3. Possible intra-ocular foreign bodies, which should be closely
correlated
with opthalmological examination.
___: cat scan of abdomen and pelvis:
IMPRESSION:
1. Small left pneumothorax and intermediate density left pleural
effusion
with a chest tube in place. Rib fractures described above. Small
left
pulmonary contusion.
2. No acute injury of the abdomen or pelvis.
___: chest x-ray:
FINDINGS: Lung volumes are low. There are displaced fractures of
the left
fourth, fifth and sixth ribs. The patient is in supine
positioning, limiting evaluation of pneumothorax; however, there
is relative ___ at left heart border consistent with a small
anterior pneumothorax, not likely significantly changed from the
prior CT examination of the same date. No pleural effusion is
seen. The cardiomediastinal silhouette is unchanged. An
endotracheal tube tip is approximately 3 cm above the carina.
Esophageal catheter tip is in the stomach
___: right forearm x-ray:
FINDINGS: Status post splinting of the known complete radial
shaft fracture on the right. The fracture is still completely
clearly visible. The contraction is minimally reduced by the
splint.
___: left humerus x-ray:
FINDINGS: Status post splinting of the known displaced left
humeral fracture with several fractured bone fragments. In the
splint, the axial deviation of the fracture is slightly reduced.
However, the complete fracture, the
displacement, and the multiple fragments are still clearly
visible.
___: chest s-ray:
FINDINGS: The left-sided chest tube is positioned with the
sidehole in the
chest wall. The tube should be advanced to avoid gas collections
in the soft tissues. In the left hemithorax, no pneumothorax is
currently visible.
Displaced left rib fractures without current evidence of pleural
fluid
collections. The patient has been intubated in the interval and
the
nasogastric tube as well as an abdominal left upper quadrant
drain has been removed. Unchanged borderline size of the cardiac
silhouette without evidence of pulmonary edema. Unchanged normal
appearance of the right lung.
___: chest x-ray:
Interval removal of left chest tube. Small left apical
pneumothorax is
unchanged from prior CXR from ___ at 12:00. Lateral view
with arm down.
Linear densities on lateral - likely components of the sling. No
significant change from prior.
Brief Hospital Course:
___ M s/p MVC ejected from vehicle, intubated at ___
for agitation, reportedly neuro intact, s/p left needle
decompression and tube thoracostomy for L ptx. Pt was admitted
to the TICU under the care of the ACS service for treatment of
the following injuries:
- Left lateral minimally displaced rib fx
- Left ptx
- Left humeral midshaft fracture
- Right radial midshaft fracture
Major events while in the ICU include:
Admitted to ___ s/p MVC, intubated at OSH, s/p L CT placement
for L ptx. Casts applied to R forearm and L arm by ortho.
Ophthalmology washed out debri from right eye thoroughly. He was
extubated. He was taken to the opertaing room onn HD #1 where
he underwent an ORIF of the right radial fracture. His
operative course was stable and he was extubated after the
procedure.
He was transferrd to the surgical floor on POD #1. His chest
tube was to water seal and discontinued later in the day. His
chest x-ray continues to show a small left apical pneumothorax.
His respiratory status is stable and he has maintained an oxygen
saturation of 97% on room air. His foley catheter was
discontinued on POD #1 and he has been voiding without
difficulty.
\
He was fitted for the left Sammento brace for his left arm and
has been evaluated by physical and occupational therapy. He has
been fitted for new upper extremity splints.
His vital signs are stable and he is afebrile. He is tolerating
a regular diet. His hematocrit is stable at 33.4 and is white
blood cell count is stable at 9.
He is preparing for discharge home with follow-up with
Orthopedics, acute care service and opthamology.
Medications on Admission:
Allegra prn, inhaler prn
Discharge Medications:
1. erythromycin 5 mg/gram (0.5 %) Ointment Sig: 0.5% ointment
Ophthalmic TID (3 times a day): both eyes.
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
5. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain: may cause drowsiness, avoid driving while on
this medicaiton.
Disp:*35 Tablet(s)* Refills:*0*
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma: MVC
L rib fx ___
small L PTX, small L pulm contusion
L humerus fx
R radius fx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Bilateral arm splints
Discharge Instructions:
You were admitted to the hospital after you were involved in a
motor vehicle accident. You sustained a left humerus fracture,
a right radial fracture, and left sided rib fractures. You also
had a small collapse of your left lung for which you had a chest
tube placed. It has since been removed and you are breathing is
normal. You are now preparing for discharge home with the
following 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 antiinflammatory 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 ).
Because of your accident, you had a small collapse of your lung,
please report the following:
*increased shortness of breath
*difficulty breathing
Please report:
*increased numbness fingers ( change from when you were
hospitaliszed)
*inabiiltiy to move your fingers
*marked swelling of your fingers
*increased pain in upper extremities
Followup Instructions:
___
|
10288490-DS-15 | 10,288,490 | 20,839,882 | DS | 15 | 2127-06-09 00:00:00 | 2127-06-20 15:05:00 |
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: cyclist fall
SAH L parietal
R clavicle
R petrous bone
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old male who complains of BICYCLE
ACCIDENT. Bike vrs bike collision. No helmet. +head trauma,
no LOC. Sustained abrasions to R hand. Complaining of
tingling to hand and R shoulder pain. No CP, SOB, abd pain.
No back pain. No weakness. Td UTD.
Timing: Sudden Onset
Quality: Sharp
Severity: Mild
Duration: Hours
Past Medical History:
none
Social History:
___
Family History:
nc
Physical Exam:
PHYSICAL EXAMINATION
Temp: 97.6 HR: 108 BP: 134/72 Resp: 20 O(2)Sat: 100 Normal
Constitutional: Comfortable
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact
R hemotympanum, no C spine tenderness, stepoff or crepitus
Chest: Clear to auscultation, no chest wall tenderness
Cardiovascular: tachycardic
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: abrasions to R hand
Neuro: Speech fluent, GCS 15, full strength
Psych: Normal mood, Normal mentation
___: No petechiae
physical examination upon discharge: ___
Vital signs: 98.9, hr69, bp=101/63, resp. rate 16, oxygen
sat=100 room air
General: Sitting in chair, moving slowly
CV: nl s1, s2, -s3, s-4
LUNGS: Clear
ABDOMEN: soft, non-tender
EXT: quarter size abrasion left knee, full knee extension bil.,
full ankle rom bil. full left arm flex./ext. + radial pulse
bil.,, full finger rom bil., right arm sling
NEURO: alert and oriented x 3, speech clear, no tremors
right ear: cotton
Pertinent Results:
___ 02:05PM BLOOD WBC-12.9* RBC-4.83 Hgb-14.6 Hct-43.6
MCV-90 MCH-30.2 MCHC-33.5 RDW-12.8 Plt ___
___ 02:05PM BLOOD Neuts-86.7* Lymphs-9.3* Monos-3.5 Eos-0.2
Baso-0.3
___ 02:05PM BLOOD Plt ___
___ 02:05PM BLOOD ___ PTT-28.7 ___
___ 02:05PM BLOOD Glucose-97 UreaN-17 Creat-0.8 Na-141
K-4.1 Cl-104 HCO3-28 AnGap-13
___: cat scan of the head:
. Acute nondisplaced fracture of the petrous aspect of the right
temporal
Preliminary Reportbone with the fracture line extending
inferiorly to the posterior aspect of
Preliminary Reportthe external auditory canal. There does not
appear to be involvement of the
Preliminary Reportmiddle or inner ear.
Preliminary Report2. Contrecoup injury manifesting as small
subarachnoid hemorrhage in the left
Preliminary Reportparietal lobe.
___: cat scan of the c-spine:
ReportIMPRESSION: No evidence of acute traumatic injury to the
cervical spine.
___: right shoulder x-ray:
MPRESSION: No evidence for fracture or dislocation.
___: right hand x-ray:
FINDINGS: There is soft tissue irregularity along the third
digit, but no
evidence for fracture, dislocation, or bone destruction.
___: chest x-ray:
IMPRESSION: Non-displaced fracture through the right mid
clavicular shaft.
___: pelvic x-ray:
IMPRESSION: No evidence of fracture.
Brief Hospital Course:
___ year old gentleman admitted to the acute care service after
he was involved in a cyclist collision stricking his head. Upon
admission, he was made NPO, given intravenous fluids, and
underwent radiographic imaging. On his head cat scan, he was
found to have acute nondisplaced fracture of the petrous aspect
of the right temporal bone. He also sustained a contrecoup
injury manifesting as small a subarachnoid hemorrhage in the
left parietal lobe. He was evaluated by Neurosurgery who
determined that he did not need any surgical intervention. He
was placed on q4 hour neuro checks. His neuro status remained
stable. He did not sustain any injury to his cervical spine.
He was evaluated by ENT who recommended ear drops and CSF
precautions. The head of his bed was elevated and sinus
precautions were reviewed. Recommendations made for follow up
for an audiogram upon discharge.
Imaging of his chest did show a non-displaced fracture through
the right mid clavicular shaft. Orthopedics was consulted and
recommended follow-up with no intervention indicated. His right
arm was placed in a sling with neuro-vascular assessment. He
was evaulated by Occupational therapy prior to discharge to
assess his cognition and his ability to manage ADL's.
His vital signs are stable and he is afebrile. He had been
started on a regular diet with no problems with nausea or
vomitting. His hematocrit is stable. He is preparing for
discharge home with follow up with Neurosurgery, ENT, and
orthopedics.
Medications on Admission:
none
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain: may cause increased sedation, avoid driving
or biking while on this medication.
Disp:*40 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: hold for loose stool.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
4. ciprofloxacin 0.3 % Drops Sig: Five (5) Drop Ophthalmic BID
(2 times a day) for 7 days: right ear.
Disp:*5 cc* Refills:*1*
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma: cyclist collision:
SAH L parietal
R clavicle
R petrous bone
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ were admitted to the hospital after ___ were involved in a
bicycle accident. ___ sustained a fracture to your rigth
clavicle and a fracture to a bone around your ear. Because ___
hit your head, ___ sustained a small bleed in your head. ___
were seen by the Neurologist and no treatment was needed. ___
were also seen by Orthopedic service who recommended a sling for
your arm. Your vital signs have been stable. ___ are preparing
for discharge home with the following instructions:
Because ___ had a fracture around your ear bone, please follow
these instructions:
*sleep with 2 pillows so your head will be elevated
*sneeze with your mouth open, no nose blowing
*please take the stool softeners as prescribed to avoid
straining with bowel movements
*avoid swimming.
*keep ear dry until follow up (Cotton ball in ear, then vaseline
smeared over ear and cotton when washing hair).
Because ___ hit your head, please watch for the following:
*increased headache
*nausea/vomitting
*changes in your vision
*facial droop
*weakness on one side of your body
*seizure
Use sling right arm, report increased difficulty in moving
fingers, numbness in fingers
Followup Instructions:
___
|
10288512-DS-7 | 10,288,512 | 20,291,296 | DS | 7 | 2195-07-29 00:00:00 | 2195-07-29 14:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Neutropenic fever, malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p liver transplant on ___ for autoimmune hepatitis who
now presents with fevers and malaise. He states his fevers only
came on in last 24 hours and his malaise was approx 48 hours. He
has been eating well without N,V or diarrhea. He had been taken
off his valcyte last week and was continuing on tacro,
mycophenolate and prednisone. His WBC has been slowly declining
over last couple of weeks. His ___ year old son has had a cold
over last couple of days as well.
ROS:
denies N/V, slurring of speech, confusion, diarrhea
Past Medical History:
-fulminant auto-immune hepatitis, underwent donor liver
transplant on ___, thought to have a bile leak
post-procedure but ERCP ___ showed anastomotic stricture
without leak - stent placed.
-right knee surgery
Social History:
___
Family History:
No family history of liver disease
Physical Exam:
99.3 110 117/72 20 100% RA
feels fatigued and malaised
sinus tachycardia
clear bilaterally
abd NT, ND, no rebound/guarding, well healing incision
no edema bilaterally
patient reported weight 215lb
Pertinent Results:
On Admission: ___
WBC-1.2* RBC-4.05* Hgb-13.3* Hct-37.2* MCV-92 MCH-32.9*
MCHC-35.9* RDW-13.3 Plt ___
Neuts-10* Bands-0 Lymphs-63* Monos-19* Eos-0 Baso-1 Atyps-3*
Metas-2* Myelos-2*
___
UreaN-15 Creat-1.5* Na-132* K-3.9 Cl-96 HCO___ AnGap-14
Glucose-130*
ALT-32 AST-29 AlkPhos-84 TotBili-1.1
Albumin-4.6 Phos-2.2*# Mg-1.2*
tacroFK-4.2*
Lactate-1.5.
....
Labs at Discharge:
Brief Hospital Course:
___ y/o male POD 99 admitted for febrile neutropenia and malaise.
The patient immediately received a dose of Filgrastim on day of
admission.
The infectious disease service was contacted who have
recommended viral and respiratory studies, CMV viral load which
was negative (IgG and IgM are also non-detectable) Blood and
urine specimens have also been sent.
The patient has also had complaint of headache, which has not
typically been relieved with Tylenol. Ultram was tried with
little relief. A small dose of IV Dilaudid did seem to help.
This did not appear as a migraine type headache.
A head CT was performed showing there is no acute intracranial
hemorrhage,acute infarction, mass or midline shift. There is no
hydrocephalus. Visualized paranasal sinuses and mastoid air
cells are clear. There is no fracture.
On the ensuing two days the patient is feeling much better after
receiving IV fluids. He received two additional doses of
Filgrastim, which had so far only minimally raised the ANC.
In total he received 5 doses of the filgrastim, and by HD 5, the
WBC was up to 4.2 from 1.2 on admission, and the diff was
showing immature forms of the PMNs.
ANC was not yet to 500, but given the improvement in the white
count and lack of fevers, it was decided the patient could be
discharged to home.
All culture data to include blood, urine and stool cultures have
been negative to date. CMV and Adenovirus are negative as well
as respiratory viral cultures. The viral culture which would be
pending for approximately 3 weeks will not keep him in the
hospital.
Patient is scheduled to have cbc with Diff done on ___ as an
outpatient in addition to routine outpatient labs and Tacro
level. He is ambulating and tolerating a regular diet.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
2. Tacrolimus 5 mg PO Q12H
3. Multivitamins 1 TAB PO DAILY
4. Acetaminophen 1000 mg PO Q12H:PRN pain
5. Famotidine 20 mg PO BID
6. Mycophenolate Mofetil 1000 mg PO BID
7. PredniSONE 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q12H:PRN pain
2. Famotidine 20 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. PredniSONE 5 mg PO DAILY
5. Atovaquone Suspension 1500 mg PO DAILY
Use instead of Bactrim
RX *atovaquone 750 mg/5 mL 10 ml by mouth Daily Refills:*6
6. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days
End date ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*10 Tablet Refills:*0
7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
End date ___
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
8. Tacrolimus 3 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Neutropenia
Neutropenic fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the transplant clinic at ___ for fever >
101, chills, nausea, vomiting, diarrhea, constipation, inability
to tolerate food, fluids or medications, yellowing of skin or
eyes, increased abdominal pain, dizziness or weakness, decreased
urine output or dark, cloudy urine, swelling of abdomen or
ankles, or any other concerning symptoms.
Please have a CBC and Diff in addition to routine labwork on
___
You will have labwork drawn 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.
On the days you have your labs drawn, do not take your Tacro
until your labs are drawn. Bring your Tacro 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.
You may shower. Allow the water to run over your incision and
pat area dry. No rubbing, no lotions or powder near the
incision.
No tub baths or swimming
No driving if taking narcotic pain medications
Avoid direct sun exposure. Wear protective clothing and a hat,
and always wear sunscreen with SPF 30 or higher when you go
outdoors.
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
Followup Instructions:
___
|
10288579-DS-9 | 10,288,579 | 29,234,985 | DS | 9 | 2110-06-16 00:00:00 | 2110-06-16 15:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain, nausea and vomiting
Major Surgical or Invasive Procedure:
___ - Placement of nasojejunal feeding tube
History of Present Illness:
This is a ___ old Male with PMH significant for anxiety, IBS
who presents with abdominal pain, nausea and vomiting for past 2
days. Patient states that last night he ate some cheesy bread
from Dominos and had abd pain associated with nonbloody vomiting
and nausea. The pain was initially in his lower quadrants and
now is diffuse. Per patient he has been drinking heavily for the
past week, about ___ shots of vodka each day with cranberry. He
concedes that he is a heavy drinker and has been drinking ___
times per week for the past year with ___ shots each night.
He went to the ___ ED, and was sent home with antiemetics. This
morning the pain escalated that he called am ambulance to take
him to ___. He denies any recent sick contacts or any recent
travel. He does endorses constipation. He states that he has
been having vague abdominal pain for the past 2 months that has
been refractory to anti-gas medications and probiotics. He notes
that his belly has become bigger and firmer since having this
abdominal pain. Has said that he has been drinking since high
school, has felt need to cut down but not guilty, anger,
eye-opener needed.
He denies any NSAID use or any history of ulcers. He states that
sitting up helps his abdominal pain. The pain is not associated
with eating.
ED course:
- initial VS 97.6 120 133/85 20 98% RA
- WBC 9.8, hemoglobin 16.5, platelets 280
- AST 69, ALT 130, AP 59, Tbili 1.0, Alb 5.0, lipase 1498
- Creatinine 1.1, lactate 4.0 (3.1 following fluids)
- Utox positive for BNZs
- U/A with blood, 2 WBCs and protein
- RUQ US with no choledocholithiasis, fatty liver noted (limited
study)
- received 2L NS and IV morphine 4 mg x 1, ondansetron 4 mg IV x
2 and clonazepam 1 mg PO x 1
REVIEW OF SYSTEMS: See HPI for pertinent details. Denies fevers
or chills; no nightsweats. No headaches or visual changes. (+)
chest discomfort that he thinks is related to his anxiety. (+)
some difficulty breathing with pain. No notable upper
respiratory symptoms or cough. No loose stools or diarrhea,
constipation or other changes in bowel habits. No dysuria or
hematuria. No new rashes, lesions or ulcers. No extremity
swelling, athralgias or joint complaints. No pertinent weight
loss or gain, change in dietary habits.
Past Medical History:
- Anxiety disorder
- Irritable bowel syndrome
Social History:
___
Family History:
Father has DM but denies FH of cancer. Whole family has IBS.
Physical Exam:
ON ADMISSION
===============
Vitals: 97.7 139/85 98 18 99% RA
General: patient appears in NAD, but anxious. Appears stated
age. Non-toxic appearing.
HEENT: normocephalic, atraumatic. PERRL. EOMI. Nares clear.
Oropharynx with no notable lesions, plaques or exudates. Good
dentition.
___: regular rate and rhythm. No murmurs. S1 and S2 noted.
Respiratory: demonstrates unlabored breathing. Clear to
auscultation bilaterally.
Abdomen: soft but with involuntary guarding, moderate tenderness
in epigastrum and midly tender in lower quadrants, distended
with normoactive bowel sounds; no significant abdominal scars;
no hepatosplenomegaly or palpable masses; non-peritoneal
although has tap tenderness.
Extremities: warm, well-perfused distally; no cyanosis, clubbing
or peripheral edema
Derm: skin appears intact with no significant rashes or lesions.
No ___ or Gray Turner's.
Neuro: alert and oriented. Normal bulk and tone. Motor and
sensory function are grossly normal. Gait deferred.
ON DISCHARGE
==============
Vitals: 98.8 102/60 81 16 97% RA
I/Os: PO 900 | TFs held | BRP
Weight: 87.6 kg
FSG: 77-112 mg/dL
General: NAD, appropriate, interactive.
HEENT: moist mucous membranes, JVP not visualized
___: RRR w nl S1,S2. No murmur.
Respiratory: Decreased breath sounds at bases (L > R) sound
improved.
Abdomen: soft, minimally tender at left quadrants and flank,
normoactive bowel sounds, minimally distended
Extremities: warm, well-perfused; no cyanosis, clubbing or
peripheral edema.
Derm: skin appears intact with no significant rashes or lesions.
Pertinent Results:
IMAGING STUDIES
=================
___ - LIVER OR GALLBLADDER US - Limited evaluation of the
pancreas due to body habitus and bowel gas. Within this
limitation, no evidence of choledocholithiasis or acute
pancreatitis. Hepatic steatosis. However, more advanced forms of
liver disease such as steatohepatitis, cirrhosis, and fibrosis
cannot be definitively excluded. 1.8 x 0.9 cm probable area of
fatty sparing within the right hepatic lobe.
___ - CHEST (PA & LAT) - The lung volumes are low.
Bilateral pleural effusions, better seen on the lateral than on
the frontal radiograph. Subsequent areas of mild atelectasis at
the lung bases. Borderline size of the cardiac silhouette
without evidence of fluid overload.
___ - CT ABD & PELVIS W & W/O - Acute pancreatitis with
diffuse inflammatory peripancreatic stranding andperipancreatic
fluid collections extending from the lesser sac along the
anterior pararenal spaces, left worse than right, and along the
paracolic gutters bilaterally into the pelvis. There is adequate
enhancement of the pancreatic parenchyma, with no evidence of
pseudocyst formation, splenic artery pseudoaneurysm or portal
veinthrombosis. Bilateral small-to-moderate pleural effusions
with associated compressive atelectasis, left worse than right.
Moderately fatty liver.
ADMISSION LABS
===============
___ 10:00AM BLOOD WBC-9.8 RBC-5.06 Hgb-16.5 Hct-48.5 MCV-96
MCH-32.5* MCHC-34.0 RDW-13.0 Plt ___
___ 10:00AM BLOOD Neuts-91* Bands-2 Lymphs-6* Monos-0 Eos-0
Baso-0 Atyps-1* ___ Myelos-0
___ 10:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 10:00AM BLOOD Plt Smr-NORMAL Plt ___
___ 10:00AM BLOOD Glucose-163* UreaN-18 Creat-1.1 Na-137
K-4.6 Cl-95* HCO3-22 AnGap-25*
___ 10:00AM BLOOD ALT-130* AST-69* AlkPhos-59 TotBili-1.0
___ 10:00AM BLOOD Albumin-5.0 Calcium-9.7 Phos-3.2 Mg-2.2
Cholest-336*
___ 10:00AM BLOOD Albumin-5.0 Calcium-9.7 Phos-3.2 Mg-2.2
Cholest-336*
___ 10:00AM BLOOD Triglyc-1274* HDL-39 CHOL/HD-8.6
LDLmeas-PND
___ 10:20AM BLOOD Lactate-4.0*
NOTABLE LABS
================
___ 07:10AM BLOOD WBC-9.9 RBC-3.38* Hgb-10.9* Hct-33.1*
MCV-98 MCH-32.3* MCHC-33.1 RDW-12.7 Plt ___
___ 09:16AM BLOOD WBC-7.4 RBC-3.72* Hgb-12.1* Hct-36.6*
MCV-98 MCH-32.6* MCHC-33.1 RDW-12.5 Plt ___
___ 05:35AM BLOOD WBC-5.2 RBC-3.78* Hgb-12.4* Hct-37.6*
MCV-99* MCH-32.8* MCHC-32.9 RDW-12.6 Plt ___
___ 05:50AM BLOOD ___ PTT-27.3 ___
___ 07:10AM BLOOD Glucose-85 UreaN-6 Creat-0.8 Na-137 K-3.8
Cl-101 HCO3-22 AnGap-18
___ 09:16AM BLOOD Glucose-90 UreaN-7 Creat-0.7 Na-134 K-3.8
Cl-100 HCO3-20* AnGap-18
___ 09:16AM BLOOD ALT-37 AST-37 AlkPhos-53 TotBili-0.5
___ 05:35AM BLOOD ALT-39 AST-32 AlkPhos-40 TotBili-0.7
___ 05:50AM BLOOD ALT-61* AST-41* AlkPhos-39* TotBili-0.9
___ 09:16AM BLOOD Triglyc-277*
___ 05:50AM BLOOD Triglyc-667*
___ 06:40AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.9
___ 07:10AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.1
___ 06:20AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.9
___ 05:35AM BLOOD Albumin-3.1* Calcium-7.7* Phos-1.9*
Mg-2.1
___ 06:25AM BLOOD Lactate-1.7
___ 07:24AM BLOOD Lactate-2.8*
___ 01:43PM BLOOD Lactate-3.1*
___ 10:20AM BLOOD Lactate-4.0*
DISCHARGE LABS
===============
___ 07:48AM BLOOD WBC-7.6 RBC-3.86* Hgb-12.3* Hct-36.6*
MCV-95 MCH-31.8 MCHC-33.7 RDW-12.8 Plt ___
___ 07:48AM BLOOD Plt ___
___ 07:48AM BLOOD Glucose-97 UreaN-16 Creat-0.9 Na-140
K-5.0 Cl-98 HCO3-29 AnGap-18
___ 07:48AM BLOOD Calcium-9.9 Phos-5.1* Mg-2.4
MICROBIOLOGY
=============
___ Urine culture - no growth
___ Blood culture (x 2) - negative
Brief Hospital Course:
___ with PMH significant for anxiety disorder and irritable
bowel syndrome presenting with abdominal pain due to
alcohol-induced acute, uncomplicated pancreatitis.
# Acute uncomplicated pancreatitis - Patient endorseD ___ years of
heavy drinking and within past week prior to admission had been
on ___ break and drinking ___ shots of vodka daily. Lipase
was elevated at 1498 on admission, and he was also found to have
a triglyceride level of 1274. RUQ US showed no cholelithiasis
but the pancreas and biliary system could not be adequately
visualized due to body habitus. GI was consulted and felt likely
alcoholic pancreatitis. Patient was treated with bowel rest and
IVF. Triglycerides downtrended to 667 then 277. No signs or
symptoms of complications. Had some dyspnea thought to be due to
bilateral pleural effusions seen on CXR which resolved over the
course of his admission without need for diuresis. On ___ an
NJT tube was inserted and he was started on tube feeds after it
was advanced to the post-pyloric region (jejunal). He also
underwent an abdominal CT which showed acute pancreatitis with
peripancreatic fluid collections extending to the pararenal
spaces, paracolic gutters, and extending into the pelvis, but no
complications. Over several days his tube feeds were
downtitrated, his diet advanced and he improved. He is
discharged with PCP and GI ___. He is to maintain a low
fat diet, per nutrition. He is to avoid all alcohol.
# Alcohol use - Patient reports ___ years of drinking ___ times a
week, about ___ drinks a week. No history of trouble with the
law due to drinking. CIWA scales were ___ and not concerning for
alcohol withdrawal. He was given MVI, folate and thiamine.
Social work was consulted to address his alcohol use and gave
contact information for SA recovery resources. He should abstain
from alcohol.
# Anxiety disorder - Patient states that he has anxiety and
reported taking clonazepam daily. Clonazepam was held initially
due to his being on a CIWA scale with diazepam written; however
clonazepam was restarted on ___, and the patient did not
experience alcohol withdrawal. During his hospitalization, the
patient continued taking his fluoxetine but refused his
buspirone most of the time.
TRANSITIONAL ISSUES:
- Has PCP and gastroenterology ___ has been scheduled.
- Abstain from alcohol, maintain low fat diet.
- Prescribed short course of dilaudid for pancreatitis pain; no
longterm needs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BusPIRone 30 mg PO DAILY
2. ClonazePAM 2 mg PO DAILY
3. Fluoxetine 60 mg PO DAILY
Discharge Medications:
1. ClonazePAM 2 mg PO DAILY
2. Fluoxetine 60 mg PO DAILY
3. BusPIRone 30 mg PO DAILY
4. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN breakthrough pain
avoid driving while taking this medication.
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 6
hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
- Acute alcoholic pancreatitis
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 acute pancreatitis. We believe this was a
result of your alcohol use. You were treated with bowel rest,
intravenous fluids, and pain medication - in addition to the
placement of a nasojejunal tube for enteral feeding. This
intervention resulted in resolution of your symptoms. We advise
you ABSTAIN from alcohol use to avoid future episodes of
pancreatitis. You also should maintain a LOW FAT diet and
exercise regularly.
Please ___ with your primary care physician, ___.
Also you should ___ with the gastroenterology specialists.
Thank you for allowing us to be part of your medical care.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10288778-DS-4 | 10,288,778 | 26,355,279 | DS | 4 | 2166-10-26 00:00:00 | 2166-10-28 11:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending: ___.
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Medicine Admission Note
CC: ___ pain
HPI: Ms. ___ is a ___ yo woman with history of
hypertension, possible CKD, prior CCY (___), here from ___
___ with pancreatits, after she presented there with
abdominal pain. She in fact developed abdominal pain 10 days
ago, on good ___, and presented to ___. She was discharged
from the ED. She was called back for possible pulmonary edema,
and to rule out MI, which was negative.
After discharge, she continued to have abdominal pain, with
nausea and anorexia. The pain has been constant, throughout her
entire abdomen, and radiating to her back. The pain was not
relieved by tylenol. She has had shortness of breath with the
pain. She had dark urine, but no changes in her stool. She has
not had fevers, but has had chills.
Prior to the onset of pain, she had been taking protein shakes,
substituting for one meal a day, for weight loss. She lost 7
lbs.
She has intermittent headaches. She denies any other urinary
symptoms, rashes, diarrhea, masses or lesions. ROS otherwise
reviewed in 13 systems and negative.
Past Medical History:
PMH
Hypertension, poorly controlled
?Hyperlipidemia
?CKD
Prior CCY, ___
Prior hysterectomy, for benign mass
Prior abnormal pap smears
Social History:
___
Family History:
___: Mother died in early ___, "old age", father still alive,
age ___, just diagnosed with cancer.
Physical Exam:
Physical exam
Vital signs: Tmax 98.0 BP 148/78 HR 60 16 91% RA O2 sat
___: in NAD, obese
HEENT: Faint scleral icterus, OP moist, no LAD, JVP difficult to
see.
Lungs: decreased at bases, no rales, no wheezes with forced
expiration.
CV: RRR without murmurs
Abdomen: soft, tender in epigastrium, and throughout upper
abdomen, no rebound or guarding. Nondistended, bowel sounds
present.
Ext: no edema
Neuro: alert/oriented X3, face symmetric, answers all questions
appropriately, full strength in upper and lower extremities.
Sensation normal.
Pertinent Results:
Relevant data:
Labs ___ ___ AGap=15
-------------
3.7 23 1.0
Trop-T: <0.01
Ca: 8.7 Mg: 1.9 P: 3.1
ALT: 803 AP: 329 Tbili: 4.1 Alb: 3.8
AST: 628
Lip: 8590
wbc 6.4 hgb 12.0 hct 38.1 plts 259
N:81.1 L:15.5 M:2.8 E:0.4 Bas:0.2
___: 11.6 PTT: 27.8 INR: 1.1
UA with trace ketones, trace protein, 1 wbc, 1 rbc
urine culture pending
RUQUS ___ ___:
IMPRESSION:
1. Status post cholecystectomy with common bile duct dilatation
to 13 mm, but no intrahepatic biliary duct dilatation. No stones
are seem in the visualized portions of the common bile duct,
though the distal duct is not well evaluated. MRCP is a more
sensitive exam for the detection of choledocholithiasis and can
be performed for further evaluation.
2. Echogenic liver consistent with fatty infiltration of the
liver. More severe hepatic disease including significant hepatic
fibrosis/cirrhosis cannot be excluded on the basis of this study
EKG ___ SB nl axis, intervals, no ischemic changes.
Labs at ___ ___:
Cr 1.04
Alk phos 372
Bili 5.4
AST 732
alt 911
Lipase 6741
CT from ___, dissection protocol: No dissection, found to have
acute pancreatitis, without pseudocyst or abscess. Small 5 mm
increased density in the region of the pancreatic head/distal
CBD could be an obstructing stone/choledocholithiasis.
ERCP REPORT: A sphincterotomy was performed in the 12 ___clock
position using a sphincterotome over an existing guidewire.
A single stone was extracted successfully using a balloon. Two
more balloon sweeps were performed that did not reveal
additional stones or sludge.
Impression: The ampulla appeared bulging concerning for an
impacted stone
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique
A moderate diffuse dilation was seen at the biliary tree with
the CBD measuring 13 mm.
The cholangiogram did not definitively show a filling defect in
the distal CBD. However given the clinical picture suggestive
of gallstone pancreatitis and the finding of bulging ampulla
concerning for an impacted stone, a decision was made to perform
a sphincterotomy.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
A single stone was extracted successfully using a balloon.
Two more balloon sweeps were performed that did not reveal
additional stones or sludge.
Otherwise normal ercp to second part of the duodenum
___ 06:10AM BLOOD ALT-132* AST-25 LD(LDH)-223 AlkPhos-159*
TotBili-0.7
Brief Hospital Course:
ICU Course:
___ with PMHx of hypertension, s/p CCY ___, who was transferred
to ___ from ___ for acute gallstone pancreatitis s/p ERCP
w/sphincterotomy ___, hospital course complicated by new onset
atrial fibrillation with rapid ventricular response.
# Afib w/RVR: After the ERCP, the patient developed new-onset
afib w/RVR. Etiology unclear, possibly related to
hypersympathetic tone in the context of acute pancreatitis. TSH
was normal. Cardiac enzymes were negative. Did not anticoagulate
her given CHADS2 score of 1 and bleeding risk from
sphincterotomy ___ during ERCP. A TTE was performed which
showed normal global and regional biventricular systolic
function, However there was mild left atrial dilatation which
may have been a cause or effect of the atrial fibrillation. The
patient spontanously converted back to sinus rhythm. Given her
CHADS 2 score, use of both aspirin and plavix can be considered.
She was started on aspirin alone, and advised to discuss with
her PCP any additional use of plavix.
# Hypoxemia: Most likely secondary to flash pulmonary edema in
the context of fluid resuscitation and new atrial fibrillation.
Resolved.
# Pancreatitis: Patient is s/p ERCP with sphincterotomy and
stone extraction. LFTs are trending down and she reports
improvement in her abdominal pain. Will continue symptom
management. LFTs improved over course of hospitalization.
# Leukocytosis: Patient presented with normal WBC 6.4 on
admission, which rose to 16.8. Likely due to inflammation from
acute pancreatitis. S/p ERCP w/sphincterotomy; no evidence of
cholangitis on ERCP, but given low-grade fevers (99.5) and
increasing leukocytosis, started empiric cipro. No evidence of
pneumonia on CXR. She will complete one week of ciprofloxacin
at home.
# Hypertension: She was discharged on amlodipine and
metoprolol. She will f/u with her PCP for continued blood
pressure management.
# ? NASH/hepatic fibrosis on ultrasound. PCP should discuss
dietary measures, consider liver biopsy to further assess.
Medications on Admission:
Home medications:
Per ___ -
she does not know her medications
Metoprolol tartare 25 mg po bid
lisinopril 10 mg po bid
HCTZ 12.5 mg po daily (last refilled in ___
amlodipine 5 mg po daily (last refilled in ___
Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
Disp:*5 Tablet(s)* Refills:*0*
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
Disp:*10 Tablet(s)* Refills:*0*
5. Aspirin Childrens 81 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
gallstone pancreatitis
atrial fibrillation
pumonary edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain and found to have
pancreatitis caused by gallstones. An ERCP was performed to
remove the stone. Your course was complicated by Atrial
Fibrillation (irregular heart rhythm) with rapid heart rate and
fluid in the lung requiring ICU stay. Your heart rate was
controlled and you were moved back to the medical floor. You
were able to start eating on ___. You will need to follow up
with your PCP to discuss treatment for Atrial Fibrillation with
at least daily aspirin, but this may also include an additonal
medication, Clopidogrel. You need to complete one week of
antibiotic treatment with ciprofloxacin and this will end on
___.
In regards to your blood pressure, please take metoprolol 25 mg
by mouth twice a day, and restart the amlodipine at 5 mg daily.
Hold the hydrochlorothiazide and lisinopril until you see Dr
___ on ___. Please start taking a baby aspirin every
day starting on ___. You may take dulcolax (bisacodyl)
to help you move your bowels.
Followup Instructions:
___
|
10288895-DS-3 | 10,288,895 | 21,300,525 | DS | 3 | 2133-04-01 00:00:00 | 2133-04-03 17:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hypothyroidism, Type II DM, prostate cancer (watchful
waiting, ___ 3+3) and chronic UTIs who presents with fevers
(Tmax- 102), with chills, sweats, bladder pain, with pain at
penile meatus, increased pain during self-catheterization as
well as generalized weakness.
Reports that he feels "swelling by prostate." No increased
difficulty in self-catheterization. This feels similar to past
UTI's, but worse. Denies recent prostate procedures. Denies
bowel incontinence. Denies back pain, gross hematuria, nausea,
vomiting, abdominal pain, constipation, diarrhea, blurry vision,
cough, chest pain, SOB, pharyngitis, rhinorrhea, nasal
congestion.
Of not the patient has had ___ UTIs in te past year a with the
past UTI being in ___ of this past year. Usually grows
pansenstive GNRs vs alpha hemolytic streptococcus.
In the ED initial vitals were: 5 100.2 92 128/65 18 99%. Exam
was notable for suprapubic tenderness and DRE large prostate, no
nodularity, non-tender. Labs were significant for a WBC 12.5
with 79.6% N, h/h of 16.6/47.4, chem 7 with BUN 24 cr 0.9,
glucose of 154, UA which was grossly cloudy with debris, 21
epis, mod bacteria >182 @BC, large leuks, nitrite positive.
Urine and blood cultures were sent. CXR was negative for
pneumonia. Patient was given 1g of IV ctx. Vitals prior to
transfer were: 0 99.9 72 129/77 18 99% RA
On the floor, patient was feeling better with no acute
complaints. Headache had resolved.
Past Medical History:
1. Hypothyroidism
2. C3-4, C4-5 disc herniations with cord impingement c6-7
discectomy
3. Lower extremity paraparesis (secondary to thoracic syrinx)
4. T11-12 compression fracture
5. chronic UTIs
6. neurogenic bladder
7. diabetes mellitus (controlled by diet, A1C 6.0%)
Social History:
___
Family History:
Brother, Mother with DM, Father died ___ CA @ ___.
Physical Exam:
Admission physical:
Vitals - T:98.6 BP: 125/91 HR: 126 RR: 16 02 sat: 95% RA Weight
80.9kg
GENERAL: pleasant cooperative male in NAD who appears younger
than stated age
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: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: Speech coherent, cognitiont intact, CN II-XII intact, ___
lower extremity weakness at baseline per patient. Upper
extremities ___.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge physical:
Vitals: 98.9 92 132/59 18 96% RA
GENERAL: pleasant cooperative male in NAD who appears younger
than stated age
HEENT: NC/AT, EOMI, PERRL, anicteric sclera, pink conjunctiva,
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: no cyanosis, clubbing or edema, 2+ DP pulses
bilaterally
NEURO: Speech coherent, cognition intact, CN II-XII intact, RLE
___ strength, LLE ___ strength (baseline per patient), lower
extremity weakness at baseline per patient. BUE strength ___.
SKIN: warm and well perfused, dry skin on BUE, no excoriations
or lesions, no rashes
Pertinent Results:
Admission labs:
___ 07:50PM BLOOD WBC-12.5*# RBC-5.12 Hgb-16.6 Hct-47.5
MCV-93 MCH-32.4* MCHC-35.0 RDW-13.9 Plt ___
___ 07:50PM BLOOD Neuts-79.6* Lymphs-13.0* Monos-6.9
Eos-0.2 Baso-0.2
___ 07:45AM BLOOD ___
___ 07:50PM BLOOD Glucose-154* UreaN-24* Creat-0.9 Na-137
K-4.1 Cl-98 HCO3-27 AnGap-16
___ 07:45AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.0
___ 10:26PM BLOOD Lactate-1.4
Micro:
Urine cx from ___: mixed flora (contamination)
Blood cx: pending
Imaging:
___ CXR
IMPRESSION:
No evidence of acute cardiopulmonary disease. Pleural-based
density which should be evaluated with chest CT when clinically
appropriate less prior studies are available to show long-term
stability. Comparison from ___ is still pending,
however. CHECK PRIORS
Discharge labs:
___ 07:45AM BLOOD WBC-11.0 RBC-4.39* Hgb-14.1 Hct-40.5
MCV-92 MCH-32.2* MCHC-34.9 RDW-13.7 Plt ___
___ 07:45AM BLOOD Glucose-133* UreaN-24* Creat-0.9 Na-140
K-3.9 Cl-102 HCO___ AnGap-15
Brief Hospital Course:
Mr. ___ is a ___ with hypothyroidism, prostate cancer
(watchful waiting, ___ 3+3), T2DM, is s/p back surgeries for
thoracic syrinx and disc herniations c/b cord impingement and
paraparesis, and chronic UTIs ___ self-catheterization for
neurogenic bladder who presents with fevers and was found to
have a catheter associated UTI.
#Complicated (Catheter Associated) UTI
Patient with neurogenic bladder and history of chronic UTI (not
on suppressive therapy) developed fevers and leukocytosis and
found to have grossly postive UA. He was given CTX in ED, which
has been maintained on the floor. UCx pending. Previous urine
cultures with pan-sensitive klebsiella, e.coli, and alpha
hemolytic strep. He was given pyridium for bladder spasms. On
the evening of ___, the patient asked to be discharged home
prior to having the results of his urine culture available (see
discussion below). He was discharged on cefpodoxime to complete
a 14 day course of antibiotics. He was agreeable to returning to
the ED if he is found to have a resistant organism. He was also
extensively counseled by nursing regarding sterile technique for
straight cathing, as he currently does not use hygienic
measures. After discharge, his cultures returned as mixed flora.
The patient was contacted and told to continue taking his
cefpodoxime and to call HCA if he develops worsening fevers or
feels unwell.
# Hypothyroidism:
-continued home levothyroxine
# chronic UTIs/neurogenic bladderL On suppressive therapy at
home (Cipro 500 mg PO BID, Macrobid ___ mg PO BID prn UTI). He
was instructed in clean techniques for self-cathing. He will
need to hold his suppressive antibiotics until further
instruction by his PCP.
# Type II DM: (controlled by diet, A1C 6.0%): patient refused
fingersticks on the floor. Reportedly diet-controlled at home.
#Leg weakness: Patient with C3-4 and C4-5 disc herniations s/p
discectomy, thoracic syrinx, T11-12 compression fx, and cord
impingment. He was evaluated by ___ given difficulty walking and
was found to need further ___ visits in-house as well as home ___.
The patient refused these interventions per below.
#AMA discharge: On ___, the patient requested to leave despite
not having a final urine culture and despite ___ concerns that
he needed more in-house ___ as well as home ___. He understood the
risks of leaving, which included death. He agreed to return to
the ED for IV antibiotics if his urine cultures grow a resistant
organism. He was also given a script for outpatient ___ and
encouraged to use it.
# Code: Full
# Emergency Contact: Wife ___ (___) home ___ cell
___
Transitional issues:
-Patient will need to f/u with his PCP ___ 1 week of
discharge.
-Will contact the patient with the results of his urine culture
and discuss his antibiotic regimen: completed per above. He
should f/u as an outpatient regarding restarting his suppressive
antibiotic therapy after finishing the cefpodoxime.
-Unable to arrange for home ___ given the time of discharge but
have written for outpatient prescription.
-Patient will complete 12 days of cefpodoxime to complete a 14
day total abx course
-Patient should maintain sterile technique when self-cathing at
home.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 175 mcg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Sildenafil 100 mg PO PRN sexual activity
4. Ciprofloxacin HCl 500 mg PO Q12H PRN recurrent infection
5. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H PRN UTI
6. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Levothyroxine Sodium 175 mcg PO DAILY
4. Phenazopyridine 100 mg PO TID Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times
daily Disp #*6 Tablet Refills:*0
5. Sildenafil 100 mg PO PRN sexual activity
6. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 12 Days
RX *cefpodoxime 100 mg 1 tablet(s) by mouth twice daily Disp
#*24 Tablet Refills:*0
7. Outpatient Physical Therapy
Please provide patient with course of outpatient physical
therapy for bilateral leg weakness.
Diganosis: Muscle weakness ICD-9: 728.87
Discharge Disposition:
Home
Discharge Diagnosis:
Catheter-associated urinary tract infection
Secondary:
Neurogenic bladder
Chronic urinary tract infections
Prostate cancer
Type 2 diabetes mellitus, diet-controlled
Hypothyroidism
Lower extremity paraparesis
C3-4, C4-5 disc herniations
T11-12 compression fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___.
As you know, you were admitted to the inpatient Medicine service
with fevers, bladder and urinary pain, and fatigue in the
setting of a urinary tract infection associated with your
self-catheterization. In the Emergency Room, your labs were
notable for an elevated white blood cell count and a urine
sample suggestive of a urinary tract infection. Urine and blood
cultures, which are still pending at the time of your discharge,
were also sent to the lab. You were started on an intravenous
antibiotic for treatment of your urinary tract infection, as
well as an oral medication which helps relieve bladder spasms
and bladder-associated pain. You felt improved and asked to be
discharged.
It is important to note that since we do not have the urine
culture results back yet, we do not know which specific organism
is causing your infection. Therefore, we do not know the optimal
antibiotic to treat you with. Additionally, the physical
therapists who saw you today recommended additional sessions in
the hospital to increase your strength and ensure that you are
safe to go home and would not fall. We explained our
recommendation that you stay an extra day in the hospital until
we receive the final urine culture results and have the physical
therapists see you for additional sessions. We explained the
risks of leaving the hospital earlier, which include death. You
stated that you understood those risks, and still asked to be
discharged. You agreed to return to the hospital should your
urine cultures return with an organism resistant to the oral
antibiotic given to you at discharge. It is very important that
you return to the hospital if you have any fevers or feel
unwell. We also urge you to use appropriate cleaning procedures
when self-cathing.
Take care, and we wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10289571-DS-5 | 10,289,571 | 25,188,698 | DS | 5 | 2156-07-27 00:00:00 | 2156-07-29 08:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with a history of Hep C, schizoaffective disorder,
alcohol abuse and diverticulitis, who presented to the ER ___
with left sided abdominal pain, diagnosed with diverticulitis,
now returning with ongoing abdominal pain. Symptoms started
___ after a drinking binge; mostly sharp LLQ pain,
intermittent, not exacerbated by passing stool but made worse by
drinking water. Some R sided and diffuse pain. No alcohol since
symptoms started. On ___, CT scan was thought consistent
with diverticulitis and patient was treated with po
cipro/flagyl. He took these medications but has had no
improvement in abdominal pain. He reports that the pain is
sharp, ___. In addition, he had one episode of loose stool 2
days ago. Of note patient has had multiple recent visit to OSH
ED's including ___ and ___, he reports that "They denied me
a CT scan, so I kept going back to different ED's and had to
waste money on an ambulance". He denies fevers/chills, nausea,
or vomiting. Pain has been moderately controlled with oxycodone.
Patient says this pain is similar to when he has had
diverticulitis previously, treated at ___. Patient reports
he had a colonoscopy at ___ in ___ and had 2 polyps
removed but it was a poor prep. Of note he has had approximately
a 70lb unintentional weight loss in the last ___ years. In
addition, patient notes that his last drink was 2 weeks ago,
though he does have a history of alcohol abuse.In the ED intial
vitals were 98 103 128/82 16 99% RA. Labs were notable for WBC
13.0, AST 51 and ALT 71 (elevated compared to one week prior),
and electrolytes wnl. Lactate was 1.8. UA negative. He received
IV cipro/flagyl with thiamine, folate and MVI. Repeat CT
abd/pelvis today in the ED was stable; however is not conclusive
for diverticulitis.
On arrival to the floor patient has no pain but is requesting
clonazepam for anxiety.
___ Spoke with PCP who provides this additional history:
CT abdomen ___- chronic diverticulosis
CT abdomen ___ - diverticulosis without diverticulitis
colonoscopy ___ showed polyp, diverticulosis in entire colon
poor prep, recommended to repeat with 2 day prep.
ED ___ at ___ - LLQ pain since ___ worse with water.
diverticulitis less likely colitis. exam benign, discharged.
Past Medical History:
Hepatitis C
Diverticulitis
Schizoaffective disorder
h/o alcohol abuse
essential tremor
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
Vitals: 97.8, 132/92, 78, 16, 96%RA
General: Alert, oriented, no acute distress
Psych: Mood okay, affect somewhat flat with blunted facial
expression.
HEENT: Sclera anicteric, MMM, oropharynx clear
Skin: oily scales and erythema in nasolabial folds, face, and
chest
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender except on deep palpation of LLQ,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley, underwear stained with urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
No significant change on discharge
Pertinent Results:
ADMISSION LABS
--------------
___ 01:50PM BLOOD WBC-13.0*# RBC-4.83 Hgb-14.5 Hct-44.1
MCV-91 MCH-30.1 MCHC-32.9 RDW-12.9 Plt ___
___ 06:00AM BLOOD WBC-8.9 RBC-4.69 Hgb-14.0 Hct-42.5 MCV-91
MCH-29.8 MCHC-32.9 RDW-12.8 Plt ___
___ 06:00AM BLOOD Glucose-88 UreaN-11 Creat-0.7 Na-134
K-4.2 Cl-98 HCO3-27 AnGap-13
___ 01:50PM BLOOD ALT-71* AST-51* AlkPhos-45 TotBili-0.2
___ 06:00AM BLOOD ALT-68* AST-48* LD(LDH)-153 AlkPhos-42
TotBili-0.5
Reports:
CT abd/pelvis ___
HISTORY: Left-sided abdominal pain for 2 weeks with last CT
showing possiblediverticulitis now presenting with unresolved
pain and diarrhea. Evaluate forcolitis or diverticulitis.
TECHNIQUE: Axial helical MDCT images were obtained through the
abdomen and
pelvis after administration of 130 cc of Omnipaque intravenous
contrast.
Multiplanar reformatted images in coronal and sagittal axes were
generated.
DLP: 537 mGy-cm
COMPARISON: CT abdomen and pelvis dated ___
FINDINGS: There is right basilar atelectasis. The visualized
heart and
pericardium are unremarkable. There is a small hiatal hernia.
CT abdomen: The liver enhances homogeneously without focal
lesions or
intrahepatic biliary dilatation. The gallbladder is
unremarkable and the
portal vein is patent. The pancreas and adrenal glands are
unremarkable. The
punctate calcification is again noted in the spleen. The
kidneys present
symmetric nephrograms and excretion of contrast with no
pelvicaliceal dilation
or perinephric abnormalities.
The stomach, duodenum and small bowel are unremarkable. There
is unchanged
appearance of a short segment of focal wall thickening in the
mid to distal
sigmoid colon without significant surrounding fat stranding.
The appendix is not visualized but there is no evidence of
appendicitis. The intraabdominal vasculature is unremarkable.
There is no mesenteric or retroperitoneal lymph node enlargement
by CT size criteria. No ascites, free air or abdominal wall
hernia is noted.
CT pelvis: The urinary bladder is unremarkable. There is no
pelvic free
fluid. There is no inguinal or pelvic wall lymphadenopathy.
Osseous structures: No lytic or sclerotic lesions suspicious
for malignancy is present.
IMPRESSION:
1. Unchanged appearance of short segment of focal wall
thickening in the of
the sigmoid colon without significant surrounding inflammatory
changes.
Findings are of unclear etiology and (as previously recommended)
colonoscopy is advised to exclude underlying lesion.
2. Moderate colonic fecal loading
Brief Hospital Course:
___ year old male with history of diverticulitis, alcohol abuse
and schizoaffective disorder, presents with three weeks of
intermittent abdominal pain and CT possibly consistent with
diverticulitis.
ACTIVE ISSUES
-------------
# Diverticulitis: patient with left lower quadrant pain and
leukocytosis on admission, with no fever or evidence of bleeding
or obstruction. CT scan was possibly consistent with
diverticulitis, although there is only a small segment of focal
wall thickening. Differential diagnosis also included colitis
or malignancy. No significant change in bowel habits however
patient has reported unintentional weight loss. There was no
evidence of acute abdomen on exam. It was suspected that
constipation may be contributing to pain as CT showed moderate
fecal loading. We spoke with PCP who provides this additional
history: patient with multiple CT scans showing chronic
diverticulosis. Colonoscopy on ___ showed polyp,
diverticulosis in entire colon; poor prep; recommended repeat.
He was seen in ___ ED on ___ and discharged
home with a diagnosis of likely diverticulosis. Patient
tolerated normal low residue diet while admitted, and was seen
by nutrition and counseled on a low residue diet. Patient had
a large bowel movement during admission on
docusate/senna/Miralax and felt better. He will complete a
course of ciprofloxacin/metronidazole on ___. Leukocytosis
resolved on the day after admission, with suspicion that a
stress response contributed.
# Transaminitis. Unclear etiology, but downtrending. This may
be secondary to medications, hepatitis C or alcohol use. This
should be followed up as an outpatient for resolution.
# Alcohol abuse: patient reports being sober for two weeks with
no signs of withdrawal. He was counseled to avoid alcohol use
in the future. He was continued on his home thiamine and folic
acid.
INACTIVE ISSUES
---------------
# Benign prostatic hyperplasia: patient currently reports no
symptoms. He had urinary retention in the past. He was
continued on home tamsulosin, finasteride, with no urinary
retention on this admission.
# Schizoaffective disorder: continued home ziprasidone,
benztropine, lorazepam, citalopram.
# Hypertension: continued home amlodipine
TRANSITIONAL ISSUES
-------------------
# Hepatitis C: transaminitis noted on this admission, though he
had normal LFTs at last ED visit. He reports stopping alcohol
use about 2 weeks ago. His LFTs should be rechecked after
discharge.
# Diverticulitis: he was discharged with a bowel regimen, and
will finish ciprofloxacin/metronidazole course on ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. ZIPRASidone Hydrochloride 120 mg PO HS
2. Benztropine Mesylate 2 mg PO HS
3. Citalopram 20 mg PO DAILY
4. Lorazepam 1 mg PO DAILY
5. Amlodipine 10 mg PO DAILY
6. Thiamine 100 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Tamsulosin 0.4 mg PO HS
10. Finasteride 5 mg PO DAILY
11. Ciprofloxacin HCl 500 mg PO Q12H
12. MetRONIDAZOLE (FLagyl) 500 mg PO TID
13. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
14. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Benztropine Mesylate 2 mg PO HS
3. Citalopram 20 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Lorazepam 1 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. Thiamine 100 mg PO DAILY
10. ZIPRASidone Hydrochloride 120 mg PO HS
11. Ciprofloxacin HCl 500 mg PO Q12H Duration: 2 Days
12. MetRONIDAZOLE (FLagyl) 500 mg PO TID
13. Polyethylene Glycol 17 g PO DAILY
14. Acetaminophen 650 mg PO Q6H:PRN abd pain, fever
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet
extended release(s) by mouth three times a day Disp #*30 Tablet
Refills:*0
15. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
16. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Capsule Refills:*0
17. Magnesium Citrate 300 mL PO DAILY:PRN constipation
do not take with antibiotics
RX *magnesium citrate [Citrate of Magnesia] 300 mL by mouth
daily Disp #*1 Bottle Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis, constipation
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 abdominal pain. This is
likely caused by your chronic diverticulosis. There may be an
infection (diverticulitis) and so you should finish your course
of antibiotics which end ___. You should follow a low
residue diet, and continue prune juice and miralax to make sure
that you have a soft bowel movement every day. Constipation is
also contributing to your pain.
Followup Instructions:
___
|
10289679-DS-16 | 10,289,679 | 26,434,232 | DS | 16 | 2123-09-24 00:00:00 | 2123-09-25 08:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
The patient is a healthy ___ year old male with a 7 month history
of chronic NSAID use -advil 400 mg daily and naproxex ___ mg bid
for knee and back pain. Two days ago he awoke with severe mid
abdominal pain along with coffee ground emesis. He did not seek
immediate evaluation because he also had developed severe tooth
pain and sought dental care. The next day he vomited again and
this time the emesis had a small amount of blood. Pain worse
after eating a banana. He went to his PCP where he was found to
be tachycardic and had guiac positive stool. He was then
referred to the ED for admission. He was started on amoxicillin
for his dental abscess since his tooth was too swollen to be
extracted.
All other review of systems negative except as above.
Past Medical History:
DJD of spine
Lichen planus
chronic knee pain
Social History:
___
Family History:
Hi MGM has HTN. His parents are both alive and in good health.
Physical Exam:
PE at discharge:
Afeb, VSS
Cons: NAD, lying in bed
Eyes: EOMI, no scleral icterus
ENT: MMM
Cardiovasc: rrr, no murmur, no edema
Resp: CTA B
GI: +bs,soft, nt, nd
MSK: no significant kyphosis
Skin: no rashes +tattoos
Neuro: no facial droop
Psych: full range of affect, a little anxious
Pertinent Results:
___ 09:10PM LIPASE-189*
___ 03:17PM LACTATE-1.9
___ 03:15PM GLUCOSE-109* UREA N-11 CREAT-0.8 SODIUM-136
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-27 ANION GAP-16
___ 03:15PM estGFR-Using this
___ 03:15PM ALT(SGPT)-26 AST(SGOT)-31 ALK PHOS-87 TOT
BILI-0.6
___ 03:15PM LIPASE-108*
___ 03:15PM ALBUMIN-4.8 CALCIUM-10.1 PHOSPHATE-3.5
MAGNESIUM-2.1
___ 03:15PM WBC-9.0 RBC-4.25* HGB-14.6 HCT-42.9 MCV-101*
MCH-34.2* MCHC-33.9 RDW-12.6
___ 03:15PM NEUTS-73.5* ___ MONOS-6.1 EOS-1.5
BASOS-0.7
___ 03:15PM PLT COUNT-364
___ 03:15PM ___ PTT-38.3* ___
================
CXR: no PNA.
EGD:
Esophagus:
Mucosa: There was some mild erythema of distal ___ of the
esophagus consistent with esophagitis.
Stomach:
Mucosa: There was significant antral erythema consistent with
gastritis.
Excavated Lesions There were 4 large cratered, clean based
ulcers arranged in a circumferential pattern in the antrum. One
ulcer had a small red spot. There was no active bleeding.
Duodenum:
Mucosa: There was significant erythema and friability of the
mucosa in the duodenal bulb consistent with duodenitis.
Impression: Abnormal mucosa in the esophagus
Abnormal mucosa in the stomach
Gastric ulcer
Abnormal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: -The patient can return to floor when recovered
from sedation
-Please start 40mg protonix twice daily
-Please send H. pylori serology and treat with triple therapy if
positive
-Avoid all ibuprofen and naprosyn, avoid alcohol
Brief Hospital Course:
___ y.O. M who presnts with abdominal pain/nausea, vomiting,
hematemesis with recent high level of nsaid use.
The pt had no bleeding while hospitalized. The GI was
consulted. Pt underwent EGD which revealed esophagitis,
gastritis, duodenitis, and a few shallow ulcers in the antrum,
c/w ulceration from NSAID use.
Post procedure the pt felt well and was able to take good PO. He
was discharged to home with a prescription for BID PPI and for
tramadol which he will try for his knee pain.
H.pylori has been sent, but the result is currently pending.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Naproxen 500 mg PO Q12H
2. Ibuprofen 400 mg PO DAILY
3. Amoxicillin 500 mg PO Q8H dental abscess
Discharge Medications:
1. Amoxicillin 500 mg PO Q8H dental abscess
2. TraMADOL (Ultram) 50 mg PO Q6H:PRN knee pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*60
Tablet Refills:*0
3. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth twice a day Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
stomach ulcer
Discharge Condition:
alert, interactive
Discharge Instructions:
You were found to have inflammation in the esophagus, stomach,
and first part of the small intestine. This is most likely from
too much acid due to the ibuprofen (advil) and naprosyn (aleve).
You will need to avoid these medications. You are now being
prescribed a medication to decrease stomach acid so that this
condition can heal. A blood test has been sent off to determine
if a specific bacteria (H.pylori) is present because it also
could be contributing to the stomach ulcer. If it is present
you will need antibiotics for a short period of time. This test
will not be back for at least 3 days.
Followup Instructions:
___
|
10289851-DS-22 | 10,289,851 | 23,850,480 | DS | 22 | 2154-12-13 00:00:00 | 2154-12-16 15:59:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Lasix / levofloxacin
Attending: ___.
Chief Complaint:
Dyspnea, leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ gentleman with HTN, mild AS, h/o TIA, carotid stenosis,
suspected MDS ___ deferred), chronic left foot and back pain
presenting with dyspnea and left leg pain. According to the ___
notes, the son, who is not with patient on arrival to ___,
___ his father in because of fatigue, poor PO, and increasing
dyspnea with exertion over the past week. The patient states
that he called his son to bring him to the doctor because
"something was wrong with my stomach", but he cannot remember
what was wrong. He says that he has chronic back pain and left
leg pain and swelling (neg for DVT last year) that are not worse
than usual, thoug he does say he feels he is due for his
acetaminophen. He denies chest pain, PND, orthopnea.
In the ___, initial vitals were: 98.3 89 181/69 16 91% ra, then
down to 88% on RA
- Labs were significant for proteinuria, Lactate 2.1, pH 7.33,
pCO246, Cr 2.1 (baseline), AST 78 no trop sent, WBC 13.1
- ___ read CXR as pulmonary edema, though final radiology read
was small lung volumes, he was ordered for 1mg IV bumex that was
not given.
- The ___ suspected an element of pneumonia so ordered 750mg IV
levofloxacin that was not completely administered due to a hives
during infusion for which he was given 12.5mg IV
diphenhydramine.
- Duplex exam of the LLE was prelim negative for DVT, but prior
to scan he was started on heparin gtt due to high suspicion for
DVT, guaiac was negative.
Vitals prior to transfer were: 98.0 62 184/77 20 92% 2L
Upon arrival to the floor, patient states that his breathing
feels normal, though he sounds wheeze and is speaking in short
sentences. He has no other complaints. He asks me not to wake up
his son, and to call him first thing in the morning instead. He
is not sure if his son is aware of his wish to be DNR/DNI.
Past Medical History:
- Hypertension
- Hyperlipidemia
- CKD
- Likely TIA ___, MRI showed small vessel disease, carotid
studies showed 60-69% L ICA stenosis
- GERD
- Chronic back and shoulder pain
Social History:
___
Family History:
No family history of malignancies or heart conditions.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.9F, BP 158/57, HR 53, RR 22, 99% on 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, EOMI, R pupil fixed (due to cataract
surgery per son), L pupil reactive, MMM, oropharynx clear
Neck: Supple, JVP 9cm, no LAD
CV: regularly irregular, normal S1 + S2, ___ systolic murmur,
rubs, gallops
Lungs: poor air movement, crackles at bilateral bases worse on
the left; bilateral expiratory wheeze and prolonged expiratory
phase
Abdomen: Soft, non-tender except to deep palpation in RLQ,
non-distended, bowel sounds present, no organomegaly, no rebound
or guarding
GU: No foley
Ext: hands and feet are cold, feet are slightly mottled, 3+
edema to distal thigh on the left, 2+ edema to the mid shin on
the right
Neuro: CNII-XII intact, moving all extremities. He is not a
great historian but knows where he is, that it is ___, but
thinks it is ___. Knows the ___.
DISCHARGE PHYSICAL EXAM:
VS: T 98.0 (98.1) BP 142/70 (105/60-142/70) P 91 (50-91) R 20 O2
92%RA
General: Alert, oriented, no acute distress
Neck: No JVD
CV: regular rhythm, normal S1 + S2, ___ systolic murmur that
radiates to carotids
Lungs: diminished breath sounds at base, clear in the upper lung
fields
Abdomen: Soft, non-tender
Ext: Extremities are cool; trace to 1+ edema on left
Pertinent Results:
ADMISSION LABS
==============
___ 08:55PM ___ PTT-32.8 ___
___ 08:55PM PLT COUNT-137*
___ 08:55PM NEUTS-81.3* LYMPHS-12.5* MONOS-4.8 EOS-1.2
BASOS-0.2
___ 08:55PM WBC-13.1* RBC-4.19* HGB-14.5 HCT-43.4
MCV-104* MCH-34.5* MCHC-33.3 RDW-15.6*
___ 08:55PM TSH-2.8
___ 08:55PM ALBUMIN-4.0
___ 08:55PM proBNP-8473*
___ 08:55PM cTropnT-0.06*
___ 08:55PM LIPASE-32
___ 08:55PM ALT(SGPT)-37 AST(SGOT)-78* ALK PHOS-125 TOT
BILI-1.0
___ 08:55PM GLUCOSE-92 UREA N-44* CREAT-2.1* SODIUM-141
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-22 ANION GAP-19
___ 09:03PM LACTATE-2.1*
___ 09:03PM ___ PO2-31* PCO2-46* PH-7.33* TOTAL
CO2-25 BASE XS--2 COMMENTS-GREEN TOP
___ 09:10PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 09:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:10PM URINE COLOR-Yellow APPEAR-Clear SP ___
PERTINENT LABS
==============
___ 03:41AM BLOOD D-Dimer-1775*
___ 04:10AM BLOOD CK-MB-6 cTropnT-0.06*
___ 03:10PM BLOOD Lactate-1.6
MICROBIOLOGY
============
___ 9:10 pm URINE
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
RADIOLOGY
=========
___ 10:03 ___ CHEST (PA & LAT)
FINDINGS:
AP upright and lateral views of the chest provided. Lung
volumes are somewhat low with central bronchovascular crowding
noted. Allowing for suboptimal technique, there is no
convincing evidence for pneumonia or CHF. No large effusion or
pneumothorax. Cardiomediastinal silhouette is stable. Bony
structures are intact.
IMPRESSION:
Limited negative.
TTE (Complete) Done ___ at 2:01:42 ___
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). 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
are moderately thickened. There is moderate aortic valve
stenosis (valve area 1.0cm2). Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild to
moderate (___) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderate aortic valve stenosis. Mild symmetric left
ventricular hypertrophy with preserved regional and global
biventricular systolic function. Moderate pulmonary artery
hypertension. Mild-moderate mitral regurgitation. Increased
PCWP.
Compared with the prior report (images unavailable for review)
of ___, the severity of aortic stenosis has slightly
progressed and the estimated PA systolic pressure is now much
higher.
___ 12:00 AM UNILAT LOWER EXT VEINS LEFT
FINDINGS:
There is normal compressibility, flow and augmentation of the
left common femoral, superficial femoral, and popliteal veins.
Normal color flow is demonstrated in the posterior tibial and
peroneal veins.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ 2:43 ___ CHEST (PA & LAT)
FINDINGS:
Small bilateral pleural effusions are new. The heart is
top-normal in size, unchanged. Mild pulmonary vascular
congestion since improved. No focal consolidation, overt
pulmonary edema, or pneumothorax. Slight elevation of the right
hemidiaphragm is unchanged.
IMPRESSION:
New small bilateral pleural effusions but no pulmonary edema.
___ LUNG SCAN
FINDINGS: Perfusion images demonstrate marked irregularity in
perfusion, worse in the bilateral lower lobes.
Ventilation images demonstrate matched defect, somewhat worse
than perfusion defect, consistent with airway disease.
Chest x-ray shows no focal consolidations.
IMPRESSION: Low likelihood ratio for recent pulmonary embolism.
DISCHARGE LABS
==============
___ 07:33AM BLOOD Glucose-107* UreaN-73* Creat-2.2* Na-139
K-4.9 Cl-102 HCO3-28 AnGap-14
___ 07:33AM BLOOD Calcium-10.0 Phos-4.4 Mg-2.0
Brief Hospital Course:
SUMMARY: ___ with history of AS (mean gradient 34mmHg), TIA,
carotid stenosis, suspected MDS ___ deferred), chronic left
leg swelling, and chronic back pain presents with fatigue and
malaise, likely due to pulmonary edema from heart failure.
# Diastolic Heart Failure | Hypoxemia
The patient was admitted with symptoms of general sense of
malaise, not feeling well, and hypoxemia. Labs of elevated
proBNP and chest x-ray of pulmonary edema suggested diastolic
heart failure as the main etiology. His weight of 59 kg was up
from his most recent PCP office weight of 57 kg. He had a TTE
that showed worsening AS to moderate severity and new elevated
estimated PA pressure. PE was considered as a less likely
possibility but he did have a non-specific positive d-dimer. He
was initiated on diuresis with bumetanide (listed allergy to
furosemide) with good response. However, he developed ___ with
diuresis so further doses of bumetanide were held. Despite
appearing clinically euvolemic, he still had hypoxemia with 2L
O2 requirement. A V/Q scan was performed, which showed low
probability of PE. With increased activity level and time, his
O2 requirement resolved, suggesting that ultimately volume
overload was the main contributor. Discharge weight was 55.7 kg.
# 2nd Degree Mobitz Type 1 Heart Block
On admission, telemetry showed that patient had intermittent
heart block, which was confirmed on EKG to be type ___lock. His heart rate dropped to ___ when sleeping,
but when awake, he was completely asymptomatic. He never
developed higher levels of AV block. Given no symptoms, no
intervention was pursued other than stopping his home beta
blocker.
# Left Knee Pain
The patient developed an acutely swollen and painful left knee
after initiation of diuresis. It was thought to be most likely
due to pseudogout vs gout. He did not have any exam findings to
suggest infection. The main findings were only a palpable
effusion. The joint was aspirated and 40mg of Depo-Medrol was
injected. The fluid analysis unfortunately did not confirm any
crystals. His knee pain shortly resolved with no ongoing
symptoms while inpatient.
# Hypertension: Held metoprolol as discussed above.
# CKD: Baseline 1.6-2.1, was 1.6 in ___. Continued
calcitriol.
# Carotid Stenosis: Continued aspirin and cholesterol meds.
# Hyperlipidemia: Continued fish oil and atorvastatin.
# Chronic Pain: Continued acetaminophen and tramadol prn.
# BPH: Continued finasteride.
# Suspected MDS: Continued B12 supplement.
TRANSITIONAL ISSUES
- Patient's metoprolol was discontinued on discharge due to
intermittent high degree 2nd degree type 1 AV block. He should
have cardiology follow up for both his diastolic heart failure
as well as the node block.
- On discharge, he was not given any diuretics due to rising
creatinine that developed with diuresis. The ___ resolved at
discharge, but given the high risk for recurrence, he was not
discharged on diuretics. Please re-evaluate this as an
outpatient. His discharge dry weight is 55.7kg.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Senna 25.8 mg PO DAILY
6. Atorvastatin 40 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO BID
8. TraMADOL (Ultram) 50 mg PO QPM
9. Cyanocobalamin 100 mcg PO DAILY
10. Acetaminophen 1300 mg PO BID
Discharge Medications:
1. Acetaminophen 1300 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Calcitriol 0.25 mcg PO DAILY
5. Cyanocobalamin 100 mcg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Senna 25.8 mg PO DAILY
9. TraMADOL (Ultram) 50 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- Acute Diastolic Heart Failure
- 2nd Degree Mobitz Type I Atrioventricular Heart Block
- Chronic Kidney Disease
- Left Knee 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 Mr. ___,
You were admitted to ___ after presenting here with feeling
fatigued. We did a work up and found that you likely had a heart
failure exacerbation from having too much fluid on board. We
gave you medications to help you pee, which ultimately improved
your oxygenation and your symptoms.
While here, you developed acute left knee pain, which we think
was due to either gout or pseudogout, an inflammatory condition.
We injected your knee with steroids, which helped improve the
pain and swelling.
We also found that your heart rate gets very slow at times.
While this is not a dangerous condition, we recommend stopping
your metoprolol, which can cause slow heart rate.
Last, please weigh yourself everyday. If you gain more than
3lbs, please call your doctor's office. It was a pleasure to
take care of you. We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10289911-DS-20 | 10,289,911 | 27,305,788 | DS | 20 | 2180-07-16 00:00:00 | 2180-07-16 20:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
sulfa drugs / Penicillins / Nubain / latex / Betadine /
Iodinated Contrast Media - IV Dye / Toradol
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
-fistula thrombolysis
History of Present Illness:
Mr. ___ is a ___ yo M with h/o of ESRD on ___ renal dialysis
through a LUE fistula who presented to the ED from a fistula
thrombectomy procedure due to acute onset dyspnea, chest pain,
hyperkalemia.
He is currently incarcerated. His ESRD is due to bilateral
hydronephrosis from urethral strictures after traumatic foley
removal, s/p multiple surgical procedures. The patient's last
dialysis session was ___. Yesterday, he was found to have a
thrombosed LUE fistula at hemodialysis and underwent
thrombectomy (___) this morning. During the procedure, his K was
found to be 7.2 in a moderately hemolyzed sample, and repeat K
remained elevated at 6.8. Was hypoglycemic at the time so was
given D50 and 5U insulin. As the thrombectomy procedure
proceeded, he began to complain of chest pain and dyspnea. The
chest pain was sharp and accompanied by soreness. It did not
radiate. He has never had such chest pain before. It improved
gradually in the 15 minutes after sitting up. His dyspnea
improved immediately on sitting up with supplemental oxygen. He
has had similar dyspnea in the past while lying flat when he was
fluid overloaded. During this episode, he denied dizziness,
vision changes. He had some nausea that improved with
ondansetron.
He claims to have had a recent nuclear perfusion test in
preparation for renal transplantation, which per his report were
normal.
In the ED, initial vital signs were T 97.9, HR 62, BP 183/110,
RR 18, Sat 99% on RA
- Labs were notable for: (Grossly hemolyzed specimen) K 5.5,
HCO3 21, lactate 1.7, BUN 63, Cr 18.3, Anion gap 22. EGFR: 3. CK
173. Mg 3.6, P 6.5. WBC 8.1, HCT 40.5, Platelets 143. ___ 10.6,
PTT 49.8, INR 1.
-Imaging was notable for a normal CXR.
- EKG: Normal sinus rhythm, mildly taller T waves with no
narrowing throughout. Compared with EKG from ___.
- Micro: blood culture pending
- Patient was given 4mg IV ondansetron for post-procedure
nausea.
On transfer, vital signs were T 97.5, HR 63, BP 182/107, RR 17,
Sat 100% RA. From the ED, he was sent to receive dialysis before
transferring to the floor. He had 2.5 L of fluids removed during
dialysis. On the floor, he denies any recurrent chest pain and
or dyspnea. He no longer has nausea, but complains of
"heartburn" and feeling like he has gas in his stomach he cannot
belch. He says he gets this feeling intermittently and it
improves with ___ tablets of tums. Otherwise, no new symptoms.
REVIEW OF SYSTEMS: As per HPI. Also negative for recent fevers,
weight loss, headache, vision or hearing changes, neck pain,
palpitations, cough, abdominal pain/diarrhea/constipation,
dysuria.
Past Medical History:
ESRD on HD ___ with AV LUE graft placement
Multiple urologic procedures
HTN
Anxiety
Sleep Apnea-not on CPAP
Ruptured appendix
Social History:
___
Family History:
Father had diabetes and stroke. Mother healthy.
Physical Exam:
INITIAL PHYSICAL EXAM:
Vitals: Afebrile, HR 86, BP 135/91, RR 16, 100% RA
General: NAD sitting up in bed.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes/rales/rhonchi
CV: Distant heart sounds RRR, normal S1/S2, no MRG. Chest not
tender on palpation.
Abdomen: Soft, NTND, normoactive bowel sounds
GU: No Foley. No CVA tenderness.
Ext: Warm, well-perfused, no cyanosis/clubbing/edema, 2+ pulses
Neuro: AAOx3, CN II-XII grossly intact, gait normal
DISCHARGE PHYSICAL EXAM
Vitals: T98.2 BP118/67 HR80s RR16 Sat99%RA
General: NAD sitting up in bed.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes/rales/rhonchi
CV: Distant heart sounds RRR, normal S1/S2, no MRG. Chest not
tender on palpation.
Abdomen: Soft, NTND, normoactive bowel sounds
GU: Suprapubic tenderness to palpation. No Foley. No CVA
tenderness.
Ext: Warm, well-perfused, no cyanosis/clubbing/edema, 2+ pulses
Neuro: AAOx3, CN II-XII grossly intact, gait normal
Pertinent Results:
INITIAL LABS
___ 07:25AM BLOOD WBC-4.9 RBC-5.05 Hgb-12.6* Hct-41.7#
MCV-83# MCH-25.0* MCHC-30.2* RDW-15.2 RDWSD-44.9 Plt ___
___ 07:25AM BLOOD Na-133 K-7.2* Cl-95*
DISCHARGE LABS:
___ 06:24AM BLOOD WBC-4.7 RBC-4.54* Hgb-11.4* Hct-37.1*
MCV-82 MCH-25.1* MCHC-30.7* RDW-15.2 RDWSD-44.7 Plt ___
___ 06:24AM BLOOD Glucose-165* UreaN-48* Creat-14.9*#
Na-134 K-4.6 Cl-92* HCO3-29 AnGap-18
___ 06:24AM BLOOD cTropnT-0.02*
___ 10:43PM BLOOD CK-MB-1 cTropnT-0.02*
___ 01:00PM BLOOD cTropnT-<0.01
IMAGING:
CXR in ED
FINDINGS: There is relative elevation of the right hemidiaphragm
with right basilar atelectasis. The lungs are otherwise clear.
The cardiomediastinal silhouette is within normal limits. No
acute osseous abnormalities. Surgical clip projects over the
right upper quadrant. IMPRESSION: No acute cardiopulmonary
process.
MICRO:
Blood culture in ED - Pending
Brief Hospital Course:
___ yo M with h/o of ESRD on ___ renal dialysis through a LUE
fistula now s/p fistula thrombectomy procedure complicated by
acute onset dyspnea and chest pain in the setting of
hyperkalemia.
ACUTE ISSUES
#ESRD: Anuric. Had an episode of hyperkalemia with no EKG
changes during thrombectomy procedure. He was hypoglycemic so he
was treated during the procedure with D50 and 5U insulin. He has
had no continued issues with hyperkalemia since admission.
Received hemodialysis on the day of admission and had 2.5L
removed. Dialyzed again on the morning of discharge.
#Chest pain: Chest pain has resolved since the episode during
thrombectomy. Troponins were <0.01, 0.02, 0.02. EKG does not
show signs of ischemia or pericarditis. No pericardial rub on
physical exam. Given these findings the chest pain/dyspnea was
likely a result of a combination of pulmonary edema vs. GERD. He
complained of GERD on arrival to the floor which greatly
improved by time of discharge.
#Suprapubic tenderness: Unclear etiology at this time. Bladder
scan showed 22cc so not concerned for bacterial cystitis in the
setting of obstruction. Pt remained afebrile without
leukocytosis during admission. Recommend follow-up as an
outpatient.
CHRONIC ISSUES
#HTN: Related to his ESRD and fluid status. Hypertensive on
arrival but improved with dialysis.
#Anxiety: well controlled at this time. No issues during
hospitalization.
TRANSITIONAL ISSUES
-please encourage dietary adherence to a renal diet
-pt endorsed suprapubic pain, bladder scan ->22 cc, pls f/u
symptoms
# Code Status: Full Code
# Emergency Contact: ___ (brother) ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcium Acetate 1334 mg PO TID W/MEALS
3. DiphenhydrAMINE 50 mg PO Q8H:PRN itching
4. darbepoetin alfa in polysorbat 100 mcg/mL injection 1X/WEEK
5. NIFEdipine CR 60 mg PO DAILY
6. Doxercalciferol 2 mcg IV 3X/WEEK (___)
7. Propranolol 5 mg PO BID
8. sevelamer CARBONATE 3200 mg PO TID W/MEALS
9. Nephro-Vite (B complex-vitamin C-folic acid) 0.8 mg oral
DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Acetate 1334 mg PO TID W/MEALS
3. DiphenhydrAMINE 50 mg PO Q8H:PRN itching
4. NIFEdipine CR 60 mg PO DAILY
5. sevelamer CARBONATE 3200 mg PO TID W/MEALS
6. darbepoetin alfa in polysorbat 100 mcg/mL injection 1X/WEEK
7. Doxercalciferol 2 mcg IV 3X/WEEK (___)
8. Nephro-Vite (B complex-vitamin C-folic acid) 0.8 mg oral
DAILY
9. Propranolol 5 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
1. End Stage Renal Disease
2. Hyperkalemia
Secondary Diagnosis
1. Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure taking care of you at ___. You were
admitted after having chest pain and difficulty breathing during
your thrombectomy procedure. You also had high potassium. After
sitting up and getting oxygen, you felt better and did not have
any more chest pain or symptoms throughout the rest of your
stay. It is unclear what caused your symptoms, but reassuring
that they improved so quickly with no medications. After the
thrombectomy procedure, you were able to get dialysis two times
during your stay and your potassium has been normal.
You also had pain in your lower stomach and a feeling of needing
to urinate that we investigated. An ultrasound of your bladder
showed minimal urine.
Please follow up with your regular doctors.
Thank you for choosing ___. We wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10289937-DS-21 | 10,289,937 | 25,495,505 | DS | 21 | 2118-04-19 00:00:00 | 2118-04-19 16:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
right leg ischemia
Major Surgical or Invasive Procedure:
___
right above the knee amputation, right femoral embolectomy
History of Present Illness:
At admission:
___ DNI/DNR, CKD, dCHF Lasix dependent, DMII, HTN, wheelchair
bound at ___ presenting with RLE
ischemia. Given her altered mental status, history was obtained
from the rehab staff and family members.
She was recently admitted 1 week ago for asymptomatic
bradycardia. No intervention was indicated. Per the rehab
nursing
staff, since her discharge a week ago she has had pain in her
RLE
and 'not letting anyone touch it'. An xray was performed that
didn't show acute fracture. She also has had a decline in her
mental status for the past week. Today, she was noted to have
discoloration and poikilothermia of her Right leg, which
prompted
ER transfer.
She has not had fevers, chills, chest pain, dyspnea, syncope,
changes to vital signs, etc.
Past Medical History:
PMH:
- HTN/HLD
- DM2
- CHF presumed chronic diastolic
- Breast Cancer
- OA
- hearing impaired
PSH
-Unknown
Social History:
___
Family History:
non contributory
Physical Exam:
At admission:
Physical Exam:
Vitals: 98.3 73 126/72 12 98RA
GEN: Confused. alert to person and son
___: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
Ext
LLE: P/p/d/d, no edema or discoloration. 4+ strength to dorsi &
plantar flexion, sensation intact.
RLE: no palpablefemoral pulse or dopplerable distal pulses.
Discoloration and erythema the extremity. No sensation to touch
or pinprick from knee to foot. unable to move the foot. No
motion
appreciated to command or pain.
At the time of discharge:
Objective
Vitals: 24 HR Data (last updated ___ @ 1507)
Temp: 95.5 (Tm 98.0), BP: 131/67 (118-147/56-77), HR: 60
(60-78), RR: 18 (___), O2 sat: 100% (99-100), O2 delivery: Ra
GENERAL: [x]NAD []A/O x 3 []intubated/sedated []abnormal
CV: [x]RRR [] irregularly irregular []no MRG []Nl S1S2
[]abnormal
PULM: []CTA b/l [X]no respiratory distress []abnormal
ABD: [x]soft [x]Nontender []appropriately tender
[x]nondistended []no rebound/guarding []abnormal
WOUND: []CD&I []no erythema/induration [x]abnormal
EXTREMITIES: []no CCE [x]abnormal: RLE s/p AKA with prevena in
place, JP drain in R groin with serosanguinous output, skin tear
on groin
PULSES: R-AKA L: p/p/d/d
Pertinent Results:
___ 05:58PM BLOOD WBC-12.8* RBC-3.00* Hgb-8.7* Hct-28.8*
MCV-96 MCH-29.0 MCHC-30.2* RDW-15.5 RDWSD-53.9* Plt ___
___ 04:50AM BLOOD WBC-15.4* RBC-3.24* Hgb-9.4* Hct-30.1*
MCV-93 MCH-29.0 MCHC-31.2* RDW-15.9* RDWSD-53.6* Plt ___
___ 05:58PM BLOOD Glucose-288* UreaN-75* Creat-1.3* Na-140
K-5.4 Cl-105 HCO3-23 AnGap-12
___ 04:50AM BLOOD Glucose-49* UreaN-34* Creat-1.0 Na-138
K-5.0 Cl-109* HCO3-22 AnGap-7*
___ 08:26AM BLOOD ALT-39 AST-30 AlkPhos-110* TotBili-0.2
___ 04:50AM BLOOD ALT-19 AST-21 LD(LDH)-296* AlkPhos-118*
TotBili-0.3
___ 04:50AM BLOOD Calcium-8.6 Phos-4.6* Mg-2.3
___ 04:50AM BLOOD CEA-6.9*
___ 04:50AM BLOOD CA ___ -PND
CTA ___:
IMPRESSION:
1. Pulmonary emboli are seen in the segmental branches of the
right middle and
right lower lobes. There is associated mild dilatation of the
pulmonary
artery.
2. Right common femoral vein acute thrombosis. Chronic
atherosclerotic
changes of the common iliac arteries bilaterally, with
associated nonocclusive
thrombosis seen in the right common iliac artery, possibly
acute. A broad-base
atheromatous plaque is seen in the aortic arch, measuring 1.3
cm.
3. A heterogeneous hypodense mass is seen in the tail of the
pancreas
measuring 4.1 cm x 3.9 cm. Recommend MR for further
characterization. No
abnormal lymph nodes are seen.
4. A 7 mm nodule is seen in the left lower lobe, series 3, image
58. Another 4
mm nodule is seen in the right upper lobe, series 3, image 20.
5. Multinodular goiter.
Brief Hospital Course:
Patient was admitted to ___ on ___ with right lower leg
ischemia. She was admitted to vascular surgery service and was
started on anticoagulation immediately. On ___ she was
taken to the OR. She underwent RIGHT GROIN CUTDOWN, RIGHT
FEMORAL EMBOLECTOMY, RIGHT ABOVE KNEE AMPUTATION. The procedure
was uncomplicated. For recovery period she was transferred to
the ICU, where she was later extubated. She continued on heparin
drip for anticoagulation. Overnight she required 2 u of red
blood cells for hematocrit drifts however she remained
hemodynamically stable. ECHO was done which showed no clear
source of embolus. On ___ she was transferred in stable
conditions to the floor. On ___ CTA was done in order to
look for embolic source. Ct showed pulmonary embolism, right
common femoral vein thrombus, right common iliac artery
nonoclusive thrombus and pancreatic mass. ___ service was
consulted re pancreatic mass - most likely cancerous, however
family would like to proceed with palliative management. Cancer
markers were obtained and ___ currently pending. Patient will
follow up with ___ surgeon dr. ___ in outpatient
settings regarding this pancreatic mass. For emoli and thrombi
she was continued on anticoagulation. She was transitioned to
lovenox. Geriatric service was also consulted - they were in
close touch with patient's family to make sure that their wishes
and patient wishes are being followed. Geriatric service also
helped with medication management. Patient was during
hospitalization at iv metoprolol. At the discharge she was
restarted on her home medication - however lisinopril,
amlodipine and hydralazine are being hold (please see the
instruction sheet). Patient is comfortable, reports no pain,
tolerating diet. She is ready for transfer to the rehab facility
where she presented from.
___ transferred to the floor
___ CTA, cc/s
___ d/c
Medications on Admission:
MEDS:
- losartan 50 mg tablet daily
- Oyster Shell Calcium 500 mg Daily
- polyethylene glycol 17 gram daily
- MVI 1 tab daily
- Lasix 20 mg Daily
- glipizide ER 7.5 mg Daily
- hydralazine 10 mg BID
- amlodipine 10 mg daily
- ASA 81 mg daily
- Atorvastatin 40 mg daily
- Novolin N NPH U-100 Insulin 15u ? Daily
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
Please take while taking narcotic medication.
2. Enoxaparin Sodium 70 mg SC DAILY
RX *enoxaparin 80 mg/0.8 mL 70 mg SC once a day Disp #*30
Syringe Refills:*1
3. NovoLIN N NPH U-100 Insulin (insulin NPH isoph U-100 human)
10 units subcutaneous DAILY
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Please do not drink alcohol or drive while taking this
medication.
RX *oxycodone 5 mg 1 tablet(s) by mouth Q4 hrs Disp #*20 Tablet
Refills:*0
5. Oyster Shell Calcium (calcium carbonate) 500 mg calcium
(1,250 mg) oral daily
6. Senna 8.6 mg PO BID:PRN constipation
Please take while taking narcotic medication.
7. Aspirin EC 81 mg PO DAILY
8. Atorvastatin 40 mg PO DAILY
Please take at the dose 40mg daily - your home dosage
9. Furosemide 20 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right lower extremity acute ischemia s/p above the knee
amputation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you at ___
___. During your hospitalization, you had surgery to
remove unhealthy tissue on your lower extremity. You tolerated
the procedure well and are now ready to be discharged from the
hospital. Please follow the recommendations below to ensure a
speedy and uneventful recovery.
LOWER EXTREMITY AMPUTATION
DISCHARGE INSTRUCTIONS
ACTIVITY
You should keep your amputation site elevated and straight
whenever possible. This will prevent swelling of the stump and
maintain flexibility in your joint.
It is very important that you put no weight or pressure on
your stump with activity or at rest to allow the wound to heal
properly.
You may use the opposite foot for transfers and pivots, if
applicable. It will take time to learn to use a walker and
learn to transfer into and out of a wheelchair.
MEDICATION
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
You will likely be prescribed narcotic pain medication on
discharge which can be very constipating. If you take
narcotics, please also take a stool softener such as Colace.
If constipation becomes a problem, your pharmacist can suggest
an additional over the counter laxative.
You should take Tylenol ___ every 8 hours for pain. If
this is not enough, take your prescription narcotic pain
medication. You should require less pain medication each day.
Do not take more than a daily total of 3000mg of Tylenol.
Tylenol is used as an ingredient in some other over-the-counter
and prescription medications. Be aware of how much Tylenol you
are taking in a day.
BATHING/SHOWERING:
You may shower when you feel strong enough but no tub baths or
pools until you have permission from your surgeon and the
incision is fully healed.
After your shower, gently dry the incision well. Do not rub
the area.
WOUND CARE:
You have prevena vac on your stump - please discontinue the
prevena on ___. Place dry dressing over the wound
if is still draining, but it is very important that there is no
pressure on the stump. If there is no drainage, you may leave
the incision open to air. Please remove prevena from your R
groin site on ___ - If site with drainage please place dry
dressing.
Your staples/sutures will remain in for at least 4 weeks. At
your followup appointment, we will see if the incision has
healed enough to remove the staples.
Before you can be fitted for prosthesis (a man-made limb to
replace the limb that was removed) your incision needs to be
fully healed.
CALL THE OFFICE FOR: ___
Opening, bleeding or drainage or odor from your stump incision
Redness, swelling or warmth in your stump.
Fever greater than 101 degrees, chills, or worsening
incisional/stump pain
NO OTHER PROVIDER, EXCEPT YOUR VASCULAR SURGEON, SHOULD
DETERMINE IF YOUR STAPLES ARE READY TO BE REMOVED FROM YOUR
STUMP!
IF THERE ARE ANY QUESTIONS, THE PROVIDER SHOULD CALL THE
VASCULAR SURGERY OFFICE AT ___ TO DISCUSS. THE
STAPLES WILL BE REMOVED IN THE OFFICE AT YOUR FOLLOWUP
APPOINTMENT WHEN IT IS DETERMINED BY THE VASCULAR SURGEON THAT
THE WOUND HAS SUFFICIENTLY HEALED.
During hospitalization pancreatic mass was found incidentally on
imaging. It will be worked up as a outpatient.
Followup Instructions:
___
|
10289937-DS-22 | 10,289,937 | 25,305,823 | DS | 22 | 2118-05-01 00:00:00 | 2118-05-01 16:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
CC: ___ bleeding
Reason for ICU Admission: Hemorrhagic versus Septic Shock
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old woman with advanced dementia, CKD,
dCHF (Lasix dependent, EF 69%), DMII, HTN, now s/p Right femoral
embolectomy and AKA for acute limb ischemia on ___,
subsequent workup revealed subsequently found to have RML and
RLL segmental PEs, R common femoral vein DVT and non-occlusive R
common iliac artery thrombus, as well as pancreatic tail mass
concerning for malignany. She was started on Lovenox and
discharged to ___ on ___ with a wound
vac in place. Yesterday, staff at the nursing home removed her
vac dressing and around 20:00 reportedly noted "pulsatile
bleeding from the staple line". They applied a pressure dressing
and called ___. At 20:13, EMS had arrived and placed a
tourniquet above the bleed. She was then transported here to the
___ ED and remained stable.
On arrival, the patient's HCP & Daughter ___ was contacted
(___) to clarify goals of care: ok for blood, ok to
reverse DNR/DNI for OR or other procedure, otherwise patient
should remain DNR/DNI and have comfort focused care as discussed
during recent hospitalization. The tourniquet was then taken
down ~21:10, no bleeding was identified, and her vitals
unchanged. The patient's daughter was then updated that no
surgical procedure would be necessary. Labs were significant for
a decreased H/H from prior admission.
On admission to the floor she was noted to be tachypneic and
required 5L O2 via facemask and she was noted to be hypotensive
to the 80/60s with significantly decreased alertness compared to
her baseline. She was given broad spectrum antibiotics, 1L LR
and 1U PRBC with improvement in her BP and transferred to the
MICU for hemodynamic monitoring and possible pressors although
she
remains DNR/DNI.
ROS: Unable to be obtained due to mental status.
Past Medical History:
- DM2
- CHF presumed chronic diastolic
- Breast Cancer
- OA
- Hearing impaired
Social History:
___
Family History:
non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: Reviewed in Metavision
GEN: Sleepy, arousable to voice, opens eyes and moves
extremities
to command, no acute distress
HEENT: NC/AT, PERRL, No
CV: Irregular, tachycardic, no murmurs, rubs, or gallops
RESP: CTAB, no increased WOB
GI: NT/ND, BS+
NEURO: Moving all four extremities appropriately
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 1153)
Temp: 97.7 (Tm 132), BP: 121/72 (121-166/62-80), HR: 76
(68-95), RR: 18 (___), O2 sat: 95% (93-100), O2 delivery: Ra
Shift: Nights
GEN: pleasant and interactive.
HEENT: NC/AT, PERRL
CV: Irregular rhythm, regular rate, no murmurs, rubs, or gallops
RESP: No increased WOB
GI: NT/ND, BS+
EXT: ___ increased in size, appears edematous with fluid
collection. tender to palpitation. Staples present. No discharge
or general signs of local infection. Minor dried blood present.
NEURO: Dysarthria, responding appropriately to questions. Moving
all four extremities appropriately
Pertinent Results:
ADMISSION LABS
==============
___ 09:05PM BLOOD WBC-14.4* RBC-2.74* Hgb-8.0* Hct-27.1*
MCV-99* MCH-29.2 MCHC-29.5* RDW-16.1* RDWSD-57.8* Plt ___
___ 09:05PM BLOOD ___ PTT-43.7* ___
___ 09:05PM BLOOD Glucose-258* UreaN-50* Creat-1.9* Na-145
K-5.7* Cl-114* HCO3-20* AnGap-11
___ 09:05PM BLOOD ALT-28 AST-33 AlkPhos-220* TotBili-0.2
___ 09:05PM BLOOD cTropnT-0.05* proBNP-2408*
___ 02:34PM BLOOD CK-MB-2 cTropnT-0.07*
___ 09:05PM BLOOD Albumin-2.3* Calcium-8.2* Phos-5.5*
Mg-2.5
___ 09:21PM BLOOD Creat-2.0* K-5.0
___ 03:00PM BLOOD Lactate-4.6*
___ 09:03PM BLOOD Lactate-2.5*
___ 03:48AM BLOOD Lactate-2.7*
___ 07:18PM BLOOD Lactate-0.9
___ 03:25AM BLOOD Glucose-73 Lactate-1.4
DISCHARGE LABS
==============
___ 05:50AM BLOOD WBC-8.5 RBC-2.99* Hgb-8.9* Hct-28.3*
MCV-95 MCH-29.8 MCHC-31.4* RDW-16.6* RDWSD-54.7* Plt ___
___ 05:50AM BLOOD Plt ___
___ 05:50AM BLOOD Glucose-63* UreaN-22* Creat-1.1 Na-146
K-5.0 Cl-113* HCO3-24 AnGap-9*
___ 05:50AM BLOOD Calcium-8.4 Phos-2.0* Mg-2.4
STUDIES/IMAGING
===============
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
In comparison with the study of ___, there again are low
lung volumes but no evidence of cardiomegaly, vascular
congestion, or pleural effusion. The right PICC line is been
removed.
___ Imaging US EXTREMITY LIMITED SO
IMPRESSION:
4.0 x 4.2 x 6.8 cm hypoechoic collection most likely hematoma in
the
anterolateral aspect of the right lower extremity stump.
___ Imaging DX CHEST PORTABLE PICC
IMPRESSION:
Compared to chest radiographs ___ through ___.
New left PIC line ends approximately 3.5 cm below the estimated
location of the superior cavoatrial junction.
Pulmonary vascular congestion has worsened along with moderate
cardiomegaly but there is no pulmonary edema or pleural effusion
is yet the lungs are clear.
Brief Hospital Course:
HOSPITAL COURSE
===============
___ is a ___ year-old woman with advanced dementia, CKD,
HFpEF, DMII, afib, HTN, recent R femoral embolectomy and AKA for
acute limb ischemia on ___ also found to have RML and RLL
segmental PEs on lovenox presenting with R AKA site pulsatile
bleeding and possible melena leading to hypotension concerning
for hemorrhagic shock. Admitted to MICU for hemodynamic
monitoring and possible vasopressor support.
ACUTE ISSUES
============
# Hypotension
# Surgical Site Bleed/Hematoma
# Leukocytosis
Hypotension likely ___ surgical site bleeding iso
anticoagulation, improved after control of bleeding. Weaned off
pressors and lactate improved. s/p vanc/ceftaz given no clear
source of infection. Was previous concern of GI bleed but no
documentation for evidence of melena or guaiac positive stool.
Vascular evaluated ___, not concerned for rebleeding or
expanding hematoma, not a contraindication to restarting
anticoagulation. Hgb stable, last transfusion ___.
# Goals of Care
# Anticoagulation
Per most recent discussion with family, patient again DNR/DNI;
can get blood, ABx, and lines but no procedures. A-line was
placed for accurate BP titration (BPs on cuffs were very labile
ranging from SBP ___. In the setting of a new Afib, DVTs,
PEs, arterial thrombus, possible new pancreatic malignancy, new
immobility iso of AKA, no clear history previous GI bleeds, and
a CHADVASC score of 9, we strongly believe the benefit of
anticoagulation outweighs the risks. She was trialed on heparin
ggt for 48 hours iso of recent bleed, asymptomatic, and then
switched to Apixaban 5mg BID.
# Afib with RVR
New this admission. Rates in the low 100s. Patient was not given
metoprolol while in the ICU or on the floor given concern for
hypotension and active bleeding. Anticoagulation discussed
above. Due to heart rates less than 100, she was not restarted
on her home metoprolol on discharge.
# ___ on CKD - Improved w fluids.
CHRONIC ISSUES
==============
# DM2
Continued home NPH 10U daily + ISS.
CORE MEASURES
=============
# Code Status: DNR/DNI
# Emergency Contact: ___ (Daughter/HCP) ___.
___ HCP) ___
TRANSITIONAL ISSUES:
=====================
[ ] Iso of new Afib, DVTs, PEs, arterial thrombus, possible new
pancreatic malignancy, new immobility iso of AKA, no clear
history previous GI bleeds, and a CHADVASC score of 9, she was
started on Apixaban 5mg BID
[ ] Discharge Hb: 8.9. Please recheck CBC a week from discharge
[ ] Discharge Cr: 1.1 Please recheck BMP a week from discharge
[ ] CTA Torso (___): "A heterogeneous hypodense mass is seen
in the tail of the pancreas measuring 4.1 cm x 3.9 cm. Recommend
MR for further characterization." However, based on patient's
age and medical history, likely not medically beneficial. Has
follow up with biliary surgery.
MEDICATION CHANGES:
====================
- Iso of new Afib, DVTs, PEs, arterial thrombus, possible new
pancreatic malignancy, new immobility iso of AKA, no clear
history previous GI bleeds, and a CHADVASC score of 9, she was
started on Apixaban 5mg BID
- Stopped ASA given bleeding risk with DOAC
- Stopped furosemide given euvolemic
Ms. ___ is clinically stable for discharge today. The total
time spent today on discharge planning, counseling and
coordination of care was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Atorvastatin 40 mg PO DAILY
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
5. Senna 8.6 mg PO BID:PRN constipation
6. Oyster Shell Calcium (calcium carbonate) 500 mg calcium
(1,250 mg) oral daily
7. Multivitamins 1 TAB PO DAILY
8. Furosemide 20 mg PO DAILY
9. NovoLIN N NPH U-100 Insulin (insulin NPH isoph U-100 human)
10 units subcutaneous DAILY
10. Enoxaparin Sodium 70 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Apixaban 5 mg PO BID
3. Atorvastatin 40 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. NovoLIN N NPH U-100 Insulin (insulin NPH isoph U-100 human)
10 units subcutaneous DAILY
7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
8. Oyster Shell Calcium (calcium carbonate) 500 mg calcium
(1,250 mg) oral daily
9. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- Surgical site bleeding/hematoma
- Hypotension
SECONDARY DIAGNOSIS
- Dementia
- CKD
- Hypertension
- Type II Diabetes
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for bleeding from your leg and low blood
pressure
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were in the hospital, you were brought to the ICU
for monitoring of your blood pressure and blood counts
- The vascular surgeons evaluated you and did not think it was
necessary to do any interventions.
-
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10289937-DS-23 | 10,289,937 | 22,758,031 | DS | 23 | 2118-05-17 00:00:00 | 2118-05-17 13:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
As per H&P by Dr. ___ ___:
___ y/o F with dementia, CKD, HFpEF, DMII, afib, HTN, recent R
femoral embolectomy and AKA for acute limb ischemia on ___,
acute DVT/PEs on anticoagulation, pancreatic tail mass and
recent
MICU adm for bleeding from amputation site who was sent in from
rehab with lethargy, low grade fevers and WBC > 20. On arrival
to the ED, pt was altered and not able to provide much history.
Exam was notable for stage IV malodorous sacral decub ulcer,
tender abdomen and clear lungs. Evaluation revealed acute
leukocytosis, ___, positive UA, lactate of 2, negative flu swab
and no ischemic changes on EKG. CT abd/pelv ordered but not
completed. Pt was treated with IVF, Vanc, Cefepime and was
transferred to the 12R.
On arrival to the floor, pt was alert but not answering all
questions. She was reporting pain but localizing only to RLE
s/p
AKA. Pt was grimacing during abd exam and groaning while being
rolled to clean sacral wound. I spoke with her daughter/HCP who
reports that she has not been eating for the last few days and
has seemed lethargic. Denies any knowledge of N/V/D, cough or
SOB. She did not know that her mom had been given a fentanyl
patch but was aware of ongoing pain in her RLE since AKA. We
discussed her recent visit to surgery for the pancreatic mass
and
HCP offers that she would not want her mom to get any surgery.
I
explained our current concern for infection, including the
sacral
decub ulcer and explained how difficult it is to heal these
wounds when non-ambulatory. After reviewing her multiple recent
admissions with declining functional status with ongoing pain, I
introduced the idea of palliative care and HCP was amenable to
consultation on ___.
ROS was otherwise unattainable given the patient's mental status
and limited ability to provide history"
Past Medical History:
Advanced dementia
CKD
dCHF (Lasix dependent, EF 69%)
DMII
HTN
s/p Right femoral embolectomy and AKA for acute limb ischemia
RML and RLL segmental PEs, R common femoral vein DVT and
non-occlusive R common iliac artery thrombus
Pancreatic tail mass concerning for malignancy, not pursuing
work
up given goals of care
Social History:
___
Family History:
None relevant to the admission
Physical Exam:
ADMISSION EXAM:
99.2 134/78 96 18 95 RA
GEN: Elderly female in NAD, lying in bed
HEENT: left eye lid lag, MMM with white exudate on tongue,
limited dentition
CV: Irreg/irreg soft SEM
RESP: CTAB no w/r
ABD: mildly distended with some TTP diffusely, BS present
GU: foley inplace
SAcrum: large stage IV sacral decub, malodorous with deep
tunneling. Mucus liquid stool present
EXTR: Right groin with staples in place, some skin breakdown in
creases, RLE s/p AKA with staples still in place, no
erythema/drainage or bleeding at stump. BLE edema 1+
NEURO: answering some questions with brief yes/no and thank you,
though many not answered. not consistently following commands,
able to identify hospital and her own name
DISCHARGE EXAM:
VITALS: ___ 0823 Temp: 98.2 PO BP: 113/56 HR: 80 RR: 18 O2
sat: 100% O2 delivery: RA FSBG: 181
GENERAL: Somnolent but arousable, NAD
EYES: Anicteric, PERRL, left eye lid lag
ENT: mmm
RESP: Breathing room air comfortably
ABD/GI: Soft, slightly distended
GU: Foley in place
SKIN: Stage IV sacral pressure ulcer not visualized this am
NEURO: Somnolent but arousable, answering selective questions,
gaze conjugate with ___
PSYCH: unable to assess
Pertinent Results:
LABS:
___ 05:45PM BLOOD WBC-20.7* RBC-3.12* Hgb-9.1* Hct-29.6*
MCV-95 MCH-29.2 MCHC-30.7* RDW-17.9* RDWSD-61.3* Plt ___
___ 05:45PM BLOOD Neuts-72.0* Lymphs-15.7* Monos-6.8
Eos-2.6 Baso-0.3 NRBC-0.2* Im ___ AbsNeut-14.94*
AbsLymp-3.26 AbsMono-1.40* AbsEos-0.53 AbsBaso-0.07
___ 07:35AM BLOOD WBC-16.5* RBC-2.97* Hgb-8.7* Hct-28.2*
MCV-95 MCH-29.3 MCHC-30.9* RDW-17.7* RDWSD-60.9* Plt ___
___ 01:08PM BLOOD WBC-19.3* RBC-3.03* Hgb-8.9* Hct-28.2*
MCV-93 MCH-29.4 MCHC-31.6* RDW-17.8* RDWSD-59.4* Plt ___
___ 06:02AM BLOOD WBC-18.3* RBC-2.63* Hgb-7.6* Hct-24.3*
MCV-92 MCH-28.9 MCHC-31.3* RDW-17.6* RDWSD-58.5* Plt ___
___ 05:45PM BLOOD ___ PTT-36.0 ___
___ 07:35AM BLOOD ___
___ 01:08PM BLOOD ___
___ 06:02AM BLOOD ___
___ 05:45PM BLOOD Glucose-268* UreaN-61* Creat-1.7* Na-142
K-7.8* Cl-111* HCO3-21* AnGap-10
___ 07:35AM BLOOD Glucose-113* UreaN-58* Creat-1.4* Na-147
K-4.3 Cl-114* HCO3-21* AnGap-12
___ 01:08PM BLOOD Glucose-150* UreaN-54* Creat-1.1 Na-150*
K-3.9 Cl-117* HCO3-22 AnGap-11
___ 06:02AM BLOOD Glucose-256* UreaN-51* Creat-1.2* Na-149*
K-3.6 Cl-118* HCO3-19* AnGap-12
___ 05:45PM BLOOD Albumin-2.0* Calcium-8.6 Phos-3.5 Mg-2.1
___ 07:35AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.9
___ 01:08PM BLOOD Calcium-8.9 Phos-2.9 Mg-1.9
___ 06:02AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.8
___ 05:45PM BLOOD ALT-19 AST-71* AlkPhos-151* TotBili-0.2
___ 01:08PM BLOOD ALT-13 AST-13 AlkPhos-129* TotBili-0.2
___ 06:00PM BLOOD ___ pO2-112* pCO2-34* pH-7.46*
calTCO2-25 Base XS-0
___ 06:00PM BLOOD Lactate-2.0 K-4.3
Flu A/B PCR negative
MICRO:
UCx ___: pending
BCx (___): pending
UCx (___): GRAM NEGATIVE ROD(S). >100,000 CFU/mL.
Culture workup discontinued. Further incubation showed
contaminatiowith mixed skin/genital flora. Clinical significance
of isolate(s) uncertain. Interpret with caution.
Wound swab cx (___):
WOUND CULTURE (Preliminary):
ESCHERICHIA COLI. MODERATE GROWTH.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of P.aeruginosa,
S.aureus and beta hemolytic streptococci will be reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT in this
culture.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
C.diff PCR (___): positive
IMAGING/STUDIES:
CXR (___): Low lung volumes. Mild pulmonary vascular
congestion. No definite focal consolidation
AXR (___):
IMPRESSION:
No evidence of obstruction.
Brief Hospital Course:
SUMMARY/ASSESSMENT:
___ y/o F with dementia, CKD, HFpEF, DMII, afib, HTN, recent R
femoral embolectomy and AKA for acute limb ischemia, acute
DVT/PEs on anticoagulation, pancreatic tail mass and recent MICU
adm for bleeding who presents from rehab with sepsis secondary
to UTI, diarrhea and large sacral decub wound.
A goals of care meeting was held with ___ of palliative
care and the patient's daughter/HCP, ___ recounted her
mother's rather steep decline in her health since ___. She
expressed concern about her mother's apparent lack of appetite
as well as her pain with transfers and even light touch. Her
mother told her when she was well that she would never want to
be intubated or have CPR. She would not want her life
"prolonged" like some acquaintances she had witnessed at the end
of their lives. ___ feels like she wants to hope for the best
and "leave it up to God" at this point. She understands that
this is likely the end of her mother's life. She wants her to be
comfortable. She wants to continue antibiotics, but because she
is having difficulty swallowing pills, to tailor the medications
to only those directed at keeping her comfortable. She
understands that she is a high risk for aspiration but would
like her to be able to eat and drink for comfort.
In addition to affirming that her mother would want to be
DNR/DNI ___ also felt that if she were to become sicker at
___, she would rather stay where she is and be made
comfortable rather than transfer back to the hospital.
She was made CMO, but will continue antibiotics.
# Sepsis ___ UTI, C.diff colitis, and infected sacral wound
As she is not able to swallow pills, she was started on Bactrim
oral solution (renally dosed) for a total of 10 days for
complicated UTI and infected decubitus ulcer (end date ___.
Continue PO vancomycin for 14 days after antibiotics are
completed (end date ___. For her sacral wound, given the
pain she experiences with dressing changes, will change
dressings as needed for soiled or wet dressings. Will continue
indwelling Foley to keep the pressure ulcer dry.
# Pain control
Continue fentanyl patch, liquid Tylenol, and liquid morphine.
PICC was left in place in case she has difficulty swallowing and
needs IV pain meds to stay comfortable at some point.
FEN: diet as tolerated
DVT ppx: none, CMO
ACCESS: ___
CODE: DNR/DNI/do not transfer to hospital/CMO
DISPO: back to ___ on ___
>30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Apixaban 5 mg PO BID
3. Fentanyl Patch 12 mcg/h TD Q72H
4. NovoLIN N NPH U-100 Insulin (insulin NPH isoph U-100 human)
10 units subcutaneous DAILY
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
6. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
9. Zinc Sulfate 220 mg PO DAILY
10. Ascorbic Acid ___ mg PO DAILY
Discharge Medications:
1. Collagenase Ointment 1 Appl TP DAILY
2. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___
mg PO Q4H:PRN Pain - Severe
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by mouth
every four (4) hours Refills:*0
3. Sulfameth/Trimethoprim Suspension 10 mL PO BID
4. Vancomycin Oral Liquid ___ mg PO QID
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
6. Fentanyl Patch 12 mcg/h TD Q72H
RX *fentanyl 12 mcg/hour Apply 1 patch to skin q72h Disp #*1
Patch Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Sepsis
Urinary tract infection
C.diff colitis
Stage IV sacral decubitus ulcer
Toxic metabolic encephalopathy
Acute kidney injury
Hypernatremia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for sepsis due to a urinary
tract infection, C.diff colitis, and an infected sacral wound.
Because of the infections you had your thinking was not clear.
You were treated with antibiotics. We had a meeting with you and
your family, and decided to transition to comfort-focused care.
We will continue the antibiotics by mouth, however.
Best wishes,
Your ___ Care Team
Followup Instructions:
___
|
10289945-DS-11 | 10,289,945 | 26,564,280 | DS | 11 | 2125-03-05 00:00:00 | 2125-04-03 12:59:00 |
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, ataxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: 3 minutes
Time (and date) the patient was last known well: 11:00 AM
___ clock)
___ Stroke Scale Score: 2
t-PA given: Yes at 14:00 on ___
___ Stroke Scale score was 2:
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 1
8. Sensory: 1
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion
HPI:
___ is a ___ year-old ambidextrous man who presented to
the ED after he had sudden onset of vertigo and incoordination
of
his left hand at 11 am. He states that he was at work this
morning when he was sitting at his computer and felt a sudden
dizziness. He described it as a rocking and lightheaded
sensation. He closed his eyes and felt as if he was falling to
the right. The sensation improved after 30 seconds, but when he
opened his eyes he noted blurring in his left eye. He stood up
to
walk and was able to ambulate for a few minutes until he felt
acutely worse, stating that he was falling to the right side
again. He sat down on the ground and called a friend for help.
He
was taken to the infirmary at ___ where he works and
then transferred to ___. A code stroke was called for which he
scored 2 points for left arm ataxia and a left hemisensory loss
to pinprick. Fingerstick was 104. He was given tPA at 14:00 as
symptoms were not improving and he was still within the window.
He has never had this sensation before and reports that his
symptoms are still present. Over the past few days he had a GI
illness associated with vomiting and diarrhea. He had felt some
intermittent pains radiating from his right neck to his ear.
Otherwise he has been in good health. He reports getting
adequate
hydration following his episodes of emesis.
On neuro ROS, the pt denies diplopia, dysarthria, dysphagia,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness. 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 constipation or abdominal pain. No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
hypertension
Social History:
___
Family History:
Father - MI at ___
Mother - deceased at ___ secondary to sepsis
Physical Exam:
Physical Exam on Admission:
Vitals: 97.6 80 145/84 20 100% 2L Nasal Cannula
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: diminished abduction of the left on on lateral gaze
(states had a lazy eye), gaze reversing nystagmus b/l.
V: Diminished pinprick on the left face
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: mild palatal assymetry with increased elevation on the
left.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: diminished pinprick over the left hemibody, intact
proprioception, intact graphesthesia
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: ataxic with the left arm, less pronounced in the
left leg. right side normal
-Gait: unsteady gait falling to the right side, good arm swing
and stride.
Pertinent Results:
Labs on Admission:
___ 12:00PM WBC-5.3 RBC-5.02 HGB-16.3 HCT-47.2 MCV-94
MCH-32.5* MCHC-34.6 RDW-12.1
___ 12:00PM PLT COUNT-171
___ 12:00PM ___ PTT-30.1 ___
___ 01:16PM GLUCOSE-103 NA+-136 K+-4.1 CL--92* TCO2-28
___ 01:15PM CREAT-0.9
___ 12:00PM UREA N-14
Relevant Labs:
___ 03:59AM BLOOD Triglyc-253* HDL-37 CHOL/HD-5.2
LDLcalc-106
Imaging Studies
HEAD CT: There is no evidence of hemorrhage, edema, mass, mass
effect, or
large territorial infarction. The ventricles and sulci are
normal in size and configuration. The basal cisterns appear
patent. No fracture is identified. Mucus retention cysts are
noted in both maxillary sinuses, but the remaining paranasal
sinuses, mastoid air cells and middle ear cavities are clear.
HEAD AND NECK CTA: The carotid and vertebral arteries are
patent with no
evidence of stenosis. The arteries of the circle of ___ as
well as the
main branches of the posterior and anterior circulation are
patent, without
stenosis or filling defect. There is no evidence of aneurysm
formation or any other vascular abnormality.
The visualized lung apices are clear. Mild degenerative changes
of the
cervical spine are observed.
IMPRESSION: No evidence of acute intracranial process. Normal
head and neck CTA examination.
MRI brain w/o contrast: Normal brain MR. ___ sinus
inflammatory changes.
Brief Hospital Course:
___ is a ___ year-old ambidextrous man who presented to
___ after acute onset of vertigo, left arm ataxia and gait
instability.
# Neuro: He was working at his computer when he felt a sudden
onset of vertigo. He had significant difficulty with ambulation.
His risk factors include hypertension, obesity and a recent
heavy smoking history. His exam is notable for a hemisensory
loss on the left side, a mild ataxia with his left arm and gait
instability. CT and CTA head/neck did not show evidence of
hemorrhage, large infarct, or thrombus. His NIHSS was 2, but
was within the window for tPA. The decision was made to give
thrombolysis with the stroke fellow and Dr. ___. Given the
pattern of deficit this could have represented a small
thalamocapsular infarct or even a cerebellar
infact. He was admitted to the neuro-ICU as per the post-tPA
protocol and monitored for 24 hours. MRI imaging was obtained
and showed no infarct. Risk factors were checked--LDL was 106,
HbA1c was 5.4. No aberrant rhythms were observed on telemetry.
In summary, we were not able to make a definitive diagnosis.
There was no stroke on MRI. We suspect TIA, but of unclear
etiology. On discharge, patient was started on aspirin 325mg qd
and simvastatin. He should follow up in stroke clinic and with
his PCP. He needs an outpatient echocardiogram with bubble
study.
Medications on Admission:
Hydrochlorothiazide 25mg PO qd
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Simvastatin 10 mg PO DAILY
RX *simvastatin 10 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
transient ischemic attack
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a possible stroke or transient ischemic
attack. Your MRI of the brain was normal. We do not think you
had a stroke because of this, but there is a chance you had a
very transient lack of blood flow to your brain that did not
leave any evidence on MRI scan. Your symptoms improved.
You should start taking aspirin 325 mg and simvastatin 10 mg
daily.
Please get your cholesterol checked again in 3 months.
You should stop taking HCTZ until you follow up with your PCP.
You should schedule an echocardiogram.
Followup Instructions:
___
|
10290354-DS-10 | 10,290,354 | 22,519,040 | DS | 10 | 2144-07-01 00:00:00 | 2144-07-01 20:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness, Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M hx of afib on coumadin, hep C cirrhosis, recent UTI tx w/
abx p/w weakness & decr PO intake x 4 wks, diarrhea x 1 wks.
Patient reports that he was diagnosed with a UTI ___ weeks ago,
and treated with a 10 day course of unknown antibiotics. On
follow up, he was found to still have a UTI and given a second
course of a different antibiotic. Somewhere in the middle of
this course he developed severe diarrhea "water mixed with
chunks." Because of this he reports significantly decreased PO
intake over the past ___ weeks. He reports feeling weak and
tired during this period and an approximate 12 lb weight loss in
the past month secondary to this anorexia and weakness. He then
saw his urologist again on ___ and had normal GU US. Saw PCP
___ ___ for weakness and weightloss and was found to have SBP
in ___, so sent to ED. Endorses chills. Denies fevers,
diaphoresis. Denies HA, vision changes, CP, SOB, cough, abd
pain, nausea, vomiting. Having several watery, yellow-brown,
non-bloody bowel movements per day, each time he eats. No recent
travel, sick contacts. Had steroid injectin R eye in ___.
Initial vitals in the ED: 98.0 77 126/79 18 98%RA. EKG showed
afib unchanged from prior. He was given 2L NS and admitted for
renal failure as his creatinine was noted to be 2.7 (baseline
1.5). Guaiac negative.
On the floor patient reported feeling very cold and chilly. He
reports no pain but endorses generalized weakness.
Past Medical History:
Hypertension, SBP usually 130
Atrial fibrillation on Aspirin (previously on Coumadin but
discontinued due to bleeding)
Right central retinal vein occlusion (from interferon)
Hepatitis C from blood transfusion c/b cirrhosis, portal
hypertension, and esophageal varices
Hemochromatosis managed by intermittent phlebotomy
GERD
Bleeding ulcer
Osteoporosis
Right leg claudication, with occlusive disease likely in the
right SFA
s/p left hip fracture
Diverticulosis
Anemia
Gallstone pancreatitis and ascending cholangitis s/p
sphincterotomy ___
s/p ERCP and placement of a biliary stent
Cholelithiasis s/p laparoscopic cholecystectomy ___
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission PE:
Vitals: Tc 97.4 BP 94/38 HR 82 RR 18 O2sat 100% on RA
General: Alert, no acute distress. Somewhat poor historian and
seems distracted easily, tangential. Pauses when speaking.
HEENT: Sclerae mildly icteric, dry mucous membranes
Neck: Supple, JVP flat, no NAD
Lungs: CTAB
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, NT/ND, BS+, Liver non-palpable
Ext: Cool to touch.
Neuro: Mild asterixis of the R hand noted.
Discharge PE:
Vitals: afebrile, 110/64, 70, 20, 99RA 1890/2900, BM x5 this AM
General: AAOx3 in NAD, lying in bed comfortably.
HEENT: Sclerae anicteric, MMM
Neck: Supple, JVP flat, no NAD
Lungs: CTAB
CV: Irregularly irregular, no MRG aprpeciated
Abdomen: Soft, NT/ND, BS+, no palpable masses
Ext: WWP no c/c/e, left ankle mildly larger than right but not
painful and thin, no peripheral edema
Neuro: No asterixis
Pertinent Results:
Admission Labs:
___ 01:51PM WBC-11.6* RBC-3.97* HGB-11.7* HCT-33.4*
MCV-84# MCH-29.5 MCHC-35.1* RDW-14.8
___ 01:51PM GLUCOSE-114* UREA N-89* CREAT-2.7*#
SODIUM-130* POTASSIUM-5.0 CHLORIDE-95* TOTAL CO2-19* ANION
GAP-21*
___ 01:51PM ALBUMIN-3.6 CALCIUM-9.6 PHOSPHATE-3.5
MAGNESIUM-1.6
___ 01:51PM ___ PTT-48.6* ___
___ 01:51PM ALT(SGPT)-25 AST(SGOT)-33 ALK PHOS-91 TOT
BILI-1.5
___ 04:10PM URINE MUCOUS-RARE
___ 04:10PM URINE RBC-49* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-<1 TRANS EPI-1
___ 04:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-LG
___ 04:10PM URINE COLOR-Yellow APPEAR-Hazy SP ___
Discharge Labs:
___ 07:00AM BLOOD WBC-5.9 RBC-3.35* Hgb-9.7* Hct-28.5*
MCV-85 MCH-28.9 MCHC-33.9 RDW-18.2* Plt ___
___ 12:55PM BLOOD ___
___ 12:55PM BLOOD Glucose-86 UreaN-19 Creat-1.3* Na-130*
K-3.5 Cl-100 HCO3-20* AnGap-14
___ 12:55PM BLOOD Calcium-8.3* Phos-3.6 Mg-1.4*
CXR ___: No acute cardiopulmonary process
Urine studies:
___ 04:10PM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:10PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-LG
___ 04:10PM URINE RBC-49* WBC->182* Bacteri-MANY Yeast-NONE
Epi-<1 TransE-1
___ 01:07AM URINE Hours-RANDOM Creat-30 Na-67 K-16 Cl-60
___ 01:07AM URINE Osmolal-319
___ 05:25PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:25PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 05:25PM URINE RBC-0 WBC->182* Bacteri-NONE Yeast-NONE
Epi-<1
Micro:
___ 5:25 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
___ 9:44 pm STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___. ___ ___
10:20AM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
___ 3:08 pm STOOL CONSISTENCY: LOOSE
Source: Stool RECEIVED STOOL SPECIMEN VIA WINDOW @
10:26AM.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
BLASTOCYSTIS HOMINIS. CLINICAL SIGNIFICANCE UNCERTAIN.
MANY POLYMORPHONUCLEAR LEUKOCYTES.
Brief Hospital Course:
___ M hx of afib on coumadin, hep C cirrhosis, recent UTI tx w/
abx p/w weakness & decr PO intake x 4 wks, diarrhea x 2 wks,
found to have E. coli UTI and C Diff, treated with cipro/flagyl,
switched to cipro/PO vanc, later found to have VRE UTI,
currently on PO vanc for Cdiff and linezolid for enterococcal
UTI.
#Diarrhea - Stool studies were done which showed positive C
diff. The patient continued to have multiple loose bowel
movments in the hospital. He was given IVF and took good POs.He
was originally treated with po flagyl and switched to po
vancomycin after his diarrhea was continuing for over a week. At
the time of discharge he was having about ___ per day, down
from 30/day.
-continue po vancomycin until 14 days after the linezolid
continues
#UTIs - Per outpatient urology records patient has had UTIs
treated in the past with macrobid. Based on outpatient records
and pharmacy records, patient had a proteus UTI on ___
sensitive to cipro and a E.coli UTI on ___ sensitive to cipro.
Previously he had been prescribed courses of nitrofurantoin on
___ and ___ per ___ pharmacy, though he never picked up the
second prescription. Initially we started ceftriaxone but based
on prior culture data showing proteus UTI from ___ resistant to
ceftriaxone this was switched to ciprofloxacin. His white count
trended down with treatment. He completed a 7-day course of
ciprofloxacin. Near the end of this course, a repeat urine
culture grew VRE. He was started on Linezolid. He will need to
finish a 14 day course of linezolid on discharge (___)
given that he has an indwelling foley for urinary retention.
-continue linezolid ___
___ - His creatinine on admission was 2.7 up from a baseline of
1.5 and was likely partly prerenal and this improved down to
1.1-1.3 during the admission.
/hypoperfusion and a FeNa of 4.64. He was given 3L NS and
started on continuous fluids with lactated ringers to which he
responded well and his creatinine trended downwards.
#Urinary Retention - Patient noted difficulty urinating on
___, and large midline abdominal mass palpated. Notably, he
did not complain of abdominal or suprapubic pain/pressure. A
bladder scan showed 1000cc and a Foley was placed and drained
1400cc. He was started on Flomax. He failed a voiding trial two
days later. A prostate exam during this admission did not
reveal a very enlarged prostate. It may have been a component
of inflammation with the UTI and it was decided to leave the
foley in place. He was also started on finasteride
-started on tamsulosin and finasteride
-pt discharged with indwelilng foley
-pt has follow-up with urology as an outpatient who can
determine if a foley is necessary.
#Hypertension - The patient's blood pressure on admission was
low (SBP 94) but improved with fluids and PO intake. Initially
his metoprolol and lisinopril were held but his nadalol was
continued for esophageal varices. Over the course of his
hospitalization his medications were gradually restarted as his
hydration status and BP improved.
-stopped dyazide
-decreased lisinopril from BID to QD
#Altered mental status - mental status on admission showed some
deficits in his memory and attention. Per his wife, this was his
baseline. His mental status did not acutely decompensate during
this admission. There was no need for lactulose/rifaximin or
head imaging.
#cirrhosis ___ Hep C - nadalol was continued for his grade 2
varices during hospitalization. There were no issues. His mental
status did not acutely decompensate during this admission. There
was no need for lactulose/rifaximin.
#Afib with supertherapeutic INR: patient was admitted with INR
6.2 which rose to a max 8.2 on HD2. Likley in setting of
decreased PO intake and recent antibiotic use. No signs of
bleeding were noted. Rate was well controlled, not tachycardic.
Coumadin was held for the beginning of hospital stay. eventually
his INR came down to the therapeutic range and his coumadin was
restarted at his home dose. His INR on discharge was 2.4.
-he was discharged on 0.5mg of warfarin and will continue this
as an outpatient and needs to have an INR check on ___, a
message was left at the ___ clinic
regarding this
#weakness - thought secondary to UTI, decreased POs and
diarrhea, as well as hypotension resulting from these factors. A
nutrition consult was called which provided recommendations for
dietary supplementation. Physical therapy worked with the
patient. By the time of discharge patient felt more energetic
and stronger. He will likely continue to recover from these
symptoms as his intake improves and his nutritional status
improves.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Warfarin 1 mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Lisinopril 20 mg PO BID
4. Nadolol 20 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Triamterene-Hydrochlorothiazide 1 CAP PO EVERY OTHER DAY
7. Ursodiol 300 mg PO TID
8. Vitamin D 400 UNIT PO DAILY
9. Calcium Carbonate 500 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. coenzyme Q10 *NF* 100 mg Oral QD
12. Docusate Sodium 100 mg PO BID
13. Magnesium Oxide 500 mg PO BID
14. saw ___ *NF* 160 mg Oral BID
15. Vitamin B Complex 1 CAP PO DAILY
16. Vitamin E 400 UNIT PO DAILY
Discharge Medications:
1. Calcium Carbonate 500 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Nadolol 20 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Ursodiol 300 mg PO TID
6. Vitamin B Complex 1 CAP PO DAILY
7. Vitamin D 400 UNIT PO DAILY
8. Vitamin E 400 UNIT PO DAILY
9. coenzyme Q10 *NF* 100 mg Oral QD
10. Magnesium Oxide 500 mg PO BID
11. saw ___ *NF* 160 mg Oral BID
12. Amlodipine 5 mg PO DAILY
13. Finasteride 5 mg PO DAILY
RX *finasteride 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
14. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
15. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day
Disp #*84 Capsule Refills:*0
16. Lisinopril 20 mg PO DAILY
17. Warfarin 0.5 mg PO DAILY16
18. bromfenac *NF* 0.09 % ___ DAILY
19. Timolol Maleate 0.5% 1 DROP LEFT EYE DAILY
20. Linezolid ___ mg PO Q12H
RX *linezolid [Zyvox] 600 mg 1 tablet(s) by mouth twice a day
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
E. coli UTI
Enterococcus UTI
C. Difficle Colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of ___ at the ___!
___ were admitted because of weakness and diarrhea. In the
hospital we did tests which determined that ___ had a urinary
tract infection (UTI) and that your diarrhea was caused by
Clostridium Difficile Colitis (C. Diff). ___ have been treated
for the urine infection but still have 7 days of treatment left.
After ___ finish your last day of your urine infection
antibiotic ___ will take the antibiotic for ___ diarreha for
another 14 days.
We also found that ___ had problems emptying your bladder and
required having a urine catheter placed. When we tried to take
it out your bladder still was not able to fully empty. ___ were
started on two medications to help with this and will keep the
urine catheter in place and stay on these medications until ___
follow-up with urology and they can reassess your bladder's
ability to empty.
Please see below regarding follow-up appointments
Followup Instructions:
___
|
10290354-DS-11 | 10,290,354 | 27,206,728 | DS | 11 | 2144-08-04 00:00:00 | 2144-08-04 12:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Oxycodone
Attending: ___.
Chief Complaint:
hematocrit drop, recurrent UTI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yea old man with history of afib on ocumadin,
hep C cirrhosis, HTN, diverticulosis, who was admitted from
___ for c-diff and E-coli and VRE UTI who now presents
with ___ point drop in his hematocrit. Patient was discahrged
on PO vancomycin for treatment of c-diff and Linezolid
(___) for treatment VRE UTI.
.
Patient reports that since being discharged he has been feeeling
extremely fatigued. He saw his PCP yesterday who checked CBC
which demonstrated significnat drop in his hematocit to 19. INR
was 1.4. Patient reports that his diarrhea has improved and
denies any melana, black tarry stools, hemathochezia or
hematamesis. He denies any chest pain. Reports feeling shorrt
of breath with activity. No lightheadedness.
.
Notable labs in the ED included platelets of 76 down from 208 on
prior discgharge, Na 132, creatinine 1.4 (basleine ~1.1-1.2),
and bicarb 20. Guaiac negative. UA was showed large leuk, small
bld, >182 WBC and 1 epi. CT Abd/Pelvis was negative for
retroperitoneal bleed but suggested colovesicular fistula.
Past Medical History:
Hypertension
Atrial fibrillation
Right central retinal vein occlusion (from interferon)
Hepatitis C from blood transfusion c/b cirrhosis, portal
hypertension, and esophageal varices
Hemochromatosis managed by intermittent phlebotomy
GERD
Hx of bleeding ulcer
Osteoporosis
Right leg claudication, with occlusive disease likely in the
right SFA
s/p left hip fracture
Diverticulosis
Anemia
Gallstone pancreatitis and ascending cholangitis s/p
sphincterotomy ___
s/p ERCP and placement of a biliary stent
Cholelithiasis s/p laparoscopic cholecystectomy ___
TIA in ___
Social History:
___
Family History:
No family history of colon cancer otherwise non-contributory
Physical Exam:
Admission Physical:
VS - Temp 97.6F, BP 126/50, HR 60, R 18, O2-sat 100% RA
GENERAL - well-appearing elderly man in NAD, comfortable,
appropriate
HEENT - pale conjunctivae, NC/AT, PERRLA, EOMI, sclerae
anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no cervical LAD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - irregularly irregular, 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
NEURO - awake, A&Ox3, CNs II-XII grossly intact, motor and
sensation grossly intact
.
Discharged Physical:
Pertinent Results:
Admission/Pertinent Labs:
___ 09:27PM BLOOD WBC-7.9 RBC-2.67* Hgb-8.0* Hct-22.2*
MCV-83 MCH-30.0 MCHC-36.1* RDW-17.0* Plt Ct-89*#
___ 05:15PM BLOOD WBC-8.3 RBC-3.13*# Hgb-9.1*# Hct-25.6*#
MCV-82 MCH-29.0 MCHC-35.4* RDW-16.3* Plt Ct-78*
___ 06:20AM BLOOD WBC-6.7 RBC-3.03* Hgb-9.0* Hct-26.4*
MCV-87 MCH-29.6 MCHC-34.0 RDW-18.3* Plt ___
___ 05:15PM BLOOD ___ PTT-32.9 ___
___ 07:58AM BLOOD ___ PTT-34.5 ___
___ 07:15AM BLOOD ___ PTT-34.0 ___
___ 12:10AM BLOOD Glucose-91 UreaN-32* Creat-1.4* Na-132*
K-3.6 Cl-99 HCO3-20* AnGap-17
___ 07:50AM BLOOD Glucose-88 UreaN-18 Creat-1.2 Na-135
K-3.6 Cl-105 HCO3-17* AnGap-17
___ 12:10AM BLOOD LD(LDH)-136 CK(CPK)-34* AlkPhos-59
TotBili-0.6
___ 05:15PM BLOOD ALT-42* AST-26 LD(LDH)-153 AlkPhos-58
TotBili-2.0* DirBili-0.6* IndBili-1.4
___ 08:20AM BLOOD TotBili-0.6 DirBili-0.2 IndBili-0.4
___ 12:10AM BLOOD UricAcd-5.9 Iron-23*
___ 08:15AM BLOOD Calcium-8.8 Phos-4.7*# Mg-2.2
___ 12:10AM BLOOD calTIBC-230* ___ Ferritn-957*
TRF-177*
___ 05:15PM BLOOD Hapto-124
___:25AM BLOOD Lactate-0.8
___ 12:10AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 12:10AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 12:10AM URINE RBC-133* WBC->182* Bacteri-MANY
Yeast-NONE Epi-0
___ 07:30AM BLOOD Glucose-83 UreaN-14 Creat-1.2 Na-132*
K-5.0 Cl-106 HCO3-11* AnGap-20
___ 07:35AM BLOOD UreaN-16 Creat-1.2 Na-135 K-3.9 Cl-108
HCO3-12* AnGap-19
___ 10:45AM BLOOD Na-137 K-3.4 Cl-110* HCO3-17* AnGap-13
___ 07:05AM BLOOD Glucose-94 UreaN-17 Creat-1.2 Na-136
K-3.9 Cl-109* HCO3-16* AnGap-15
___ 11:12AM BLOOD Type-ART pO2-113* pCO2-24* pH-7.43
calTCO2-16* Base XS--5 Intubat-NOT INTUBA
.
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ENTEROBACTER CLOACAE COMPLEX. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| ENTEROBACTER CLOACAE
COMPLEX
| |
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S 256 R
PIPERACILLIN/TAZO----- 16 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
.
Blood Culture: No growth
.
EKG: ___
Atrial fibrillation. Right bundle-branch block. Indeterminate
frontal QRS axis. Compared to the previous tracing of ___
limb lead voltages have increased. Atrial fibrillation persists.
The other findings are similar.
.
CXR: ___: IMPRESSION: No acute cardiopulmonary process.
.
CT Abdomen/Pelvis w/o Contrast: ___
IMPRESSION:
1. No retroperitoneal hematoma or other cause to explain
hematocrit drop.
2. Bladder thickening and intra-luminal air raises concern for
colovesical fistula (however intraluminal air can be secondary
to recent instrumentation). A 2.6cm air and fluid collection at
the right lateral apsect of the bladder dome with loss of clear
fat plane between this and the adjacent colon. It's exact
location is unclertain- it may be submucosal/intramural within
the bladder wall vs adjacent to it with secondary bladder wall
thickening. Sequela of diverticular disease with fistula
formation is possible. Consider additional imaging such as
repeat exam with IV contrast and oral/rectal contrast to further
assess.
3. Diverticulosis without evidence of diverticulitis.
.
MR ___ w and w/o Contrast: ___: IMPRESSION:
1. Intramural abscess within the right superolateral wall of
the urinary bladder is in close proximity to the sigmoid colon
with suggestion of a communicating track between the intramural
abscess and sigmoid colon. Although evaluation is limited due to
absence of rectal contrast, there does appear to be enteric
material within the intramural abscess.
2. Peripherally rim-enhancing fluid collection is located below
the level of the prostate and intimately posterior to the
urethra. Differential considerations include urethral
diverticulum, although rare in a male patient, large Cowper's
gland duct cyst, complex periurethral cyst, periurethral corpus
spongiosum cyst; superinposed infection (given the rim
enhancement)can not be excluded.
3. Ill-defined enhancement of the right peripheral zone of the
prostate gland should be correlated with digital rectal exam and
PSA values, as prostate malignancy cannot be excluded. Findings
of benign prostatic hyperplasia. Asymmetry of the seminal
vesicles, smaller on the right.
.
Investigation of Transfution Reaction:
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. ___ experienced
a rise in bilirubin approximately 7 hours after receiving two
units of packed red blood cells on ___. He had no symptoms
concerning for a hemolytic reaction, such as fever, chills, or
flank pain. His vital signs were unremarkable, and other
laboratory values (including LDH and haptoglobin) were also
unremarkable. Blood bank workup revealed no evidence of
hemolysis.
Transient, non-hemolysis related, mild elevations in serum
bilirubin levels can be seen after red cell transfusions. As
such, the rise in bilirubin may be due to this effect and levels
typically return to baseline after 24 hours. Other
non-transfusion related causes should also be considered. No
change in standard transfusion practices is required for this
patient at this time.
.
Discharged Labs:
Pathology Examination
Name ___ Age Sex Pathology # ___ MRN#
___ ___ ___ Male ___
Report to: ___. ___
___ by: ___. ___
SPECIMEN SUBMITTED: sigmoid colon.
Procedure date Tissue received Report Date Diagnosed
by
___ ___. ___
Previous biopsies: ___ HERNIA SAC.
___ GASTRIC BXS.
___ GALLBLADDER, LIVER BIOPSY.
___ Consult slides referred to Dr. ___.
(and more)
DIAGNOSIS:
Sigmoid colon, sigmoid colectomy (A-F):
1. Diverticular disease with organizing mural abscess formation
and associated focal serositis.
2. Regional lymph nodes with no diagnostic abnormalities
recognized.
3. Resection margins affected by diverticular disease without
accompanying inflammatory changes.
___ 07:40AM BLOOD WBC-10.0 RBC-3.05* Hgb-9.2* Hct-27.5*
MCV-90 MCH-30.1 MCHC-33.3 RDW-20.2* Plt ___
___ 01:40AM BLOOD WBC-8.3 RBC-2.91* Hgb-8.9* Hct-26.4*
MCV-91 MCH-30.4 MCHC-33.6 RDW-20.5* Plt ___
___ 01:35PM BLOOD WBC-8.0 RBC-3.12* Hgb-9.8* Hct-28.4*
MCV-91 MCH-31.5 MCHC-34.7 RDW-20.5* Plt ___
___ 08:10AM BLOOD WBC-8.9 RBC-3.34* Hgb-9.8* Hct-29.4*
MCV-88 MCH-29.2 MCHC-33.2 RDW-18.3* Plt ___
___ 07:15AM BLOOD WBC-7.8 RBC-3.17* Hgb-9.3* Hct-27.1*
MCV-85 MCH-29.3 MCHC-34.3 RDW-18.0* Plt ___
___ 06:20AM BLOOD WBC-6.7 RBC-3.03* Hgb-9.0* Hct-26.4*
MCV-87 MCH-29.6 MCHC-34.0 RDW-18.3* Plt ___
___ 07:58AM BLOOD WBC-7.4 RBC-3.16* Hgb-9.3* Hct-27.3*
MCV-86 MCH-29.4 MCHC-34.1 RDW-18.1* Plt ___
___ 07:50AM BLOOD WBC-8.3 RBC-3.02* Hgb-8.7* Hct-25.3*
MCV-84 MCH-28.9 MCHC-34.5 RDW-18.0* Plt ___
___ 08:20AM BLOOD WBC-9.9 RBC-3.06* Hgb-9.1* Hct-26.4*
MCV-86 MCH-29.6 MCHC-34.3 RDW-17.0* Plt ___
___ 08:15AM BLOOD WBC-10.3 RBC-3.15* Hgb-9.2* Hct-26.0*
MCV-83 MCH-29.3 MCHC-35.5* RDW-16.2* Plt ___
___ 05:15PM BLOOD WBC-8.3 RBC-3.13*# Hgb-9.1*# Hct-25.6*#
MCV-82 MCH-29.0 MCHC-35.4* RDW-16.3* Plt Ct-78*
___ 12:10AM BLOOD WBC-6.6 RBC-2.31* Hgb-6.9* Hct-19.1*
MCV-83 MCH-29.9 MCHC-36.3* RDW-17.0* Plt Ct-76*
___ 07:45AM BLOOD ___ PTT-43.6* ___
___ 06:30AM BLOOD ___ PTT-41.0* ___
___ 02:00AM BLOOD ___ PTT-50.0* ___
___ 01:35PM BLOOD ___ PTT-46.6* ___
___ 07:15AM BLOOD ___ PTT-34.0 ___
___ 06:20AM BLOOD ___ PTT-34.6 ___
___ 07:58AM BLOOD ___ PTT-34.5 ___
___ 06:50AM BLOOD Glucose-80 UreaN-12 Creat-1.1 Na-134
K-3.9 Cl-107 HCO3-20* AnGap-11
___ 06:40AM BLOOD Glucose-105* UreaN-10 Creat-1.1 Na-134
K-4.6 Cl-107 HCO3-20* AnGap-12
___ 06:30AM BLOOD Glucose-121* UreaN-12 Creat-1.2 Na-132*
K-4.2 Cl-106 HCO3-17* AnGap-13
___ 07:40AM BLOOD Glucose-97 UreaN-13 Creat-1.2 Na-137
K-4.5 Cl-111* HCO3-20* AnGap-11
___ 01:40AM BLOOD Glucose-106* UreaN-12 Creat-1.0 Na-140
K-4.3 Cl-113* HCO3-20* AnGap-11
___ 05:22PM BLOOD Glucose-122* UreaN-12 Creat-1.1 Na-138
K-3.8 Cl-110* HCO3-19* AnGap-13
___ 07:30AM BLOOD Glucose-122* UreaN-15 Creat-1.1 Na-138
K-3.5 Cl-109* HCO3-17* AnGap-16
___ 06:50AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.8
___ 06:40AM BLOOD Albumin-2.8* Calcium-8.4 Phos-2.1* Mg-1.9
___ 06:30AM BLOOD Calcium-8.4 Phos-2.3* Mg-2.3
___ 07:40AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.7
___ 01:40AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.8
___ 05:22PM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1
___ 08:32AM BLOOD ___ pO2-160* pCO2-36 pH-7.33*
calTCO2-20* Base XS--6
CHEST (PORTABLE AP) Study Date of ___ 1:25 AM
REASON FOR EXAMINATION: New onset of hypothermia.
Portable AP radiograph of the chest was reviewed in comparison
to ___.
Heart size and mediastinum are unremarkable. Epidural catheter
is in place. No pneumothorax is seen. Lungs are essentially
clear. There is no pneumothorax.
Brief Hospital Course:
___ year old man with history of atrial fibrillation on coumadin,
hx of TIA (in ___, hep C cirrhosis, HTN, diverticulosis, who
presented with ___ point drop in his hematocrit as well as
recurrent UTI.
.
# Symptomatic Anemia: Patient presented with extreme fatigue and
found to have acute drop in his hematocrit from 28.3 to 19.1 in
10 days. He had been on two weeks of linezolid therapy which
most likely resulted in acute myelosuppression as evidenced by
his very low retic count of 0.3% and thrombocytopenia. He may
also have had some slow GI blood loss few days prior to
admission from his c-diff infection. However during this
admission he did not have any melena, hematochezia or
hematemesis to suggest GI blood loss. Additionally he was guaiac
negative with no signs of intraabdominal bleeding per CT
abdomen. There was no evidence of hemolysis on labs. He was
transfused with two units of blood with appropriate rise in his
hematocrit. There was some concern about elevated t-bili after
blood transfusion. However since patient did not have any
symptoms during his transfusion the rise in t-bili was
considered to be transient event without any evidence of
hemolysis per blood bank investigation. His hematocrit remained
stable and slightly increased during this hospital course and
his retic count was noted to increase to 6.3 suggesting recovery
of bone marrow.
.
# Thrombocytopenia: Patient PLT had dropped from 208 to 89 on
admission which was attributed to Linezolid. His platelets
continued to rise during the course of this hospitalization. He
did not have any bleeding episodes.
.
# Recurrent UTIs- He was most recently treated w/ 7 day with 14
day course of linezolid (___) for VRE UTI. On admission
he was once again found to have UTI. He had an MRI to evaluate
the exact cause of patient's recurrent UTIs which revealed
intraluminal bladder abscess with fistula tract to sigmoid
colon. Urology and colorectal surgery were consulted who wanted
patient to be far out from his c-diff infection and give ___
time to "cool" his infection with antibiotics before performing
surgery. Urine cx once again grew E-coli and klebsiella which
were both sensitive to cipro. Patient remained afebrile without
leukocytosis or signs of sepsis. ID was consulted who
recommended cipro and flagyl until his surgery. He has surgery
on ___ -------
.
# Perioperative Risk Assessment for scheduled surgery on ___:
Per the Revised ___ cardiac risk index (___), the 6
independent predictors of perioperative cardiac complications
are: 1) High-risk surgery, 2) History of ischemic heart disease,
3) History of Heart Failure, 4) Stroke, 5) preoperative
treatment with insulin (eg IDDM), 6) Creatinine >2.0 mg/dL
.
Mr. ___ does not have any active cardiac conditions. He
denies any prior history of MI and does not have pathologic q
waves on EKG. He has atrial fibrillation with well controlled
rate. Prior TTE in ___ does not show severe valvular disease
and he has never had a congestive heart failure. In terms of
clinical risk factors, he had TIA in ___. He has chronic renal
insufficiency with GFR<60. In term of functional status patient
meets <4mets and his limited by mobility; no chest pain or
shortness of breath. His colovesicular fistula repair surgery
falls in the intermediate risk surgery. Therefore based on
___ risk stratification the patient has 2 risk factors, and
hence has a 2.4% risk of perioperative cardiac complications.
At this time there is no indication for any further cardiac
testing since it would not change management.
.
However it terms of operative mortality, patient has history of
hepatitic C cirrhosis. Although patient cirrhosis is well
compensated (Child A) he has high risk of operative mortality
which per Liver team is estimated around 10%. Please refer to
OMR note from Liver for overall risk stratification based on his
hep C cirrhosis. He should be continued on his home nadolol.
.
# Atrial Fibrillation: Rate was well controlled on nadolol.
CHADS2 score of 4. His coumadin was held in anticipation of
surgery on ___. He was started on lovenox as a bridge.
---------
.
# ___ on CKD: Patient Cr on admission was 1.4 which returned to
baseline level of 1.1 after blood transfusion and fluid
resuscitation suggesting pre-renal etiology.
.
# Diarrhea - Diagnosed w/ C. diff during prior hospitalization.
He was continued on po vancomycin. Patient reported having on
average 4 bowel movements per day much improved form his c-diff
episode. Per ID recs, he should continue po vancomycin 7 days
after end of current antibiotics treatment.
.
# H/o Urinary Retention - Patient noted to have difficulty
urinating during last admission and was started on Flomax and
finasteride. Patient did not have any difficulty with urination
during this admission. He was continued tamsulosin and
finasteride for BPH. His MRI showed some Ill-defined
enhancement of the right peripheral zone of the prostate gland.
Urology was consulted who recommended outpatient urology follow
and evaluation. He will follow up with urology for further
management.
.
# Hypertension - Blood pressure well controlled during this
admission. He was continued on lisinopril, amlodipine and
nadolol.
.
# Cirrhosis ___ Hep C - Complicated by grade 2 varices, but has
been stable recently. No evidence of GI bleed given guaiac
negative stools. No evidence of encephalopathy on exam. Seen by
liver team for perioperative risk management given his
cirrhosis. Patient without decompensated liver disease and
estimated operative mortality of 10% per liver team. He was
continued on nadolol.
.
# CODE: Full (confirmed w/ pt)
.
Transitions of care:
- ? Coumadin, ? Lovenox, ? rechek INR on----
- Patient will continue PO vancomycin 7 days after end of
current antibiotics treatment with cipro and flagyl.
- Patient had ill defined enahancement in his prostate gland and
will follow up with urology for further management.
COLORECTAL SURGERY DISCHARGE SUMMARY
Mr. ___ was taken to the operating room on ___ for open
sigmoid colectomy and end colostomy for definitive management of
his colovesicular fistula. Despite being a high risk patient, he
tolerated the procedure well and was extubated to the PACU, and
later transferred to the floor. He was made NPO overnight and
his diet was gradually advanced to sips and clears on POD1-2 and
eventually to a regular diet when his ostomy opened up with
stool and gas on POD4. His antibiotics were discontinued on
POD2. He had low blood pressure for most of his stay (no lower
than high ___ systolic) and received albumin and crystalloid
boluses as needed. His blood pressure medications were held
throughout his stay. He received an epidural for pain control
which was discontinued on POD3. Because he has a history of
agitation and low tolerance for narcotics, he initially received
only ibuprofen and tylenol for pain control. He had some issues
with pain control on POD4 and 5 so tramadol was added at night
time with good relief. His foley catheter remained until POD5
and he voided spontaneously without difficulty. A urine was
checked on POD4 which was high in white cells but did not grow
any bacteria. He was briefly started on cipro and flagyl which
were discontinued on POD5 because he was not symptomatic and
urine culture was negative. 1mg Coumadin was re-started on POD5
(___), he is continuing on lovenox as a bridge until
therapeutic.
On POD6 he had adequate pain relief, was voiding spontaneously,
with adequate ostomy output, hemodynamically stable, and
afebrile. He was deemed safe for discharge to rehab with
instructions to follow up with Dr. ___ in clinic in ___
days. The JP drain will stay in place until the patient's
follow-up appointment 7 days after surgery.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Nadolol 20 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Ursodiol 300 mg PO TID
6. Vitamin B Complex 1 CAP PO DAILY
7. Vitamin D 400 UNIT PO DAILY
8. Vitamin E 400 UNIT PO DAILY
9. coenzyme Q10 *NF* 100 mg Oral QD
10. Magnesium Oxide 500 mg PO BID
11. saw ___ *NF* 160 mg Oral BID
12. Amlodipine 5 mg PO DAILY
13. Finasteride 5 mg PO DAILY
14. Tamsulosin 0.4 mg PO HS
15. Vancomycin Oral Liquid ___ mg PO Q6H
16. Lisinopril 20 mg PO DAILY
17. Warfarin 0.5 mg PO DAILY16
18. bromfenac *NF* 0.09 % ___ DAILY
19. Timolol Maleate 0.5% 1 DROP LEFT EYE DAILY
20. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. bromfenac *NF* 0.09 % ___ DAILY
3. Finasteride 5 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Nadolol 20 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Tamsulosin 0.4 mg PO HS
8. Timolol Maleate 0.5% 1 DROP LEFT EYE DAILY
9. Ursodiol 300 mg PO TID
10. Vancomycin Oral Liquid ___ mg PO Q6H
11. Vitamin B Complex 1 CAP PO DAILY
12. Vitamin D 400 UNIT PO DAILY
13. Vitamin E 400 UNIT PO DAILY
14. coenzyme Q10 *NF* 100 mg Oral QD
15. Magnesium Oxide 500 mg PO BID
16. saw ___ *NF* 160 mg Oral BID
17. Lisinopril 20 mg PO DAILY
18. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID
19. Ciprofloxacin HCl 500 mg PO Q12H
20. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
21. Calcium Carbonate 500 mg PO DAILY
22. Enoxaparin Sodium 60 mg SC BID
23. Acetaminophen 500 mg PO Q6H
24. Ibuprofen 600 mg PO Q6H
25. TraMADOL (Ultram) 50 mg PO QHS
26. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal congestion
27. Miconazole Powder 2% 1 Appl TP BID
28. Sodium Bicarbonate 650 mg PO BID
29. Warfarin 0.5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Colovesicular Fistula complicated by recurrent UTIs
2. Symptomatic Anemia secondary to Linezolid
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 ___ during your
hospitalization at ___. ___ were admitted because of feeling
fatigued and had very low blood counts which likely resulted
from Linezolid antibiotic treatment ___ were on for your urinary
tract infection. ___ were given two units of blood transfusion
with significant improvement in your symptoms and energy level.
During this admission ___ were found to have another recurrent
urinary tract infection. On further imaging evaluation, ___
were found to have an abscess collection (infection) in your
bladder with a fistula (connection between your large bowel and
bladder). After consultation with colorectal surgery, urology
and infectious disease, decision was made to treat the abscess
for couple of weeks with antibiotics before performing surgery
which is now scheduled for Wednessday ___. Your coumdain has
been held in anticipation of your surgery and ___ were started
on lovenox.
___ were admitted to the colorectal surgery team after a Sigmoid
Colectomy and colostomy for surgical management of your
colovesicular fistula (abnormal connection between your colon
and bladder). ___ have recovered from this procedure well and
___ are now ready to go to rehab to regain your strength before
returning home. Samples from your colon were taken and this
tissue has been sent to the pathology department for analysis.
___ will receive these pathology results at your follow-up
appointment. If there is an urgent need for the surgeon to
contact ___ regarding these results they will contact ___ before
this time. ___ have tolerated a regular diet, passing gas and
your pain is controlled with pain medications by mouth. ___ may
go to a rehab facility to finish your recovery.
___ have a new colostomy. It is important to monitor the output
from this stoma. It is expected that the stool from this ostomy
will be solid and formed like regular stool. ___ should have ___
bowel movements daily. If ___ notice that ___ have not had any
stool from your stoma in ___ days, please call the office. ___
may take an over the counter stool softener such as Colace if
___ find that ___ are becoming constipated from narcotic pain
medications. Please watch the appearance of the stoma, it should
be beefy red/pink, if ___ notice that the stoma is turning
darker blue or purple, or dark red please call the office for
advice. The stoma (intestine that protrudes outside of your
abdomen) should be beefy red or pink, it may ooze small amounts
of blood at times when touched and this should subside with
time. The skin around the ostomy site should be kept clean and
intact. Monitor the skin around the stoma for bulging or signs
of infection listed above. Please care for the ostomy as ___
have been instructed by the wound/ostomy nurses. ___ will be
able to make an appointment with the ostomy nurse in the clinic
7 days after discharge. ___ will have a nurse at rehab helping
to monitor your ostomy, and may have a visiting nurse at home
for the next few weeks after rehab helping to monitor your
ostomy until ___ are comfortable caring for it on your own.
If ___ have any of the following symptoms please call the office
for advice or go to the emergency room if severe: increasing
abdominal distension, increasing abdominal pain, nausea,
vomiting, inability to tolerate food or liquids, prolonged loose
stool, or constipation.
___ have a long vertical incision on your abdomen that is closed
with absorbable sutures (do not need to be removed) and a
special glue, which will eventually wear away on its own. This
incision can be left open to air or covered with a dry sterile
gauze dressing if your skin becomes irritated from clothing.
Please monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if ___ develop a
fever. Please call the office if ___ develop these symptoms or
go to the emergency room if the symptoms are severe. ___ may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
___ also have a drain in your abdomen which is used to drain
out fluid from your belly. This will stay in until your
follow-up appointment with Dr. ___.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. ___ may gradually increase
your activity as tolerated but clear heavy exercise with Dr.
___.
___ will be prescribed a small amount of the pain medication
Tramadol for nighttime. Please take this medication exactly as
prescribed. ___ may take Tylenol and Ibuprofen as recommended
for pain. Because of your history of cirrhosis please do not
take more than 2500mg of Tylenol daily. Do not drink alcohol
while taking narcotic pain medication or Tylenol. Please do not
drive a car while taking narcotic pain medication.
OTHER MEDICATIONS
Blood thinners ___ are currently receiving lovenox injections
for your atrial fibrillation because ___ couldnt take your
Coumadin immediately before and after surgery. We re-started
your Coumadin yesterday, and ___ may resume taking it at your
normal home dose. ___ should follow up at the rehab and with
your primary care physician for further management of these
medications and to decide when to take ___ off of the Lovenox.
Blood pressure medications We did not give ___ your lisinopril
or amlodipine after your operation because your blood pressure
was running on the low side. ___ should follow up with your
primary care physician or the doctor at the rehab to determine
when is the best time to resume these medications.
Thank ___ for allowing us to participate in your care! Our hope
is that ___ will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
___
|
10290354-DS-12 | 10,290,354 | 20,460,540 | DS | 12 | 2144-09-14 00:00:00 | 2144-09-15 10:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Oxycodone / narcotics
Attending: ___.
Chief Complaint:
scrotal swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o M w/ afib on warfarin, HCV cirrhosis, diverticulitis c/b
colovesicular fistula s/p repair and colostomy, and multiple VRE
UTIs, now presenting from ___ w/scrotal pain and swelling
x3-4 days. Noted to have significant swelling. Was started on
Vancomycin for concern of scrotal abscess and sent here for
urology eval.
In the ___, initial vitals 98.3 80 127/74 20 100% ra.
Pt currently appears well. Denies fevers, chills, dysuria,
hematuria, difficulty with urination, abdominal pain, nausea, or
vomiting. No penile pain or swelling. Patient's wife reports the
scrotum "double in size in ___ hours." Of note, patient reports
mechanical fall onto L side 2 weeks ago. Persistent left sided
rib pain with deep breaths. No difficulty breathing or taking
deep breaths.
Labs notable for WBC 14 with 75% PMNs, lactate 1.2, creatinine
1.2, anemia to 30 (baseline 26), and INR 3.3 (baseline 1.2).
The pt underwent a scrotal ultrasound which showed: Hyperemia of
the bilateral epidydimi and testes - c/w orchitis/epidydimitis.
Thickening, edema, and hyperemia of the scrotal skin. No
testicular torsion.
In addition to previously administered vancomycin, he received
ceftriaxone + clindamycin in the ___ for infection and ketorolac
for pain. Urology was consulted in the ___, but no note was
present in OMR, no comments were present in ___ signout. Pt was
admitted to medicine for further management.
Of note, Pt had a complicated recent admission for 3 wks in ___, when he had another UTI and was found to have an
intraluminal bladder abscess with fistula tract to sigmoid
colon, presumed to be due to his sigmoid diverticulitis. Pt had
a sigmoid colectomy, takedown of colovesicular fistula, and end
colostomy on ___. Pt was discharged and was apparently doing
well, but reported testicular pain while sitting at ___ visit
w/ colorectal NP, who suggested scortal support and elevation.
Pt's reports having left scrotal swelling over the past ___
days. He denies fevers or chills. Per ___ note, he was
seen by Dr. ___ urologist, 4 days ago and started
on fluconazole, per wife for yeast infection possibly in urine.
On arrival to the floor,
VS: 97.4, 128/80, 88, 16, 99% RA
Pt reports that he feels much better after getting pain
medications. Denies fever, cough, SOB. No nausea, no vomiting.
No dysuria, hematuria. Reports that he has no problems
urinating. States that his scrotum has been getting more and
more swollen. Reports feeling very cold for the last several
months. Wants to move to ___. Pt's wife states that he was
seen by urology in ___, was told that he could probably leave
tomorrow.
REVIEW OF SYSTEMS:
(+) testicular swelling and pain
(-) 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:
Hypertension
Atrial fibrillation on warfarin
Right central retinal vein occlusion (from interferon)
Hepatitis C from blood transfusion c/b cirrhosis, portal
hypertension, and esophageal varices
Hemochromatosis managed by intermittent phlebotomy
GERD
Hx of bleeding ulcer
Osteoporosis
Right leg claudication, with occlusive disease likely in the
right SFA
s/p left hip fracture
Diverticulosis
Anemia
Gallstone pancreatitis and ascending cholangitis s/p
sphincterotomy ___
s/p ERCP and placement of a biliary stent
Cholelithiasis s/p laparoscopic cholecystectomy ___
TIA in ___
Social History:
___
Family History:
father had MI in ___
Physical Exam:
PHYSICAL EXAM:
97.4, 128/80, 88, 16, 99% RA
GENERAL - thin 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, RLQ colostomy bag in place w/ brown
semi-formed stool.
Pelvic - scrotum uniformly edematous, approx 10 by 5 cm. Mild
erythema, no warmth. Mild tenderness to palpation. Several small
scabs on glans of penis. Pt states he wipes himself off with
tissues frequently. No inguinal lymphadenopathy. No other
rashes.
EXTREMITIES - WWP, very emaciated, no edema
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact except blind in
R eye, muscle strength ___ throughout, sensation grossly intact
throughout
Pertinent Results:
ADMISSION LABS
___ 10:47PM URINE HOURS-RANDOM UREA N-525 CREAT-66
SODIUM-37 POTASSIUM-50 CHLORIDE-56
___ 10:47PM URINE OSMOLAL-386
___ 10:47PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-LG
___ 10:47PM URINE RBC-1 WBC-131* BACTERIA-FEW YEAST-NONE
EPI-0
___ 04:31PM COMMENTS-GREEN TOP
___ 04:31PM LACTATE-1.2
___ 04:20PM GLUCOSE-85 UREA N-38* CREAT-1.2 SODIUM-135
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-22 ANION GAP-14
___ 04:20PM estGFR-Using this
___ 04:20PM ALT(SGPT)-18 AST(SGOT)-26 ALK PHOS-67 TOT
BILI-1.0
___ 04:20PM WBC-14.0* RBC-3.34* HGB-10.4* HCT-30.4*
MCV-91 MCH-31.1 MCHC-34.1 RDW-16.8*
___ 04:20PM NEUTS-72.9* ___ MONOS-3.3 EOS-0.5
BASOS-0.3
___ 04:20PM PLT COUNT-224
___ 04:20PM ___ PTT-42.0* ___
___ 10:47 pm URINE Source: ___.
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Pending):
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Pending):
BCx ___ x 2 - pending
UCx ___ - pending
Scrotal US with Doppler:
1. Hyperemic epididymi consistent with epididymitis. Equivocal
evidence of testicular hyperemia, orchitis not excluded.
2. Diffuse scrotal skin thickening and hyperemia consistent
with superficial cellulitis.
3. No evidence of testicular torsion
DISCHARGE LABS
___ 07:10AM BLOOD WBC-10.8 RBC-3.17* Hgb-9.7* Hct-29.6*
MCV-93 MCH-30.6 MCHC-32.8 RDW-16.6* Plt ___
___ 07:10AM BLOOD Glucose-74 UreaN-38* Creat-1.3* Na-134
K-4.3 Cl-102 HCO3-22 AnGap-14
___ 07:10AM BLOOD Albumin-3.2* Calcium-8.7 Phos-3.5 Mg-1.0*
Brief Hospital Course:
___ y/o M w/ afib on warfarin, HCV cirrhosis, diverticulitis c/b
colovesicular fistula s/p repair and colostomy, and multiple VRE
UTIs, now presenting from ___ w/scrotal pain and swelling
x3-4 days.
# orchitis / epidydimitis: Pt p/w testicular pain and scrotal
swelling, and US findings consistent w/ orchitis/epidydimitis.
Pt has significant swelling but minimal erythema and warmth of
scrotum. Recently diagnosed with yeast UTI outpatient and
started on Fluconazole, per discussion with urologist this could
lead to oorchitis if the patient has retrograde flow of urine.
Fluconazole dose was increased as tolerated by kidney function,
to increase penetration into the testicles if yeast is the cause
of his oorchitis. Also levofloxacin was started per Urology recs
to treat more common bacterial causes of oorchitis/epididymitis.
Pain controlled with Tylenol.
- f/u blood and urine cultures
- f/u urine gonorrhea and chlamydia (low suspicion, patient
without recent sexual activity)
- outpatient urologic f/u w/ Dr. ___
# atrial fibrillation: suprathapeutic on warfarin, likely due to
recent fluconazole use. Held Warfarin at discharge, patient will
get labs drawn in 2 days and Coumadin may be restarted at that
time by outpatient PCP.
# Cirrhosis ___ Hep C - Complicated by grade 2 varices, but has
been stable recently. No evidence of GI bleed given guaiac
negative stools. No evidence of encephalopathy on exam. Patient
without decompensated liver disease.
- continue home ursodiol, nadolol, pantoprazole 40mg po bid
# Hypertension - currently normotensive. Wife says she stopped
giving him his lisinopril, triamterene-hctz, amlodipine, and
nadolol because he had lost a lot of weight and his blood
pressures were normal.
- restart nadolol as above
- held other agents at DC since the patient was not hypertensive
# h/o colovesicular fistula s/p takedown w/ colostomy: No
current issues w/ colostomy function.
# CKD: Cr at 1.2, which is at baseline, EGFR 44
-renally dose meds
-avoid nephrotoxins
# CODE: full, confirmed
# CONTACT: wife ___ with updates ___
TRANSITIONAL ISSUES
- Follow up GC/chlamydia swap pending at discharge
- Follow up BCx and UCx pending at discharge
- F/U with PCP and ___ outpatient
- patient will get labs drawn in 2 days and Coumadin may be
restarted at that time by outpatient PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nadolol 20 mg PO DAILY
2. Pantoprazole 40 mg PO Q12H
3. Ursodiol 300 mg PO TID
4. Warfarin 1.5 mg PO DAILY16
5. Lisinopril 20 mg PO BID
6. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
7. Amlodipine 5 mg PO DAILY
8. Citracal + D *NF* (calcium phosphate-vitamin D3) 250 mg
calcium- 250 unit Oral qid
9. Magnesium Oxide 280 mg PO QID
10. Cyanocobalamin 1000 mcg PO DAILY
11. Vitamin E 800 UNIT PO DAILY
12. Fish Oil (Omega 3) 1000 mg PO DAILY
13. saw ___ *NF* 160 mg Oral bid
14. Co Q-10 *NF* (coenzyme Q10;<br>coenzyme Q10-vitamin E) 100
mg Oral daily
15. milk thistle *NF* 140 mg Oral daily
16. Multivitamins 1 TAB PO DAILY
17. potassium chloride *NF* 10 mEq Oral daily
18. Tamsulosin 0.4 mg PO HS
19. Finasteride 5 mg PO DAILY
20. Ferrous Sulfate 325 mg PO BID
21. Fluconazole 100 mg PO Q24H Duration: 14 Days
last day of therapy ___
22. Paroxetine Dose is Unknown PO DAILY
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Nadolol 20 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Tamsulosin 0.4 mg PO HS
8. Ursodiol 300 mg PO TID
9. Vitamin E 800 UNIT PO DAILY
10. Acetaminophen ___ mg PO BID:PRN pain, fever
11. Levofloxacin 250 mg PO Q24H
RX *levofloxacin 250 mg 1 tablet(s) by mouth daily Disp #*8
Tablet Refills:*0
12. Citracal + D *NF* (calcium phosphate-vitamin D3) 250 mg
calcium- 250 unit Oral qid
13. Co Q-10 *NF* (coenzyme Q10;<br>coenzyme Q10-vitamin E) 100
mg Oral daily
14. Ferrous Sulfate 325 mg PO BID
15. Magnesium Oxide 280 mg PO QID
16. milk thistle *NF* 140 mg Oral daily
17. potassium chloride *NF* 10 mEq Oral daily
18. saw ___ *NF* 160 mg Oral bid
19. Outpatient Lab Work
please draw INR on ___ and fax results to:
PCP ___ # ___, phone # ___
20. Fluconazole 200 mg PO Q24H
RX *fluconazole 100 mg 2 tablet(s) by mouth daily Disp #*9
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- oorchitis/epididymitis
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 swollen and painful
testicles, and you were found to have an infection of your
testicles. You will be treated with antibiotics and antifungal
agents, and follow up with your PCP and ___.
It is important that you take all medications as prescribed, and
keep all follow up appointments.
Followup Instructions:
___
|
10290586-DS-9 | 10,290,586 | 27,665,934 | DS | 9 | 2187-05-13 00:00:00 | 2187-05-13 12:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pressure and syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of CAD s/p BMS to RCA ___, HTN, HLD and HepC s/p
liver transplant ___ years ago) currently cleared of HCV after
treatment with Harvoni who develops substernal chest
squeezing/bandlike sensation that wrapped around to the back.
This was associated with diaphoresis, but was not associated
with shortness of breath, jaw pain, or arm pain. Lasted 10
minutes. Due to pain patient took one aspirin 324 mg, sublingual
nitroglycerin and subsequently took another sublingual
nitroglcyerin within 20 seconds of the prior. Patient
subsequently developed acute onset light headedness, dizziness,
headache. Patient's wife noted that patient had pallor and
diaphoresis. He was able to lay down without any fall or loss of
consciousness. EMS was called, evaluated patient adn noted blood
pressure 70/palpable with HR 60.
Of note, patient was admitted with similar symptoms in ___.
At that time patient underwent stress test which was normal.
In the meantime, he has not had further episodes of chest
tightness, shortness of breath, orthopnea, PND, palpitations.
In the ED initial vitals were: 17:39 0 97.9 65 106/66 18 96% RA
EKG: RR 56, PR Int 134, QRS 82, QTc 417; new TWI V1-V2
Labs/studies notable for: wbc 11.1, h/h 12.6/28.8, creat 1.1,
trop
<0.01 and normal lfts.
-CXR showed no acute intrathoracic process.
-
Patient had POCUS: reportedly showed no pericardial fluid, good
contractility, ?RV dilation, no PTX b/l.
Vitals on transfer: Today 22:32 0 98.1 57 128/65 15 97% RA
On the floor patient denies any further chest pain, chest
tightness, or chest discomfort.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: ___: DES to RCA. Had
moderate LAD and LCx disease managed medically.
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
hepatitis C status post liver transplant (___), No fibrosis
and recurrent
HCV on ___ biopsy
hypertension
hypercholesterolemia
chronic renal insufficiency
osteopenia
basal cell carcinoma x2, status post Mohs procedures.
PVD c/b claudication.
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: 97.7, 123/66, 67, 18, 99% on RA.
GENERAL: Pleasant affect, laying in bed in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with no elevated JVP.
CARDIAC: RRR, S1 and S2 pressent, no m/r/g.
LUNGS: Clear to auscultation, no wheezes, rales or rhonchi.
ABDOMEN: Soft, NTND. surgical scar from prior liver transplant
well healed..
EXTREMITIES: No lower extremity edema.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
___ 08:30PM BLOOD WBC-11.1* RBC-4.45* Hgb-12.6* Hct-38.8*
MCV-87 MCH-28.3 MCHC-32.5 RDW-13.9 RDWSD-44.0 Plt ___
___ 08:30PM BLOOD Neuts-83.3* Lymphs-10.1* Monos-4.9*
Eos-0.8* Baso-0.4 Im ___ AbsNeut-9.22*# AbsLymp-1.12*
AbsMono-0.54 AbsEos-0.09 AbsBaso-0.04
___ 08:30PM BLOOD ___ PTT-23.1* ___
___ 08:30PM BLOOD Glucose-106* UreaN-22* Creat-1.1 Na-138
K-4.3 Cl-104 HCO3-23 AnGap-15
___ 08:30PM BLOOD ALT-28 AST-33 AlkPhos-95 TotBili-0.5
___ 08:30PM BLOOD Albumin-4.2
___ 11:25PM URINE Color-Yellow Appear-Clear Sp ___
___ 11:25PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 11:25PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 11:25PM URINE CastHy-4*
___ 11:25PM URINE Mucous-RARE
CXR ___
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous
structures are intact. No free air below the right
hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Brief Hospital Course:
___ with PMH of CAD s/p BMS to RCA ___, HTN, HLD and HepC s/p
liver transplant ___ years ago) currently cleared of HCV after
treatment with Harvoni who develops substernal chest
squeezing/bandlike sensation that wrapped around to the back.
This was associated with diaphoresis, but was not associated
with shortness of breath, jaw pain, or arm pain. Lasted 10
minutes. Due to pain patient took one aspirin 324 mg, sublingual
nitroglycerin and subsequently took another sublingual
nitroglcyerin within 20 seconds of the prior. Patient
subsequently developed acute onset light headedness, dizziness,
headache. Patient's wife noted that patient had pallor and
diaphoresis. He was able to lay down without any fall or loss of
consciousness. EMS was called, evaluated patient adn noted blood
pressure 70/palpable with HR 60.
Afebrile, HDS in ED, EKG with new TWI V1-2, CXR neg for acute
process, POCUS: no pericardial fluid, good contractility, ? RV
dilation, no PTX.
VS on floor 97.8 150/104 70 18 98%RA, upset and wanted to leave,
mentating, aware of risks, did not comply with exam. Patient
advised of the risks of leaving before workup completed and he
agrees to take the risk, will return if chest pressure returns.
Mr. ___ chose to leave prior to being seen and examined by the
attending cardiologist.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Metoprolol Succinate XL 12.5 mg PO DAILY
3. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
4. Tacrolimus 1 mg PO Q12H
5. Tamsulosin 0.4 mg PO EVERY OTHER DAY QHS
6. ValACYclovir 500 mg PO Q12H:PRN HSV outbreak
7. Aspirin 81 mg PO DAILY
8. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Tacrolimus 1 mg PO Q12H
5. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
BID
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
7. Tamsulosin 0.4 mg PO EVERY OTHER DAY QHS
8. ValACYclovir 500 mg PO Q12H:PRN HSV outbreak
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pressure
Syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
Patient admitted for workup of chest pressure and syncope in the
setting of multi vessel CAD with BMS to RCA ___. EKG with new
TWI in V1-2, biomarkers negative x 2. Patient insisting on
leaving prior to completion of workup because of a very
important appointment this morning.
Patient was verbally notified of the risks of leaving prior to
completing the workup for possbile cardiac ischemia. He did not
wait for paperwork and left the floor. He states that is aware
of the possibility of a bad outcome if he does not wait for the
completion of the workup and that he is putting himself in
danger by leaving prior to its completion. He also states that
he will follow with his cardiologist Dr. ___ on ___ and
that he will return if he has any recurrence of his chest
pressure.
Followup Instructions:
___
|
10291088-DS-28 | 10,291,088 | 20,027,601 | DS | 28 | 2128-09-28 00:00:00 | 2128-10-01 20:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Bactrim / Beta-Blockers (Beta-Adrenergic
Blocking Agts) / propranolol
Attending: ___
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old lady with H/O IDDM, hypertension, CAD s/p MI in
___, seizures, SLE, CKD, and recent discharge for syncope on
___ thought secondary to a seizure presents with chest
discomfort, dyspnea on exertion and fatigue today of sudden
onset while exerting herself. She denied palpitations but did
state that her heart felt like it had slowed down dramatically
when this occurred. She states she has never had symptoms like
this before, but has had substernal chest pain previously upon
awakening in the morning that was relieved with eating a meal.
Due to these new symptoms, she went to the ED where she was felt
to have sinus bradycardia to the ___ and hypertension. She was
recently started on propranolol 10 mg BID by her PCP for
essential tremor on ___. Her chest pain resolved by the time
she reached the ED, and over the ED course, it was noted that
she went from presumed sinus bradycardia to regular rhythm with
rates in the ___ but with a prolonged PR interval of ~300
msec. Cardiology was consulted in the ED who felt that her
bradycardia was secondary to her newly started propranolol, and
recommended admission to ___ for observation. After arrival to
the cardiology floor, she has no complaints.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
- Insulin dependent diabetes (Dr. ___
- CAD (s/p MI ___
- Hypertension
- Hypercholesterolemia
- SLE (Dr. ___
- ___ arthritis
- Osteoporosis
- Cervical dysplasia
- Bell palsy
- Syphilis s/p penicillin Rx
- Fibular Fx and Tibial Fx s/p ORIF, ___
Social History:
___
Family History:
Mother - DM, CVA. Daughter - DM
Physical ___:
Admission Physical Exam:
General: Elderly ___ woman, alert, oriented, no
acute distress, hard of hearing
Vitals: T 98.0 BP 190/61 HR 78 RR 18 SaO2 94% on RA
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP ~10 cm, no LAD
Lungs: Bilateral bibasilar rales ___ up
CV: Regular rate and rhythm, normal S1 + S2; no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace pedal and pretibial edema.
Discharge Physical Exam:
General: Alert, oriented, no acute distress, hard of hearing
Vitals: T 98.4, BP 154/69, HR 53, RR 16, SaO2 95% on RA
HEENT: NC/AT. Sclera anicteric
Lungs: Minimal rales in the Right base. No wheezes, rhonchi.
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur at LUSB and RUSB; no rubs or gallops
Abdomen: soft, non-tender, non-distended, normo-active bowel
sounds present
Ext: Warm, well perfused, no edema.
Pertinent Results:
___ 07:16PM BLOOD WBC-8.8 RBC-3.57* Hgb-10.8* Hct-32.7*
MCV-91 MCH-30.2 MCHC-33.0 RDW-14.2 Plt ___
___ 07:16PM BLOOD Neuts-58.3 ___ Monos-8.5 Eos-2.5
Baso-0.3
___ 07:16PM BLOOD ___ PTT-31.1 ___
___ 07:16PM BLOOD Glucose-180* UreaN-40* Creat-1.7* Na-130*
K-5.1 Cl-99 HCO3-23 AnGap-13
___ 07:16PM BLOOD proBNP-1618*
___ 07:00AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.2
___ 07:00AM BLOOD TSH-1.0
DISCHARGE LABS (from day prior to discharge)
___ 07:00AM BLOOD WBC-7.2 RBC-3.63* Hgb-11.1* Hct-32.9*
MCV-91 MCH-30.6 MCHC-33.8 RDW-16.4* Plt ___
___ 06:43AM BLOOD Glucose-72 UreaN-32* Creat-1.2* Na-141
K-5.0 Cl-107 HCO3-29 AnGap-10
___ 07:16PM BLOOD cTropnT-<0.01
___ 07:00AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:00AM BLOOD CK(CPK)-88
URINE STUDIES
___ 11:22PM URINE Color-Straw Appear-Clear Sp ___
___ 11:22PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
___ 11:22PM URINE RBC-0 WBC-2 Bacteri-MOD Yeast-NONE Epi-1
TransE-<1
___ 11:22PM URINE CastHy-15*
___ 12:50AM URINE Hours-RANDOM UreaN-333 Creat-79 Na-12
K-30 Cl-11
___ 12:50AM URINE Osmolal-223
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION.
EKG ___
Ectopic atrial rhythm at a very slow rate. Left ventricular
hypertrophy with associated ST-T wave changes, although ischemia
or infarction cannot be excluded. Compared to the previous
tracing the rate is much slower.
___
___
EKG ___
Ectopic atrial rhythm at a normal rate with P-R interval
prolongation. Left ventricular hypertrophy with strain pattern.
Lateral T wave inversions. Non-specific ST segment flattening in
the inferolateral leads and non-specific J point elevation in
the right precordial leads. Compared to the previous tracing of
the prior date the rate is faster and now normal, although still
with leftward P wave axis. Left anterior fascicular block and
left ventricular hypertrophy with strain and/or ischemia are
unchanged. Non-specific repolarization abnormalities are
similar.
___
___
CXR PA/LAT ___
The heart size is at the upper limits of normal, likely
exaggerated by AP technique. The mediastinal contours
demonstrate a mildly tortuous aorta with calcified
atherosclerotic disease of the aortic knob. The lungs again
demonstrate a prominent reticular pattern particulary at the
bases without clear evidence of new consolidation. There is no
large pleural effusion or pneumothorax.
Brief Hospital Course:
___ year old lady with history of IDDM, hypertension, CAD s/p MI
in ___, seizures, SLE, CKD, and syncope who presented with
substernal chest pain, dyspnea on exertion and subjective
feeling of her heart slowing, found to have non-sinus
bradycardia and shortness of breath. Her bradycardia was felt
secondary to recently starting propanolol. She was monitored in
the hospital for propanolol washout, and her bradycardia
resolved (as such, she did not require a pacemaker). She should
avoid beta blockers in the future (now listed as an allergy).
>> Active Issues:
# Bradycardia: Following initiation of a nodal blocking agent,
Ms. ___ presented with a symptomatic ectopic atrial
bradycardic rhythm. Her propanolol was stopped, and her
bradycardia resolved. She also had first-degree AV block.
Hypothyroidism was less likely as a cause (TSH was wnl). Acute
MI was also unlikely as she had negative troponins and no
obvious ischemic ECG changes from baseline. Her chest discomfort
was likely due to new bradyarrhythmia.
- She was discharged in sinus rhythm and heart rate consistently
between 60-70.
- She should avoid all nodal blocking agents in the future.
# Shortness of breath: On admission, she was mildly volume
overloaded with JVD, rales, mild room air hypoxia, likely an
exacerbation of her chronic diastolic CHF. She responded well to
gentle diuresis with furosemide 20 mg IV.
# Acute Kidney Injury: Cr of 1.7 on admission, improved to 1.2
on discharge. FENa was less than 1%, so more likely pre-renal.
She endorsed poor PO intake prior to admission. ___ could also
be secondary to poor renal perfusion due to decreased cardiac
output when bradycardic, as well as diastolic heart failure.
# Hypertension: She was hypertensive on admission, which may
have caused exacerbation of diastolic heart failure. She was
started on doxazosin every evening to maintain control of BP
throughout the day. She was continued on her amlodipine and
ACE-I.
# CAD: Stable on this admission. Her chest pain today was in the
setting of bradycardia, and dyspnea suggestive of exacerbation
of diastolic CHF. Her more chronic symptom of morning
sub-sternal pain which is relieved with food and worsened by
lying down seems more related to dyspepsia or GERD than ischemic
in origin. She had no evidence of MI with serial normal
troponins, and was continued on her aspirin dihydropyridine
calcium channel blocker, and statin.
# Epigastric pain: Given the association with lying down and
eating, likely dyspepsia or GERD. She was started on omeprazole
for this.
>> Chronic issues
# History of seizures: Continued levetiracetam.
# SLE: Continued prednisone, hydroxychloroquine.
# DM, type 2: In house, she was managed with Humalog ISS and NPH
___.
>> TRANSITIONAL ISSUES
- CODE: Full.
- Contact: daughter is also HCP, ___ ___
- The patient reports that she actually takes hydroxychloroquine
twice daily, as opposed to alternating with lower dose.
- She should avoid nodal blocking agents in the future.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. DimenhyDRINATE 50 mg PO Q8H:PRN nausea
5. Docusate Sodium 100 mg PO BID
6. Enalapril Maleate 20 mg PO BID
7. LeVETiracetam 750 mg PO BID
8. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
9. PredniSONE 5 mg PO DAILY
10. Simvastatin 10 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Furosemide 20 mg PO DAYS (___)
13. Hydroxychloroquine Sulfate 200 mg PO DAILY; One tablet daily
alternating with 2 tablets daily.
14. NPH 15 Units Breakfast; NPH 5 Units Dinner
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Enalapril Maleate 20 mg PO BID
6. Hydroxychloroquine Sulfate 200 mg PO DAILY; One tablet daily
alternating with 2 tablets daily.
7. NPH 15 Units Breakfast; NPH 5 Units Dinner
8. LeVETiracetam 750 mg PO BID
9. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
10. PredniSONE 5 mg PO DAILY
11. Simvastatin 10 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. DimenhyDRINATE 50 mg PO Q8H:PRN nausea
14. Furosemide 20 mg PO 3X/WEEK (___)
15. Doxazosin 2 mg PO HS
RX *doxazosin [Cardura] 2 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
16. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Ectopioc atrial bradycardia, due to
Beta blocker toxicity
Chest pain
Coronary artery disease
Hypertension
Shortness of breath
Acute on chronic left ventricular diastolic heart failure
Acute kidney injury
Gastroesophageal reflux disease
Tremor
Diabetes mellitus
Hypothyroidism
Systemic lupus erythematosis
Rheumatoid arthritis
Seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted because of chest pain and a slow heart rate.
We made sure you did not have a heart attack. Your slow heart
rate was likely due to being started on Propranolol. We
observed you off the medication and your heart rate resolved.
We have listed "beta blockers" as an allergy. Please discuss
possible alternative treatments for your tremor with your
Primary care doctor.
We made the following changes to your home medication list:
-STOP Propranolol
-START Omeprazole
Followup Instructions:
___
|
10291112-DS-12 | 10,291,112 | 28,226,328 | DS | 12 | 2152-01-04 00:00:00 | 2152-01-05 07:32:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trauma: pedestrian struck with lower ext. crush injury
Major Surgical or Invasive Procedure:
___:
1. Washout and debridement open fractures site right and
left tibia down to and inclusive of bone.
2. Application uniplanar external fixator right and left
tibia.
3. Closed reduction of distal tibia fractures bilateral
with manipulation.
4. Application of uniplanar external fixator right femur.
5. Closed treatment right femur fracture with manipulation.
___:
1. Removal of external fixator under anesthesia, right
lower extremity.
2. Irrigation and debridement, fracture, skin to bone,
right tibia.
3. Retrograde femoral nail, right femur.
4. Anterior grade tibial nail, right tibia.
5. Debridement, fracture open skin to bone, left tibia,
under separate prep and drape.
___:
On the right lower extremity
1. A free gracilis flap.
2. Pedicled soleus flap.
3. Split-thickness skin graft 8 x 20.
4. Antibiotic impregnated cement spacer to tibia.
5. Surgical preparation site 20 x 8 cm.
Left side
1. Pedicled soleus flap.
2. Split-thickness skin graft 8 x 17.
3. Surgical preparation of site 8 x 17 cm.
4. Excision of fibula with open fracture.
___:
1. Irrigation and debridement, fracture open skin to bone,
left tibia.
___:
1. Irrigation and debridement, fracture open skin to bone,
left tibia.
2. Removal of external fixator under anesthesia, left
tibia.
3. Open reduction, internal fixation, Schatzker 6,
bicondylar tibial plateau fracture.
4. Intramedullary nailing, left tibial shaft fracture.
___:
Tracheostomy placement
___: RLE Split-thickness skin grafting, 14 x 5 cm.
___: PEG placement
___: Trach downsized to #6, non-cuffed, passey muir valve
placed
History of Present Illness:
___ year old female who was brought into the hospital by EMS as a
pedestrian struck. She was pinned between 2 cars, crushing both
lower
extremities. She had initially no pulses at the scene but
transient lower extremity pulses while in route. She reports
severe pain in both legs that recalls no other injuries and
reports no pain in the head, neck, chest, hips, or arms.
Past Medical History:
Emphysema on 2.5L home o2.
HTN
HLD
GERD
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission Physical Examination:
General: Severe Distress
HEENT: Eyes: Lids Normal; . NCAT, midface
stable. Neck: No Lymphadenopathy, No Meningismus and Supple;
in surgical immobilization Respiratory: No Resp Distress,
Chest non-tender and Normal Breath Sounds Cardio-Vascular:
No murmur, No rub and RRR Abdomen: Non-tender and Soft Back:
No Midline Tenderness and Non-tender; kyphotic, long midline
scar Extremity: Bilateral lower extremity open fractures
below-the-knee with clear deformity, thready dp pulse
bilaterally, diffuse pain throughout; difficult to assess
sensation distal to fractures due to extreme pain
Neurological: Alert, Oriented X3, No Gross Weakness and
Speech Normal Skin: No rash, No Petechiae, Warm and Dry
Psychological: Mood/Affect Normal and Normal Memory/Judgment
Discharge Physical Exam:
VS: 97.9 PO 92/60 76 19 95 RA
Gen: A&O x3
HEENT: Trach site CDI
CV: HRR
Pulm: LS dim at bases
Abd: soft NT/ND. GT site CDI
GU: Foley with cyu
Ext: RLE/LLE multiple healed incisions, donor graft site on each
thigh, grafts to bilat shins.
Pertinent Results:
Initial Labs:
___ 04:15PM BLOOD freeCa-0.92*
___ 04:15PM BLOOD Hgb-11.3* calcHCT-34 O2 Sat-90 COHgb-4
MetHgb-0
___ 04:15PM BLOOD Glucose-134* Lactate-3.2* Na-134 K-3.6
Cl-105
___ 04:15PM BLOOD ___ pO2-77* pCO2-55* pH-7.22*
calTCO2-24 Base XS--5 Intubat-INTUBATED
___ 06:30PM BLOOD Calcium-8.2* Phos-4.1 Mg-1.4*
___ 04:05PM BLOOD Lipase-43
___ 06:30PM BLOOD Glucose-124* UreaN-6 Creat-0.6 Na-137
K-3.6 Cl-106 HCO3-21* AnGap-14
___ 04:05PM BLOOD ___ 04:05PM BLOOD ___ PTT-27.8 ___
___ 04:49PM BLOOD Plt ___
___ 04:49PM BLOOD Neuts-73.1* Lymphs-16.5* Monos-8.5
Eos-0.4* Baso-0.2 Im ___ AbsNeut-6.23* AbsLymp-1.41
AbsMono-0.72 AbsEos-0.03* AbsBaso-0.02
___ 04:05PM BLOOD WBC-7.7 RBC-3.44* Hgb-10.8* Hct-33.0*
MCV-96 MCH-31.4 MCHC-32.7 RDW-14.7 RDWSD-51.1* Plt ___
Interval Labs:
___ 02:51AM BLOOD freeCa-1.10*
___ 02:43AM BLOOD freeCa-1.05*
___ 03:26PM BLOOD Glucose-121* Lactate-1.8 Na-134 K-4.6
Cl-102
___ 06:57PM BLOOD Type-ART Temp-34.3 pO2-186* pCO2-42
pH-7.34* calTCO2-24 Base XS--2
___ 09:09PM BLOOD Type-ART pO2-60* pCO2-49* pH-7.33*
calTCO2-27 Base XS-0
___ 09:18AM BLOOD Type-ART pO2-76* pCO2-44 pH-7.34*
calTCO2-25 Base XS--2
___ 02:43AM BLOOD Type-ART Rates-/___ Tidal V-380 PEEP-5
pO2-75* pCO2-43 pH-7.45 calTCO2-31* Base XS-4 Intubat-INTUBATED
Vent-SPONTANEOU
___ 02:00AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.0
___ 05:20AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.8
___ 01:45AM BLOOD ALT-26 AST-42* AlkPhos-257* TotBili-1.1
___ 05:20AM BLOOD Glucose-103* UreaN-10 Creat-0.4 Na-140
K-3.2* Cl-100 HCO3-30 AnGap-13
___ 02:03AM BLOOD ___ PTT-32.7 ___
___ 05:28AM BLOOD Plt ___
___ 03:24PM BLOOD WBC-8.6 RBC-2.45* Hgb-7.3* Hct-21.7*
MCV-89 MCH-29.8 MCHC-33.6 RDW-16.5* RDWSD-52.9* Plt Ct-75*
___ 05:28AM BLOOD WBC-15.3* RBC-3.11* Hgb-9.3* Hct-30.9*
MCV-99* MCH-29.9 MCHC-30.1* RDW-18.0* RDWSD-63.0* Plt ___
___ 02:18AM BLOOD WBC-9.7 RBC-2.71* Hgb-8.1* Hct-25.3*
MCV-93 MCH-29.9 MCHC-32.0 RDW-16.3* RDWSD-52.6* Plt ___
___ 05:28AM BLOOD WBC-15.3* RBC-3.11* Hgb-9.3* Hct-30.9*
MCV-99* MCH-29.9 MCHC-30.1* RDW-18.0* RDWSD-63.0* Plt ___
Imaging:
___: CXR:
1. No acute cardiopulmonary process.
2. Suspect acute fractures at the left superior and inferior
pubic rami.
___: Lower Extremity Fluro:
Right and left is not clearly labeled on the images. Numerous
fluoroscopic images demonstrate placement of external fixation
pins in the calcaneus and proximal tibial shaft and in the
proximal femoral shaft. There are displaced fractures seen of
the mid femoral shaft with a prominent butterfly fragment, of
the proximal tibial metaphysis, and a severely comminuted
fracture through the distal lower leg involving the tibia and
fibula. Please refer to the operative note for additional
details. The total intraservice fluoroscopic time was 47.7
seconds.
___: CT Head:
1. No acute intracranial abnormality
2. Peripheral calcification of the cavernous portion of the left
internal
carotid artery measuring 1.6 x 1.4 x 1.1 cm, highly suspicious
for an
underlying aneurysm.
___: CT A/P:
1. Extensive comminuted open fractures involving the bilateral
lower
extremities as described. The bilateral anterior tibial and
peroneal arteries are not visualized distal to the level of the
mid tibia, concerning for vascular injury.
2. Multiple pelvic fractures as described. There is no evidence
of active
extravasation or large extraperitoneal hematomas. Multiple
pelvic fractures including displaced left iliac fracture and
left
superior and inferior pubic rami fractures. Slight widening of
the left
sacroiliac joint and offset of the pubic symphysis joint.
Posterior to
fracture fragments of the left ilium
3. Small amount of simple ascites without evidence of traumatic
injury to the intra-abdominal organs.
4. Small bilateral pleural effusions without evidence of acute
intrathoracic injury.
___: CT C-spine:
1. Widening of the anterior disc space at C6-C7 which may
reflect underlying ligamentous injury
2. High-density material in the posterior epidural space at
C5-C6 and C6-C7, reflective of acute hemorrhage.
___: CTA b/l ___:
1. Extensive comminuted open fractures involving the bilateral
lower
extremities as described. The bilateral anterior tibial and
peroneal arteries are not visualized distal to the level of the
mid tibia, concerning for vascular injury.
2. Multiple pelvic fractures as described. There is no evidence
of active
extravasation or large extraperitoneal hematomas.
3. Small amount of simple ascites without evidence of traumatic
injury to the intra-abdominal organs.
4. Small bilateral pleural effusions without evidence of acute
intrathoracic injury.
___: MR C-spine:
1. No evidence of an epidural hematoma. No cord signal
abnormalities
identified.
2. No evidence of acute ligamentous injury identified within the
anterior
longitudinal ligaments. Previously noted widening of the
anterior aspect of the C6-C7 vertebral body is likely
degenerative in etiology.
3. Cervical spondylosis, as described in detail above most
pronounced at C4-5 and C5-6.
4. Unchanged left internal carotid artery aneurysm, previously
demonstrated by head CT on ___.
___: R Hand x-ray (PA/LAT/Oblique):
1. Diffuse osteopenia.
2. Prominent soft tissue swelling.
3. Suspected old healed distal right radial fracture. Clinical
correlation to confirm this is requested.
4. Equivocal nondisplaced fracture in the proximal metaphysis of
the fourth metacarpal bone, seen only on one view.
Alternatively, this could reflect changes due to remote healed
fracture or bony ridging at the base of the metacarpal.
Brief Hospital Course:
Ms. ___ presented to ___ on ___ after being pinned
between two cars with bilateral lower extremity open fractures
and right femur fracture. The patient was seen by Orthopaedics,
Plastic Surgery and Vascular Surgery who coordinated her care.
Regarding her bilateral open tibia/fibula fractures, and right
femur fracture, she went urgently to the operating room for I&D
and ex-fix of the R femur, R ankle ex-fix, and L ankle ex-fix.
She maintained Doppler signals throughout. She was transfused
as needed for bleeding/oozing originating from her leg wounds.
She was transferred to the Trauma ICU for further care and
required pressers. On ___, she underwent R antegrade tibial
nail, R retrograde femoral nail, and washout of the LLE. RUE
duplex demonstrated a superficial clot but was negative for DVT.
Subcutaneous heparin was started. On HD4, the patient remained
afebrile during the day, she was stable on the vent, and she was
started on tube feeds and NG meds. She was given 1 unit PRBCs
for drifting hematocrit.
She had an initial ___ evaluation on ___. On ___, she
underwent ORIF and L tibial nail as well as Right: free gracilis
flap, pedicled soleus flap, split-thickness skin graft,
antibiotic impregnated cement spacer to tibia, and excision of
fibula with open fracture. At this date, she also had irrigation
and debridement of left tibia, removal of external fixator, open
reduction/internal fixator, and left tibial intramedullary
nailing.
On ___, the patient had a BAL which showed ___ e.
coli. She was started on cefepime for the e.coli VAP. The
patient was taken to the operating room and underwent ORIF of
the L tibia & free flap, L gracili to RLE, and aspirin was
recommended per Plastic Surgery. On ___, tube feeds were
held secondary to concern for refeeding syndrome. Levophed
increased from .06->.08 then decreased back to .06. On
___, the patient failed extubation trial and was
reintubated. Tube feeds were resumed. On ___, the patient
received 20mg IV lasix x2 with good response. On ___, the
patient was taken to the operating room and underwent
Tracheostomy. The patient tolerated this procedure well. On
___, the patient's WBC was 18.0, she desatted to the 70's,
and she responded with increased FiO2. On ___, there were
no acute events, she tolerated a trach mask all day, c. diff
was negative. Her IJ was removed and her subcutaneous heparin
was discontinued and she was started on Lovenox.
On ___, Cefepime was discontinued. WBC decreased to 15,000
from 17,00. A passy muir valve was placed, but she could not
tolerate the valve for long periods of time. On ___, a PEG
was placed, foley catheter was removed, but was later replaced
overnight for retention. On ___, the patient's tube feeds
were increased to goal. On ___, the patient's foley
catheter was discontinued at midnight but was then replaced on
___ for urinary retention.
Per Orthopaedics, the patient should remain in b/l knee
imobilizers, a short air cast for the LLE and a long aircast for
the RLE, RUE in volar resting slab. On ___, the patient
underwent and failed FEES with Speech & Swallow. She was made
strict NPO and continued on tube feedings. The trach tube was
down-sized on ___ to a #6 fenestrated, non-cuffed tube. She
tolerated this well and underwent placement of passy-muir valve.
She has had no difficulty in mobilizing her secretions.
On ___, the patient went back to the OR with Plastic Surgery
for a split thickness skin graft to the right lower extremity
and for a PEG placement. Postoperatively, tube feeds were
started and advanced to goal which she tolerated well. On ___,
the VAC was taken down from the skin graft site, which appeared
well-healing. The STSG donor site was left open to air.
The patient continued to work with Physical Therapy and it was
recommended that she be discharged to rehab to continue her
recovery.
Medications on Admission:
Verapamil ER 180mg daily
Duloxetine ER 60mg daily
Simvastatin 40mg daily
Gabapentin 300mg qhs
Klor-con 1 tab BID
Folic acid 1mg daily
Omeprazole 20mg daily
Bupropion XL 300 qam
Klonazepam 0.5mg qam & 1mg qhs
Trazodone 100mg qhs
Reglan 10mg daily
Valsartan 80 mg daily
Magnesium oxide
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheezing
4. Aspirin 121.5 mg PO DAILY
5. Bisacodyl 10 mg PR QHS
6. BuPROPion 150 mg PO BID
7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
8. ClonazePAM 1 mg PO QHS
9. Docusate Sodium 100 mg PO BID
10. Fleet Enema ___AILY:PRN constipation
11. Ipratropium Bromide MDI ___ PUFF IH Q4H:PRN wheeze
12. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
13. Lactulose 15 mL PO DAILY
14. Mineral Oil ___ mL PO DAILY:PRN constipation
15. Multivitamins 1 TAB PO DAILY
16. OxycoDONE Liquid 15 mg PO Q4H:PRN Pain - Moderate
hold for increased sedation, resp. rate <8
17. Polyethylene Glycol 17 g PO DAILY
18. QUEtiapine Fumarate 25 mg PO BID
19. Senna 8.6 mg PO BID
20. Silver Sulfadiazine 1% Cream 1 Appl TP DAILY to left hand
eschar
21. Thiamine 100 mg PO DAILY
22. Verapamil 40 mg PO Q8H hold for SBP <90 or HR <60
hold for systolic blood pressure <110, hr <60
23. Simvastatin 10 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Trauma:
[] Bilateral lower long bone fractures
[] Bilateral, open, comminuted lower extremity wounds
[] Multiple pelvic fractures: comminuted fracture of the left
iliac wing and fractures of the left superior and inferior pubic
rami, with minimal diastasis of the left SI joint and pubic
symphysis
[] Subacute fractures of the right sixth and seventh ribs
posteriorly
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for
bilateral lower extremity fractures and underwent Right tibial
and femoral nail, L tibia ORIF, tracheostomy, G-tube placement.
You are recovering well and are now ready for discharge. Please
follow the instructions below to continue your recovery:
General Surgery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Wound care instructions:
*For the left lower extremity you will need daily dressing
changes that consist of warm soap and water applied with 4x4
sterile gauze. This should be allowed to dry and followed by
thin layer of A&D ointment over which xeroform should be applied
over the wound. Next please take ___ sterile gauze 4x4's and
unfold them to create large area with multiple layers of
dressing. Place this over the xeroform bandages. Lastly, wrap
the extremity in Webril gauze.
*For the right lower extremity you will need daily dressing
changes that consist of xeroform applied to wounds followed by
___ sterile gauze 4x4's and unfold and layer them to create
large area with multiple layers of dressing. Lastly, wrap the
extremity in Webril gauze.
Followup Instructions:
___
|
10291122-DS-16 | 10,291,122 | 24,097,387 | DS | 16 | 2132-08-16 00:00:00 | 2132-08-17 13:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
Unwitnessed fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ with h/o asthma, h/o PE (not on anticoagulation),
OCD, Tourette's, bipolar d/o, and intellectual disability
presents as transfer from ___ after unwitnessed
fall on ___ AM with c/f head strike.
Per patient and mother ___ (present at bedside), ___ has had
decreased appetite, poor PO intake, and weakness since ___
when her psychiatric medications were changed in the setting of
behavioral issues. Her Aripiprazole and Zoloft were discontinued
and Vraylar (new atypical antipsychotic) was initiated. ___
subsequently experienced nausea and vomiting in addition to the
anorexia and weakness. Mom notes she has lost 12 lbs in the past
month d/t lack of appetite. In ___ was admitted to
___ for Lithium toxicity with ___ level greater
than 2.0. Her Lithium was downtitrated from 300 mg BID to ___ mg
qAM and 300 mg qHS. Vraylar was tapered and discontinued with
last dose 2 weeks prior to admission.
On ___ morning, ___ missed her bus to go to a 'dayhab'
program. Her mother was at work and came home after the bus
company notified her that ___ missed the bus and a neighbor
knocked on the door with no answer. ___ was found on the ground
near a chair out of which her mother suspects she fell and was
too weak to lift herself up. Her mother notes that 45-60 minutes
elapsed between the time she saw ___ and returned home. ___ was
awake and groggy (slightly more than baseline; takes many
sedating medications) and endorsed a slight headache but was
found to have no bumps, scrapes, or bruises anywhere on her body
(floor is carpeted).
Patient was evaluated at ___ 10 days prior to
admission for cough. Pneumonia was ruled out; she was given
respiratory therapy with suctioning of secretions and started on
Albuterol nebulizer (has history of mild asthma) which mom says
has helped to improve breathing and reduced secretions.
___ denies any fever, dizziness (unsteady gait at baseline),
nausea, vomiting, diarrhea, chest pain, dyspnea, trouble with
urination.
In the ED, initial vital signs were: 98.0, 71, 104/69, 18, 99%
RA
- Exam notable for: no focal neurological deficits
- Labs were notable for: metabolic acidosis, ___, elevated WBC
to
12, elevated lithium level to 1.7
- Patient was given:
___ 05:00 IVF NS 1L
___ 11:31 PO/NG FLUoxetine 20 mg
___ 11:31 PO Propranolol LA 80 mg
___ 11:31 PO/NG ARIPiprazole 10 mg
___ 11:31 PO/NG ClonazePAM 1 mg
- Vitals on transfer: 98.6, 77, 100/54, 14, 97% RA
Upon arrival to the floor, the patient is resting comfortably
and
interactive and responsive to questioning with mom's help. Notes
no headache, lightheadedness, dizziness, chest pain, dyspnea,
nausea, vomiting, or diarrhea
Review of Systems: as per HPI otherwise 10 point ROS negative.
Past Medical History:
- asthma
- h/o PE ___ year ago, on Coumadin for ___ year, not on
anticoagulation currently
- OCD
- Tourette's
- Bipolar diorder
- Intellectual disability
- Spinal fusion at ___ (___) with removal of rods at ___ (___)
Social History:
___
Family History:
Maternal grandmother - emphysema, coronary bypass
Father - MI
No history of sudden cardiac death
Physical Exam:
ON ADMISSION -
Vitals- T98.8, BP96/62, HR 74, RR18, SaO2 98% on RA
GENERAL: AOx2 (difficulty with year), NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor or injection, sclera anicteric and without
injection. Moist mucous membranes
NECK: Thyroid feels slightly enlarged diffusely but is normal in
texture, no nodules. No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, normal S1/S2, no
murmurs/rubs/gallops. No JVD.
LUNGS: Clear to auscultation bilaterally with slightly decreased
breath sounds in R lung base. No wheezes, rhonchi or rales.
BACK: Skin. no spinous process tenderness. no CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants. Tympanic to percussion.
No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema, diminished muscle
bulk in bilateral upper extemities. Pulses DP/Radial 2+
bilaterally.
SKIN: brownish discoloration of web spaces of feet and hands
bilaterally; No evidence of ulcers, rash or lesions suspicious
for malignancy
NEUROLOGIC: CN2-12 grossly intact. diminished muscle bulk in
bilateral upper extremities, moving all extremities equally.
Normal sensation. Slightly decreased strength to knee extension,
hip flexion, on left and ___ on right. Otherwise ___ strength
throughout.
ON DISCHARGE -
Vitals- T98.0, Tmax 98.3, BP99/64 (93-105/59-69), HR 69
(69-79), RR18, SaO2 96% on RA
GENERAL: AOx2 (difficulty with year), NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor or injection, sclera anicteric and without
injection. Moist mucous membranes
NECK: Thyroid feels slightly enlarged diffusely but is normal in
texture, no nodules. No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, normal S1/S2, no
murmurs/rubs/gallops. No JVD.
LUNGS: Clear to auscultation bilaterally with slightly decreased
breath sounds in R lung base. No wheezes, rhonchi or rales.
BACK: Skin. no spinous process tenderness. no CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants. Tympanic to percussion.
No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema, diminished muscle
bulk in bilateral upper extemities. Pulses DP/Radial 2+
bilaterally.
SKIN: brownish discoloration of web spaces of feet and hands
bilaterally; No evidence of ulcers, rash or lesions suspicious
for malignancy
NEUROLOGIC: CN2-12 grossly intact. diminished muscle bulk in
bilateral upper extremities, moving all extremities equally.
Normal sensation. Slightly decreased strength to knee extension,
hip flexion, on left and ___ on right. Otherwise ___ strength
throughout.
Pertinent Results:
Admission Labs
===============
___ 12:03AM BLOOD WBC-12.3* RBC-3.74* Hgb-11.8 Hct-36.2
MCV-97 MCH-31.6 MCHC-32.6 RDW-13.2 RDWSD-47.7* Plt ___
___ 12:03AM BLOOD Neuts-58.4 ___ Monos-8.8 Eos-4.3
Baso-0.6 Im ___ AbsNeut-7.22* AbsLymp-3.40 AbsMono-1.08*
AbsEos-0.53 AbsBaso-0.07
___ 06:40AM BLOOD WBC-9.7 RBC-3.13* Hgb-10.2* Hct-30.6*
MCV-98 MCH-32.6* MCHC-33.3 RDW-14.1 RDWSD-50.9* Plt ___
___ 12:03AM BLOOD ___ PTT-30.7 ___
___ 12:03AM BLOOD Glucose-94 UreaN-14 Creat-1.2* Na-141
K-4.4 Cl-111* HCO3-17* AnGap-17
___ 12:03AM BLOOD Calcium-9.7 Phos-3.5 Mg-2.2
Pertinent Labs
===============
___ 07:00AM BLOOD TSH-0.02*
___ 07:00AM BLOOD Free T4-2.0*
___ 12:03AM BLOOD Lithium-1.7*
___ 07:00AM BLOOD Lithium-1.0
___ 06:40AM BLOOD Lithium-0.9
Discharge Labs
==============
___ 06:40AM BLOOD Glucose-96 UreaN-6 Creat-1.0 Na-140 K-3.3
Cl-109* HCO3-18* AnGap-16
___ 06:40AM BLOOD Calcium-9.5 Phos-3.9 Mg-1.8
___ 06:40AM BLOOD Osmolal-289
___ 08:50AM URINE Hours-RANDOM Creat-71 Na-<20 K-9 Cl-22
___ 08:50AM URINE Osmolal-170
___ 06:40AM BLOOD Lithium-0.9
Imaging
=========
___ EKG Emergency Dept
RatePRQRSQTQTc (___) ___
___ ___
___ EKG
RatePRQRSQTQTc (___) ___
___ EKG
Sinus rhythm. Again noted are rather extensive lateral,
anterior, and
anterolateral ST-T wave abnormalities suggestive of left
ventricular strain or hypertrophy or less likely myocardial
ischemia.
TRACING #3
RatePRQRSQTQTc (___) ___
___ ___
CT Head ___ IMPRESSION:
2 mm punctate hyperdense focus in the left frontal lobe is
unchanged since
study performed 8 hours prior and is unlikely to represent
hemorrhage and more likely to be a focus of calcification.
CT Neck ___ FINDINGS:
There is no acute fracture or traumatic malalignment. There is
no
prevertebral soft tissue swelling. There is no significant
spinal canal
stenosis or neural foraminal narrowing. Mild degenerative disc
disease is
noted at C5-C6.
The lung apices are clear. Layering secretion is noted in the
upper trachea. The thyroid gland is somewhat heterogeneous but
no large nodule is seen. There is no cervical lymphadenopathy.
Brief Hospital Course:
___ is a ___ year-old female with history of mild
asthma, history of PE (not currently on anticoagulation), OCD,
Tourette's, bipolar disorder, and intellectual disability who is
admitted as transfer from ___ after unwitnessed
fall on ___ AM with concern for head strike in the setting of
supratherapeutic lithium level.
#Unwitnessed Fall:
Per her mother ___, patient had an unwitnessed fall from chair
onto carpeted floor on ___ AM. Found to be groggy but
responsive with mild headache with uncertainty about headstrike
and low likelihood of loss of consciousness though patient does
not remember fall. This was in the setting of poor PO intake and
weight loss in context of psychiatric medication changes dating
back to ___. Non-contrast head CT showed calcifications but
no hemorrhages. Cervical spine CT showed no fractures or
malalignment. While syncope due to orthostasis is possible and
cannot be ruled out, it is also possible that ___ slipped out of
her chair and was too weak to lift herself up. EKG initially
showed prolonged QTc in the ED but normalized upon arrival to
the medicine service and monitoring on telemetry revealed no
arrhythmias. Orthostatic vital signs were checked and were
within normal limits. Seizure was felt to be unlikely given that
patient is on topiramate and no focal signs or post-ictal state.
She remained afebrile with no elevated WBC count and with stable
vital signs during her stay and a urinalysis revealed pyuria but
no concern for infection. She was given normal saline in the ED
and D5W during the initial part of her stay with no reported
dizziness, lightheadedness, chest pain, or shortness of breath.
It is believed her fall was due to muscle weakness.
# Lithium toxicity:
___ was hospitalized overnight at ___ ___
for lithium toxicity > 2.0. At that time, lithium was
downtitrated from 300 mg BID to ___ mg qAM and 300 mg qPM. Her
lithium was found to be supratherapeutic at 1.7 while at
___. She endorses subacute weakness; denies
diarrhea (last BM "few days ago"), dizziness, nausea, stomach
pains, vomiting, slurred speech (mother notes improved
comprehensibility of speech compared with last week), or
tremors. Physical exam revealed mild lower extremity weakness.
from ___ trending down to 0.9 (___). Initial labs revealed
mild hypernatremia, hyperchloremia, and non-gap metabolic
acidosis with elevation of creatinine to 1.2 (baseline kidney
function not known). Her lithium was held since ___ AM with
recommendation by psychiatry to hold until outpatient psychiatry
appointment on ___. EKG in the ED initially showed
prolonged QTc but normalized upon admission to the medicine
floor. Urine electrolytes were checked due to concern for
nephrogenic diabetes insipidus or Type 1 renal tubular acidosis
and showed production of dilute urine, however, the results were
difficult to interpret in the setting of her having received IV
fluids. At discharge, her lithium level was 0.9.
#Hyperthyroidism
TSH found to be 0.02 (LLN 0.24) and Free T4 2.0 (ULN 1.7).
Patient endorses weakness, emotional lability, and weight loss
with diminished appetite. Denies anxiety, tremor, palpitations,
heat intolerance, increased perspiration, or urinary frequency.
Despite low TSH, free T4 is only mildly elevated so unclear how
mild/severe symptoms would be. Differential diagnosis includes
lithium toxicity (though lithium usually inhibits thyroid
hormone release leading to goiter and hypothyroidism,
retrospective studies have noted that hyperthyroidism is
associated with ___ greater fold prevalence in those on ___
compared with gen population), Graves' disease, toxic nodular
goiter, and painless subacute lymphocytic thyroiditis. Given
thyroid exam was remarkable only for mildly diffusely enlarged
thyroid with no irregular texture/nodularity and no findings
associated with Graves' disease, Lithium toxicity and possibly
subacute thyroiditis are most likely. She was advised to
continue her home propranolol as this can be a treatment for
elevated thyroid hormones levels and advised to ___ her
thyroid function as an outpatient.
CHRONIC ISSUES
#Bipolar Disorder
-hold home Lithium
-Continue home Aripiprazole, Fluoxetine, Topiramate
#Asthma
-Continue home Albuterol nebulizer
#OCD
-Continue home Fluoxetine
-Continue home Clonazepam
#Tourette's
-Continue home Aripiprazole
-Continue home Propanolol
RESOLVED
# Long QTc:
History of long QTc, unclear if this is d/t structural disease
vs medication effect (she is on several psych medications that
could contribute). QTc in the ED was 569 and QTc 455 on ___
on floor ___ night). Risk for Torsades de Pointes. Resolved
to 387 on discharge.
# ?___:
Cr 1.2 with BUN 14, baseline unclear. Given 1 L NS in the ED and
D5W on the floor with improvement of Cr to 1.0. Likely
intrarenal given BUN/Cr < 15 and no e/o obstruction. Lithium
toxicity can lead to chronic tubulointerstitial disease.
Baseline creatinine unknown. Stable at discaharge.
# Mixed gap / non gap metabolic acidosis: despite AG of 15,
patient with delta gap of -7 and worsening of her acidosis after
NS indicating a concurrent hyperchloremic metabolic acidosis.
Improved during stay. Possible chronic component, and
recommended outpatient followup
TRANSITIONAL ISSUES
--------------------
1) Please do not take Lithium until you are seen by Dr. ___
on ___
2) Consider re-checking kidney function, serum electrolytes, and
urine electrolytes, as well as plasma ADH if concern for chronic
kidney injury or diabetes insipidus.
3) Consider re-checking thyroid function as TSH was low and free
T4 were high during hospitalization.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Propranolol 80 mg PO DAILY
2. Lithium Carbonate 150 mg PO QAM
3. Lithium Carbonate 300 mg PO QPM
4. Topiramate (Topamax) 50 mg PO QHS
5. Cetirizine 10 mg PO QPM
6. ClonazePAM 0.5 mg PO QAM
7. ClonazePAM 1 mg PO QHS
8. FLUoxetine 20 mg PO DAILY
9. ARIPiprazole 15 mg PO QHS
Discharge Medications:
1. ARIPiprazole 15 mg PO QHS
2. Cetirizine 10 mg PO QPM
3. ClonazePAM 1 mg PO QHS
4. ClonazePAM 0.5 mg PO QAM
5. FLUoxetine 20 mg PO DAILY
6. Propranolol 80 mg PO DAILY
7. Topiramate (Topamax) 50 mg PO QHS
8.Rolling Walker
Dx: Lithium toxicity, muscle weakness
Px: Good
Length of Need: 13 months
9.Outpatient Physical Therapy
Please evaluate and treat for muscle weakness and gate
instability. ICD-10-CM Code ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Lithium Toxicity
Secondary:
Hyperthyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for concern for an unwitnessed fall
in the setting of a high Lithium level. You were given
intravenous fluids and your lithium medication was stopped.
The psychiatry team saw you during your stay. Given the toxic
effects of high lithium, they recommended monitoring your kidney
function, electrolytes, and heart function on EKG. They
recommended that you continue all your other psychiatric
medications and that you do not take your lithium until you see
your outpatient psychiatrist, Dr. ___, on ___.
While evaluating you, we found that your thyroid hormone levels
were slightly elevated and that your thyroid stimulating hormone
was low. This can be due to high lithium levels and due to other
reasons as well. We recommend that your primary care physician
___ your thyroid gland function in the near future.
If you develop signs of mania (increased distractibility,
grandiose thoughts, racing ideas, agitation, decreased need for
sleep, rapid speech, decreased inhibition), please contact your
psychiatrist and primary care physician.
It was a pleasure taking care of you. We wish you the best in
your health.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10291303-DS-3 | 10,291,303 | 23,548,594 | DS | 3 | 2179-09-01 00:00:00 | 2179-09-06 23:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Left buttock pain and swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F w/ hx of AR/MR/TR with pulm htn, Afib on rivaroxiban,
CVA in ___ transferred for left buttock hematoma. She says she
has been on Xarelto for several years without an issue but three
weeks ago noticed brusing on her right leg without any memory of
trauma that became hard and sore but self-resolved. 1 week ago
she noticed similar bruising on her left leg but it was worse
than prior and very painful, limiting ambulation. She denies any
falls or trauma, but notes some lightheadedness and SOB during
the week as well as increasing fatigue yesterday and today.
Daughters noticed pallor on the patient yesterday. She went to
___ where she was found to have a hematoma with possible
extravasation so was given 1 unit pRBCs for Hct of 24. She
denies nosebleeds, BRBPR, melena, or other bleeding.
In the ED, initial vitals were: 98.8 74 105/41 16 94%. She was
noted to firm swelling of left buttock and lateral thigh, with
eccymosis covering lumbar region of back, buttocks and lateral
thigh. No signs of trauma.
- Labs were significant for K3.5, H/H 8.1/25.3 (up from 7.___.7
at ___ today, baseline Hgb 11 as recently as ___ INR 1.4
PTT 30.4 Plt 335
Upon arrival to the floor, she is tired but feels well, noting
that she hasn't slept in >24 hours and has had very little to
eat. She denies current SOB/CP. She has no pain currently.
REVIEW OF SYSTEMS: As per HPI, otherwise negative.
Past Medical History:
1. Atrial fibrillation.
2. CVA (___).
3. Aortic regurgitation-mild.
4. Mitral regurgitation-mild.
5. Tricuspid regurgitation-mild.
6. Pulmonary hypertension-mild.
7. Melanoma (greater than ___ years ago)
8. Anxiety.
9. Hysterectomy.
10. HTN
Social History:
___
Family History:
not relevant to the current hospitalization
Physical Exam:
ADMISSION PHYSICAL EXAM:
PHYSICAL EXAM:
Vitals: 98 124/57 75 18 96%RA 43.7kg
General: Well appearing woman lying in bed in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Irregularly irregular rhythm, normal S1 + S2, II/VI SEM
murmur loudest at LLSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Ecchymosis from left posterior thigh to lower back
extending over midline in lumbar region. 10 cm nontender soft
tissue swelling, not warm to touch, on posterior left tight.
Neuro: AAOX3, motor and sensory exam grossly intact
DISCHARGE PHYSICAL EXAM:
Vitals: T 98-98.3, BP 126/60-113/57, HR 73-67, RR ___, O2Sat
97-98% RA.
General: Well apearing thin elderly woman, pleasant and in NAD.
HEENT: Head ATNC, EOMI, PERRL.
CV: Irregular rate and rhythm, ___ holosystolic murmur, high
pitched early diastolic murmur. No S3, S4.
Lungs: Clear to auscultation bilaterally.
Abdomen: Flat, non tender to palpation, +BS
Ext: Markedly improved left buttock swelling and echymosis.
minimal echymosis remains over leteral left buttock and lower
back. Remainder of extremities warm and well perfused, without
peripheral edema.
Neuro: CN II-XII grossly intact.
Pertinent Results:
INITIAL LABS:
___ 11:15PM BLOOD WBC-8.4 RBC-2.73* Hgb-8.1* Hct-25.3*
MCV-93 MCH-29.7 MCHC-32.0 RDW-19.7* RDWSD-59.1* Plt ___
___ 11:15PM BLOOD Neuts-71.7* Lymphs-14.9* Monos-11.8
Eos-1.0 Baso-0.2 Im ___ AbsNeut-6.04 AbsLymp-1.25
AbsMono-0.99* AbsEos-0.08 AbsBaso-0.02
___ 11:15PM BLOOD ___ PTT-30.4 ___
___ 11:15PM BLOOD Glucose-73 UreaN-14 Creat-0.7 Na-137
K-3.5 Cl-103 HCO3-23 AnGap-15
___ 06:30AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.2
IMAGING:
___
___
Left Hip/femur/pelvis XR
IMPRESSION: Left hip, left femur, and pelvis radiographs
demonstrate
no evidence for a fracture, allowing for technically suboptimal
cross-table lateral view of the left hip, as well as partial
obscuration of the sacrum/coccyx by bowel gas.
CXR
IMPRESSION:
1. No evidence for acute cardiopulmonary abnormalities.
2. Prominence of the right upper mediastinal shadow could be
related to the patient's tilted position.
RECOMMENDATION(S):
Recommend repeated radiographs, when feasible, for better
assessment of the right upper mediastinal shadow.
CT Abd/pelv w and w/o con ___
IMPRESSION:
1. Large hematoma centered in the left gluteus medius muscle.
Two
small calcific densities within the hematoma may reflect an
avulsion
injury at the gluteus medius tendon insertion. Following
contrast
administration there is a small area of pooling of contrast
adjacent
to these bony fragments is which may reflect active
extravasation however there is minimal diffusion of the contrast
on the delayed phase suggesting this is either intermittent or
very slow flow extravasation
2. Marked enlargement of the right heart and inferior vena cava
consistent with right heart failure
3. 5.4 cm simple appearing cyst in the right lower quadrant.
While this may reflect an ovarian cyst, this is not the typical
location and this may in fact be a GI duplication cyst. An
ultrasound may be helpful to clarify if clinically indicated.
4. Extensive degenerative changes and a scoliotic curve in the
lumbar spine.
5. Atherosclerotic calcification in the abdominal aorta.
EKG: ___ ___ Afib rate 69
CXR ___ ___
FINDINGS:
Compared to the prior study there is no significant interval
change. The
patient positioning is slightly improved and as such the right
upper
mediastinal silhouette now appears normal. The heart is
continues to be
severely enlarged and there continues to be a scoliosis convex
left both
shoulders are noted to be high-riding with degenerative changes
DISCHARGE LABS:
___ 01:30PM BLOOD WBC-8.7 RBC-2.95* Hgb-8.6* Hct-28.4*
MCV-96 MCH-29.2 MCHC-30.3* RDW-19.1* RDWSD-64.7* Plt ___
___ 10:35AM BLOOD ___ PTT-75.3* ___
___ 04:09AM BLOOD PTT-79.8*
___ 06:30AM BLOOD Glucose-86 UreaN-14 Creat-0.7 Na-137
K-3.9 Cl-104 HCO3-25 AnGap-12
___ 06:30AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.1
Brief Hospital Course:
Ms. ___ is an ___ year old woman with a PMHx of a-fib on
rivaroxaban who presented to us from an outside hospital with a
left buttock hematoma after a presumed trauma that the patient
couldn't recall. She was admitted from ___ - ___.
.
ACTIVE ISSUES:
1. Left Buttock hematoma: During her stay interventional
radiology was involved, however, their services were not
necessary as she improved without intervention. Upon arrival we
gave her fluids and one unit of packed red blood cells. We
stopped her rivaroxaban and trended her CBCs which remained
stable and were trending up upon discharge (see discharge labs).
We restarted anticoagulation in the hospital with heparin
(titrated to PTT ___ for her age and weight) for 24 hours and
she remained stable. She was discharged on apixaban for long
term anticoagulation.
.
2. Atrial fibrillation: Throughout her hospitalization she was
monitored on telemetry. Chest x-ray was unchanged from previous.
Her home medications were continued and she remained well rate
controlled with HR ranging from ___. She was anticoagulated
as above.
.
CHRONIC ISSUES:
3. Hypertension: we continued her home medications and she
remained normotensive throughout her stay.
4. Deconditioning: patient described frequent accidental trauma
secondary to bumping into things. Physical therapy evaluated her
and recommended a walker and impatient rehabilitation. This was
set up through her retirement living community.
TRANSITIONAL ISSUES:
1. Please monitor bleeding on apixaban.
2. Please follow up with anticoagulation regimen for a-fib.
3. Recommend repeat CBC at next PCP appointment to ensure
continued up-trending H&H.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Gabapentin 300 mg PO QHS
3. Hydrochlorothiazide 25 mg PO DAILY
4. Rivaroxaban 20 mg PO DAILY
5. Simvastatin 20 mg PO QPM
6. Aspirin 81 mg PO DAILY
7. Acetaminophen 500 mg PO Q6H:PRN pain
8. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
9. diphenhydrAMINE-acetaminophen ___ mg oral QHS:PRN insomnia
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Apixaban 2.5 mg PO BID a-fib
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth Twice daily
Disp #*30 Tablet Refills:*0
3. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
4. diphenhydrAMINE-acetaminophen ___ mg oral QHS:PRN insomnia
5. walker miscellaneous DAILY unsteady gait
ICD-9: 728.2
RX *walker [Ultra-Light Rollator] Please use while walking
Disp #*1 Each Refills:*0
6. Amiodarone 200 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Gabapentin 300 mg PO QHS
9. Hydrochlorothiazide 25 mg PO DAILY
10. Simvastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Left Buttock Hemotoma
Atrial Fibrillation
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:
Hello Ms. ___,
It was a pleasure participating in your healthcare here are ___
___. You came to us with a left
buttock hematoma while you were taking rivaroxaban. We stopped
your ribaroxaban, monitored your bleeding, and got
interventional radiology involved. Fourtunately, you improved on
your own without further procedures. We anticoagulated you with
heparin while you were in the hospital and you had no further
bleeding events. Your hematoma comtinued to improve while you
were being anticoagulated. We started you on apixaban instead of
rivaroxaban and had physical therapy evaluate you while you were
here. Physical therapy suggested that you get home physical
therapy and use a walker to get around. Below you will find a
list of the recommendations we have made for you:
1. Please stop rivaroxaban indefinetly.
2. Please start apixaban 2.5 mg twice daily (one time in the
morning and one time in the evening). This medication is
replacing your rivaroxaban.
3. We are sending you home with a prescription for a walker.
Please have this filled so you can use the walker at home.
4. We have arranged for you to go to the ___
rehabilitation part of your living facility. We feel that this
will give you the care you need to fully recover.
5. You have two follow up appointments to attend after this
hospitalization, please see description below.
6. Additionally, please call and schedule a follow up
appointment with your primary care provider ___ ___ weeks.
Name: ___
Address: ___, ___, ___
Phone: ___
Fax: ___
Thank you for choosing ___ for
your health care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10291406-DS-5 | 10,291,406 | 21,239,119 | DS | 5 | 2190-06-14 00:00:00 | 2190-06-14 17:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
Fatigue, chest pressure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo gentleman with h/o hypertension, hyperlipidemia, HIV who
presents with 5 days of constant substernal chest pressure,
dyspnea on exertion, increased fatigue and lightheadedness. He
was referred in by his PCP's office due to an EKG in office
showing subtle changes and possible Q waves.
Regarding his symptoms, patient reported waking up with the
above
symptoms. The chest pressure is constant, does not radiate and
occurs both at rest and with exertion. It is not pleuritic.
Dyspnea symptoms resolves with rest. Patient also states he has
had some "indigestion" but denies vomiting, diarrhea, blood in
the stool.
He has a significant family history of CAD in both parents.
On review of systems, he denies fevers, chills, and cough.
Although patient has known to be bradycardiac since ___
(initially thought to be atenolol in the setting of ___, the
above symptoms are new.
Although patient presented with non-specific symptoms and his
work-up for acute coronary syndrome has been negative, he has
multiple risk factors for coronary disease. In terms of
bradycardia, it is chronic and based on the review of his
telemetry, he appears to have appropriate although also possibly
slightly blunted chronotopic response with exertion.
Cardiology recommended an exercise stress with nuclear imaging
given that a stress echo in ___ had poor image quality. He
stayed in the ED overnight from ___. The stress test here
revealed normal myocardial perfusion and increased left
ventricular cavity size with normal systolic function (EF >
55%).
He was admitted to medicine for further workup of his
lightheadedness.
Upon arrival to the floor, patient reports that the fatigue
began
on ___ and has persisted throughout the weekend. He describes
that he felt lightheaded and felt as though he was "dizzier"
than
usual although could not describe any gait instability or
sensation of whether he or room was spinning. He reports that he
has been sleeping much more than usual over the weekend. He also
had about 3 margaritas with his friends over the weekend but
felt
very fatigued and did not enjoy the night. He denies any recent
extraordinary exertion or exercise but does take his ___-month old
puppy out about four times daily. He has significant R-sided
pain
associated with being pulled by his puppy and feels that his arm
is about to fall off. Now his chest discomfort is continuous,
non-radiating. He has not had this chest discomfort before. He
describes that it was ___ when he arrived in the ED and is now
___, but he is not sure what makes it better.
He has had regular PO intake recently and reports one episode on
___ which he thinks is associated with the vegetables he
cooked. He has had no diarrhea since. He denies any fever, night
sweats, abdominal pain, constipation, cough, shortness of
breath,
sick contacts, or recent falls. He has had headache since these
symptoms started, which is described as mild and generalized. He
does not really take medications for this. He has had recent
blurred vision but notes that he tried new bifocal contacts
recently and is currently still trialing them. He denies any
photophobia or neck stiffness. He did report one episode of
chills one week ago. He has not noticed any new rashes or skin
changes. He does endorse current alcohol use but denies other
drug or substance use.
He also reports that he does snore at night but has never been
diagnosed with sleep apnea. He does not have any major
complaints
or concerns today other than that described above. He has been
taking all of his medications as prescribed. He has been able to
ambulate regularly although feels that grocery shopping has been
more taxing than usual. His support system includes many friends
in the area and in his apartment as well as distant family
members.
Regarding his history of bradycardia, he was seen by Dr. ___
in
outpatient cardiology clinic in ___ and at that time, his
bradycardia was attributed to atenolol in the setting ___ or
increased vagal tone. At his ___ stress test, it was also
noted that he had a blunted heart rate response to exercise. He
was supposed to follow up with cardiology in ___ but was
lost
to follow up.
Past Medical History:
Symptomatic sinus bradycardia
Diastolic hypertension
HIV on Complera
Anxiety/ depression, h/o suicide attempt ___
Social History:
No tobacco use
ETOH: History of alcohol use disorder, relapsed in ___
after
___ years sobriety. He continues to drink about ___ beverages per
week usually on weekends.
Illicits:
-positive for amphetamines in ___
-iv drug use, clean for ___ years
The patient was born and raised as 1 of 4
children in ___. He lost one sister to cancer in
___.
Both his parents are deceased. He reports that both parents had
problems with alcohol. He identifies as homosexual. Has had
meaningful intimate relationships in the past but not currently.
No children. Has a ___ in ___, has worked as a ___
___. Lost his ___ old ___ in ___.
Currently lives in ___. He was diagnosed with HIV in ___.
Family History:
Significant alcohol use in sister and parents
___ in parents
MI in father in ___
___ in 2 sisters
Physical ___:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: 98.5
PO 140 / 88 52 18 96 RA
GENERAL: Well-appearing male in no acute distress. BMI 34
consistent with mild obesity.
HEENT: PERRL, EOMI, Moist mucous membranes
NECK: No lymphadenopathy, no meningeal signs.
MSK: Right lower sternal pain noted, reproducible to palpation.
Upon raising arm, he also notes significant right sided pain.
CARDIAC: Bradycardic HR ___, regular, no murmurs
LUNGS: Clear bilaterally. Good air flow.
ABDOMEN: Soft, Nondistended, mildly tender to RUQ upon deep
palpation without rebound tenderness. Normoactive bowel sounds.
EXTREMITIES: Cold at feet, otherwise warm , no evidence of
edema. No toe swelling appreciated
NEUROLOGIC: Alert, oriented, no focal neuro deficits
appreciated
SKIN: No rashes or bruises
PSYCH: Appears appropriate, normal mood, responds appropriately
DISCHARGE PHYSICAL EXAM:
VITAL SIGNS:
___ ___ Temp: 97.6 PO BP: 142/89 HR: 42 RR: 16 O2 sat: 96%
O2 delivery: Ra
GENERAL: Well-appearing male in no acute distress.
HEENT: PERRL, EOMI, Moist mucous membranes
MSK: Right lower sternal pain noted, reproducible to palpation.
CARDIAC: Bradycardic HR ___, soft heart sounds,regular, no
murmurs
LUNGS: CTAB
ABDOMEN: Soft, Nondistended,
EXTREMITIES: Cold at feet, otherwise warm , no evidence of
edema.
No toe swelling appreciated
NEUROLOGIC: Alert, oriented, no focal neuro deficits appreciated
SKIN: No rashes or bruises
PSYCH: Appears appropriate, normal mood, responds appropriately
Pertinent Results:
ADMISSION LABS:
CBC: WBC 3.7 Hgb 14.7 Hct 42.5 Plt 184
Trop M 0.01 x 2
BNP 25
Chem 10: Na 141 K 4.4 Cl 106 CO2 23 BUN 13 Cr 1.1 AG 12 Glc 106
LFTs: AST 22 ALT 32 Alk Phos 89 Tbili 0.4 Lipae 27
Albumin 4.1
UTox: Neg for benzodiazepines, barbiturate, opiates, cocaine,
amphetamines, oxycodone, and methadone
UA: Neg for nitrites, neg for protein, neg forleukocytes
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-4.0 RBC-4.65 Hgb-16.0 Hct-44.9 MCV-97
MCH-34.4* MCHC-35.6 RDW-12.4 RDWSD-44.0 Plt ___
___ 02:00PM BLOOD WBC-PND Lymph-PND Abs ___ CD3%-PND
Abs CD3-PND CD4%-PND Abs CD4-PND CD8%-PND Abs CD8-PND
CD4/CD8-PND
___ 07:30AM BLOOD Glucose-95 UreaN-18 Creat-1.1 Na-140
K-4.2 Cl-103 HCO3-24 AnGap-13
IMAGING/STUDIES:
CXR ___
No acute cardiopulmonary process.
EXERCISE STRESS TEST ___
No ischemic EKG changes in the presence of atypical anginal
symptoms. Blunted heart rate response to exercise. Nuclear
report sent
separately.
CARDIAC PERFUSION ___
1. Normal myocardial perfusion.
2. Increased left ventricular cavity size with normal systolic
function.
MICRO:
___ 3:55 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Brief Hospital Course:
___ yo gentleman with h/o hypertension, hyperlipidemia, HIV who
presented with 5 days of constant substernal chest pressure,
dyspnea on exertion, increased fatigue and lightheadedness. He
was referred to the ED, for concern of chest pain and he ruled
out for ACS with negative troponins and a negative stress test.
He was admitted for further workup of his lightheadedness and
bradycardia. EP was consulted and recommended no indication for
pacemaker. He was discharged with PCP and cardiology ___.
# Fatigue, lightheadedness:
His fatigue is described as acute to subacute over the last 2
weeks, and lightheadedness with standing after lying down. His
workup was notable for normal hemoglobin, TSH, negative ACS
workup as below, borderline positive orthostatic vital signs for
which she received IV fluids. EP was consulted for his
bradycardia as below, but did not feel that his symptoms were
related or that a pacemaker was indicated. Behavioral or social
stressors were also unlikely per patient report. He had normal
ambulatory O2 sat monitoring and good heart rate response,
including during his stress test. The etiology is not quite
clear, but may be related to a viral illness (patient now
reporting sinus headache, but denied fevers or chills in the
days preceding admission). His heart rate on discharge was in
the ___. If his fatigue remains in 2 weeks, a referral for
sleep study should be considered given his obesity.
# Leukopenia:
Mild neutropenia ANC 1100: Commonly seen in HIV positive
patients. Sometimes has been associated with antiretroviral
therapy but also many infections. His WBC count on discharge was
4.0. He should have repeat CBC drawn at his next visit.
# Chest pain:
Etiology is likely musculoskeletal given reproducibility on
exam. ACS ruled out with trop and stress test. EKG without
significant changes compared to prior- has TWI in III and TWF in
aVF. Possibly costochondritis secondary to a viral etiology as
above. He was recommended to continue Tylenol, NSAIDs as needed.
# Bradycardia:
Patient has history of symptomatic bradycardia. He was monitored
on telemetry, where his heart rates remained in the ___. EP
was consulted as above and did not feel that his symptoms were
related to his bradycardia.
# HIV on complera (Emtricitabine / Rilpivirine / Tenofovir).
His last CD4 count in ___ was in the 600s. A repeat CD4 was
drawn but pending on discharge.
# Diastolic hypertension: BP 140/80 on admission to floor.
-Continue chlorthalidone
# Anxiety, depression; Patient with hospitalization in ___ for
suicidal ideation in the setting of recent loss of his dog,
recent diagnosis of HIV, and difficulty coping with loss of
sister. Currently reports improved mood.
- Continue wellbutrin and celexa
- Ativan-- home regimen of 0.5mg q6h prn
# Preventative medications
# Significant family history of CAD
- On aspirin 81mg daily and atorvastatin 10mg daily
TRANSITIONAL ISSUES:
====================
[] Please ensure follow up with cardiology. Appointment request
placed.
[] Please follow up his repeat CD4 count
[] Repeat CBC to monitor WBC (4.0 on discharge ___.
[] Consider referral for sleep study if fatigue unresolved two
weeks post discharge
# CODE: full (presumed)
# CONTACT: ___
Relationship: brother
Cell phone: ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. BuPROPion XL (Once Daily) 300 mg PO DAILY
6. Complera (emtricita-rilpivirine-tenof DF) 200-25-300 mg oral
DAILY
7. LORazepam 0.5 mg PO DAILY:PRN anxiety
8. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg ___ tablet(s) by mouth q8h PRN Disp
#*30 Tablet Refills:*0
2. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *ibuprofen 400 mg 1 tablet(s) by mouth q6h PRN Disp #*30
Tablet Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD ONCE:PRN R lower sternum
apply over site of pain
RX *lidocaine [Lidoderm] 5 % 1 patch once a day Disp #*7 Patch
Refills:*0
4. Citalopram 20 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 10 mg PO DAILY
7. BuPROPion XL (Once Daily) 300 mg PO DAILY
8. Cetirizine 10 mg PO DAILY
9. Chlorthalidone 25 mg PO DAILY
10. Complera (emtricita-rilpivirine-tenof DF) 200-25-300 mg
oral DAILY
11. LORazepam 0.5 mg PO DAILY:PRN anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pain
Lightheadedness
Bradycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you during this admission,
Why was I admitted to the hospital?
-You were admitted because your heart rate was noted to be very
slow and you were having symptoms of lightheadedness and chest
pressure
What happened while I was in the hospital?
-You had a stress test of your heart, which was normal.
-You were seen by our cardiologists, who felt that your symptoms
were likely not related to your slow heart rate.
-Your given IV fluids to ensure you were hydrated.
What should I do when I leave the hospital?
-Please see your primary care doctor as below
-Please continue taking your medications as listed
-Please ask your primary care doctor about doing a possible
sleep study if your fatigue remains after 2 weeks
-Please continue taking her medications as instructed.
We wish all the best,
___
Followup Instructions:
___
|
10291484-DS-15 | 10,291,484 | 25,661,493 | DS | 15 | 2159-11-03 00:00:00 | 2159-11-06 12:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Hydrochlorothiazide / Benicar
Attending: ___
___ Complaint:
right thigh pain
Major Surgical or Invasive Procedure:
___: Debridement and drainage of right deep thigh abscess
___: PICC line placement by ___
History of Present Illness:
Ms. ___ is a ___ female with a history of hypertension,
Graves disease, acid reflux, hyperlipidemia, right hip fracture
in ___ who comes in with inability to ambulate due to right hip
pain for the last month.
She has had right hip pain for approximately ___ year. She
confirmed having a steroid injection ___ year ago that provided
pain relief for about 6 months. When the pain gradually
worsened, she had another steroid injection done in early
___. This relieved the pain for a couple of days and came
back. Of note, after the injection, she noticed that her right
thigh began to swell where she got the injection and the pain
progressively worsened. In the past couple of months, she has
lost ___ unintentionally (she attributes a lot of it to her
inability to walk and get food comfortably).
Notably, her PCP sent her to the ED on ___ to have the hip
pain evaluated for septic arthritis. Orthopedics evaluated
patient at that time, and due to low concern for fracture or
infection, was sent home.
She was seen by her PCP again on ___ and had a CT
abdomen/pelvis done which revealed a large 13.2 x 10.6 cm
heterogeneous enhancing soft tissue lesion adjacent to the
proximal right femur, concerning for sarcomatous changes or
sarcoma. Biopsy should be performed for further evaluation. PCP
sent her to the ED subsequently for biopsy and further work up.
She denied: fever, shaking chills, chest pain, SOB, urinary
symptoms, diarrhea, constipation, abdominal pain, muscle
weakness.
She confirmed: ___
Family History:
Mother had diabetes.
Physical Exam:
Admission exam:
============
Vital Signs: 98.2 135 / 68 87 20 95 RA
General: Alert, oriented x3, nontoxic appearance
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 and S2, systolic murmur
best heard ___
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Right thigh: erythema, swelling and warmth on anterolateral
surface of proximal thigh. No pain on log roll. No pain on
straight leg raise to 45 degrees. Pain on palpation of erythema
Discharge exam:
============
Vital Signs: 98.5 126 / 66 83 94 Ra
General: Lying comfortably in bed in NAD
CV: RRR, normal S1 and S2, II/VI systolic murmur best heard LLSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Right thigh: Wound vac removed, large lateral incision with well
approximated edges, no induration or erythema, no drainage,
minimal TTP
Pertinent Results:
Initial labs:
==============
___ 10:05AM BLOOD WBC-12.8* RBC-3.68* Hgb-9.2* Hct-29.3*
MCV-80* MCH-25.0* MCHC-31.4* RDW-16.7* RDWSD-48.0* Plt ___
___ 10:05AM BLOOD Neuts-88.9* Lymphs-5.5* Monos-4.2*
Eos-0.2* Baso-0.3 Im ___ AbsNeut-11.40* AbsLymp-0.70*
AbsMono-0.54 AbsEos-0.02* AbsBaso-0.04
___ 10:05AM BLOOD Hypochr-OCCASIONAL Anisocy-2+ Poiklo-1+
Macrocy-OCCASIONAL Microcy-2+ Polychr-NORMAL Ovalocy-1+
Burr-OCCASIONAL Pencil-OCCASIONAL Tear ___
___
___ 10:05AM BLOOD ___ PTT-29.5 ___
___ 10:05AM BLOOD Ret Aut-1.6 Abs Ret-0.06
___ 10:05AM BLOOD Glucose-117* UreaN-11 Creat-0.6 Na-137
K-4.0 Cl-97 HCO3-23 AnGap-21*
___ 10:05AM BLOOD ALT-12 AST-14 LD(LDH)-168 AlkPhos-102
TotBili-0.4
___ 10:05AM BLOOD Albumin-3.2* Iron-18*
___ 10:05AM BLOOD calTIBC-151* Hapto-515* Ferritn-961*
TRF-116*
___ 10:05AM BLOOD TSH-3.7
___ 10:05AM BLOOD CRP-142.3*
Microbiology:
==============
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Studies:
=========
Pelvis and femur radiograph ___:
- The bony pelvic ring appears intact. The heterogeneous
enhancing soft tissue lesion adjacent to the right proximal
femur is better assessed on recent CT exam. Left hip aligns
normally though there is a similar pattern of moderate to severe
osteoarthritis.
US interventional procedure ___:
1. Large, complex mass with regions of loculated fluid within
the proximal anterolateral right thigh.
2. Technically successful ultrasound-guided percutaneous fluid
aspiration and soft tissue component biopsy. Fluid samples were
sent for Gram stain/culture as well as cell count and
differential. The soft tissue biopsy samples were sent to
pathology.
Pathology:
===========
SURGICAL PATHOLOGY REPORT - Final
PATHOLOGIC DIAGNOSIS:
"RIGHT HIP DEEP TISSUE", DEBRIDEMENT:
Fibrovascular and adipose tissue with granulation tissue
formation and acute and chronic inflammation.
Note: There is no evidence of malignancy. See concurrent
microbiology studies for further characterization.
CLINICAL HISTORY:
Right thigh abscess.
GROSS DESCRIPTION:
The specimen is received fresh in a container labeled with the
patient's name, ___, the medical record number,
and is additionally labeled "right hip deep tissue". The
specimen consists of a red-tan soft tissue fragment that
measures 2.7 cm x 2.2 cm x 0.4 cm and is entirely submitted in
cassette 1A.
Discharge Labs:
================
___ 04:41AM BLOOD WBC-12.8* RBC-3.34* Hgb-8.4* Hct-27.8*
MCV-83 MCH-25.1* MCHC-30.2* RDW-17.5* RDWSD-52.0* Plt ___
___ 04:41AM BLOOD Glucose-127* UreaN-11 Creat-0.7 Na-139
K-3.5 Cl-101 HCO3-29 AnGap-13
Brief Hospital Course:
Ms. ___ is a ___ female with a history of hypertension,
Graves disease, acid reflux, hyperlipidemia, right hip fracture
in ___ s/p IMN who came in with inability to ambulate due to
right hip pain who was found to have a large abscess of right
thigh, likely ___ to seeding from right trochanteric bursa
injections. s/p I&D in OR with Ortho. Per Orthopedics, abscess
tracked down to hardware and bone. ID was consulted and
recommended at least 6 week course of IV antibiotics until
___ with possible longer course of PO following the IV
course given concern for possible hardware infection.
ACUTE ISSUES
# Right Thigh Abscess
Please see above for course. There is concern from ID for
hardware infection so patient was deemed to require 6 weeks of
IV antibiotics. Plan to add on rifampin about 2 weeks into the
course followed by likely 12 weeks of PO suppression in
effort to clear bone and hardware infection. Ortho did not rule
out completely taking out the prior intramedullary nail, but
they felt that it was not indicated at the moment.
# Anemia
Review of OMR results, new anemia. MCV 80, borderline with
increased RDW. Clinically, stable vital signs and denied bloody
bowel movements. Could be anemia of chronic inflammation in the
setting of infection. No history of thalassemia or other
inherited blood disorders. Iron studies most consistent with
anemia of chronic inflammation. Received 1U pRBC during this
hospitalization on ___ for H/H of 6.9/23.5.
# Coagulopathy
INR elevated to 1.5 on presentation. No history of liver disease
and LFTs WNL. Denied being on anticoagulation medications.
Fibrinogen, haptoglobin, and LDH reassuring for no evidence of
hemolysis/DIC. Likely etiology is poor PO intake and
inflammation from chronic disease. Started on vitamin K PO
challenge, which improved INR slightly.
CHRONIC ISSUES
# GERD
Patient was on omeprazole in the past but self discontinued as
it was not helping her. Started Gaviscon with relief. However,
patient wanted to start omeprazole again in house and was
started on 40 mg daily of omeprazole. However, she developed
worsening acid reflux symptoms, and was started on famotidine in
addition to increasing omeprazole to 40 mg BID.
# Hypothyroidism
Was on levothyroxine 25mcg/day but self discontinued because she
did not feel better. TSH normal. Did not start levothyroxine in
house. Will need repeat TSH on outpatient basis.
# Hypertension
Continued home regimen of labetalol 50 mg BID initially, but
patient's BP was not elevated, and she reported dizziness with
standing. Therefore, labetalol was held with plans to restart as
outpatient if needed.
TRANSITIONAL ISSUES
[ ] Will need follow up with infectious disease for ongoing
treatment of her osteomyelitis.
[ ] Enrolled in ___ OPAT program. Will need nafcillin 2g IV
q4hr until at least ___.
[ ] Patient will need weekly CBC with differential, BUN, Cr,
AST, ALT,
Total Bili, ALK PHOS, CRP surveillance labs, which should be
sent to: ATTN: ___ CLINIC - FAX: ___.
[ ] Orthopedics follow up in clinic in 2 weeks
[ ] Consider restarting labetalol if needed
Greater than 30 minutes was spent on this patient's discharge
day management.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 50 mg PO BID
2. Gaviscon Extra Strength (aluminum hydrox-magnesium carb)
160-105 mg oral PRN
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Magnesium Oxide 400 mg PO DAILY
5. Omeprazole 40 mg PO BID
6. Vitamin D 1000 UNIT PO DAILY
7. Citracal + D Maximum (calcium citrate-vitamin D3) 315-250
mg-unit oral ___ tablets PO daily
8. Acetaminophen ___ mg PO DAILY:PRN Pain - Mild
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Benzonatate 100 mg PO TID:PRN cough
3. Bisacodyl ___AILY:PRN No BMs >24 hours
4. Famotidine 20 mg PO Q12H
5. Nafcillin 2 g IV Q4H
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
8. Polyethylene Glycol 17 g PO DAILY:PRN No BMS >24 hours
9. Senna 17.2 mg PO BID
10. Citracal + D Maximum (calcium citrate-vitamin D3) 315-250
mg-unit oral ___ tablets PO daily
11. Gaviscon Extra Strength (aluminum hydrox-magnesium carb)
160-105 mg oral PRN
12. Magnesium Oxide 400 mg PO DAILY
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Omeprazole 40 mg PO BID
15. Vitamin D 1000 UNIT PO DAILY
16. HELD- Labetalol 50 mg PO BID This medication was held. Do
not restart Labetalol until your PCP instructs you to restart
it.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
===================
- Abscess, right thigh
- Anemia
- Coagulopathy
Secondary Diagnoses:
=====================
- Right trochanteric bursitis
- GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You were concerned about your worsening right leg pain
What did you receive in the hospital?
- You were found to have an abscess (fluid collection infection)
where you were having pain. You were taken to the operating
room, and it was cleaned out.
- Since the infection may be involving the bone and your prior
hardware from surgery, we consulted the infectious disease
specialists who recommended at least 6 weeks of antibiotics.
What should you do once you leave the hospital?
- You will need to continue receiving antibiotics from your new
___ line until at least ___.
- Please follow up with your infectious disease doctor as
scheduled below.
- Please follow up with your orthopedic surgeon as scheduled
below.
- Please return to the hospital if your right thigh pain
worsens.
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated right lower extremity
- range of motion as tolerated right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
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
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10291942-DS-10 | 10,291,942 | 21,444,976 | DS | 10 | 2176-08-03 00:00:00 | 2176-08-03 23:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
EGD ___
Colonoscopy ___
Radiation treatment ___
History of Present Illness:
Mr. ___ is a ___ male with the past medical
history of h/o CVA on lovenox, DM2, MVT with UGIB, obstructive
duodenal adenocarcinoma s/p gasterojejunostomy bypass and GJ
tube
placement for gastric outlet syndrome (___) presenting
with
acute anemia.
The patient was recently hospitalized on the
Medicine/Hepatobiliary/ACS services from ___ - ___ after
presenting with 3 weeks of nausea and vomiting, followed by a
syncopal episode, found to have a duodenal mass causing gastric
outlet and biliary obstruction. He underwent an EGD with biopsy
which reported a malignant-appearing mass, though pathology
non-diagnostic. He was transferred to ___ for consideration
of
ERCP vs surgical management. ERCP was attempted but could not
stent the area that was obstructed, so he had a biliary drain
placed. After placement of the drain his LFTs improved. The
drain
was capped with continued stability of LFTs. For his gastric
outlet obstruction, he was started on TPN (enteral feeding via
NGT was attempted several times but unable to be placed due to
discomfort). His course was complicated by persistent
nausea/vomiting resulting in hemorrhagic shock ___ ___
tear (treated with epi, hemospray, blood products, which
required
an ICU stay from ___. His hospital course was also
complicated by a Type II NSTEMI and ___.
After he eventually stabilized, he was taken for an ExLap on
___. During the operation a large mass was found adherent to
the duodenum and causing obstruction. Biopsy was positive for
adenocarcinoma. The decision was made not to proceed with a
Whipple operation and a gastrojejunostomy bypass was done
instead. A GJ feeding tube was placed for enteral access. He
completed a 5-day course of zosyn due to positive intra-op
cultures and pain was treated with a dilaudid PCA (converted to
po once patient was taking po). TPN was discontinued once the
TFs were at goal. He was started on lovenox at treatment dose
given history of CVA (felt to be cardioembolic in origin) and
also started on standing insulin along with SS. At the time of
discharge, the patient was tolerating fulls, ambulating, and
voiding without difficulty. His medications were changed to
liquids due to difficulty with swallowing pills.
He presents today to the ED as a referral for a dropping Hgb
(8.4
on ___ to 4.8 on ___ He received 2 units of blood on ___ for
a
Hgb of 5.4, with improvement to 7 mg/dL. The following day on
___, his Hgb was dropped again to 4.8 and he received another
two
units of PRBCs. He was transferred to the ___ ED for further
evaluation. The patient denies any hematemesis, bloody stools,
melena, nausea, vomiting, chest pain, or SOB. He has had some
postural lightheadedness over the last few days when sitting up.
He feels generally weak since his discharge. Of note, while at
rehab, his TFs have been at goal and he has been able to do
crushed ice and small sips of water by mouth. No abdominal pain
or discomfort, he thinks he may have had diarrhea a couple of
days ago.
In the ED, VSS. He was seen by GI and surgery - exam was
notable
for melena and guaiac positive stool. A CTA abd/pelvis was
negative for active bleeding as was a gastric lavage. He was
given 1 unit of PRBCs and protonix IV, and admitted to medicine
for further management. Currently he is feeling OK, no specific
concerns or complaints.
Past Medical History:
- CVA
- HTN
- HLD
Social History:
___
Family History:
- Mother, asphyxiated on food
- Father, CAD s/p multiple MIs; colon cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate, MM
slightly dry.
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, slightly distended, non-tender to palpation.
Staples c/d/I, no surrounding erythema. G-tube also c/d/I
without drainage and erythema. 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
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM
PHYSICAL EXAM:
VITALS:
24 HR Data (last updated ___ @ 902)
Temp: 97.7 (Tm 97.7), BP: 129/74 (100-135/67-80), HR: 87
(82-115), RR: 18, O2 sat: 97% (95-98), O2 delivery: Ra
GENERAL: NAD, flat affect, alert
HEENT: EOMI, MMM, anicteric sclera
CV: RRR no R/M/G
RESP: CTAB, no accessory muscle use, no wheeze or rales
GI: Abdomen soft, NTND , no rebound or guarding. GJ tube in
place dressing c/d/i, PTBD in place and capped, dressing c/d/i.
Staples out, steri strips on diagonal incision c/d/i
MSK: Neck supple, moves all extremities
SKIN: No rashes or ulcerations noted, surgical incision at LUQ
NEURO: A/O x3, speech fluent, no focal neurologic deficits
PSYCH: appropriate, flat affect
Pertinent Results:
ADMISSION LABS:
___ 09:12AM BLOOD WBC-14.3* RBC-2.33* Hgb-6.8* Hct-21.6*
MCV-93 MCH-29.2 MCHC-31.5* RDW-20.7* RDWSD-63.7* Plt ___
___ 09:12AM BLOOD Neuts-82.1* Lymphs-10.4* Monos-4.7*
Eos-1.5 Baso-0.3 NRBC-0.1* Im ___ AbsNeut-11.77*
AbsLymp-1.49 AbsMono-0.68 AbsEos-0.21 AbsBaso-0.05
___ 09:50AM BLOOD ___ PTT-40.8* ___
___ 09:12AM BLOOD ALT-39 AST-39 AlkPhos-230* TotBili-0.5
___ 09:12AM BLOOD Lipase-2172*
___ 09:12AM BLOOD Albumin-1.9*
___ 05:17AM BLOOD %HbA1c-5.1 eAG-100
Tagged RBC scan: No evidence of active GI bleeding at 90
minutes.
CT A/P:
1. No evidence of active GI bleed.
2. Heterogeneous mass at the porta hepatis appears increased in
overall size,
concerning for progression of disease in this patient with known
duodenal
adenocarcinoma. Satellite nodules inferior to the duodenum also
concerning
for disease progression.
3. Abnormal appearance of the right renal artery concerning for
thrombosed
dissection, similar to most recent prior. Of note the right
renal artery
remains patent.
4. Unchanged dissecting aneurysm of the celiac trunk and
infrarenal abdominal
aortic aneurysm.
5. Status post recent gastrojejunostomy with new perihepatic
collection,
possibly organized hematoma versus abscess.
6. Worsening intrahepatic biliary ductal dilation despite the
presence of a
PTBD.
7. Increased pancreatic ductal dilation now measuring 9 mm with
subtle
peripancreatic stranding concerning for pancreatitis.
8. New liver hypodense lesion in segment 6, attention on
follow-up as
metastatic lesion not excluded.
Brief Hospital Course:
Mr. ___ is a ___ male with the
past medical history and findings noted above who presents with
acute blood loss anemia and melena, concerning for bleeding from
his duodenal tumor.
ACUTE/ACTIVE PROBLEMS:
# Acute upper GI bleed
# Acute blood loss anemia: Patient presented with melena and Hgb
6.8. He received 1U pRBC with improvement in Hgb to 8. He had an
EGD which showed no site of active bleeding but did show
duodenal mass with surrounding friable/oozing areas. CT-A did
not show any site of active bleeding. Tagged RBC scan was
negative for bleed and colonoscopy negative for bleed. Mass was
suspected to be the source of bleed and since mass is
unresectable, radiation oncology was consulted for treatment. He
received ***** treatments with radiation oncology.
# Elevated Alk Phos and lipase, c/f biliary and pancreatic
obstruction
# Duodenal adenocarcinoma
- Spoke to ERCP on the phone who stated that at this time
without
clinical signs of pancreatitis, no intervention to do. In
addition, the duodenal mass would prevent ERCP scope from
getting to pancreatic duct. Was treated with radiation therapy
as above. Had not yet seen medical oncologist in clinic prior to
re-admission.
#Severe protein-calorie malnutrition: Albumin 1.9 on admission.
On tube feeds. Continued tube feeds during admission. Speech and
swallow eval was done which showed ****.
CHRONIC/STABLE PROBLEMS:
# h/o CVA
- patient left here on lovenox with plans to bridge back to
warfarin; at rehab after consultation with Neurology, patient
was
started on ASA/Plavix and continued on lovenox at rehab (with
plans to take the lovenox off after 2 days). Given bleeding,
will hold all anticoagulants and antiplatelets for now.
- Started on ___ for DVT ppx, but not yet back on therapeutic
anticoagulation. Risk/benefit was discussed with patient ****.
# DM type II
- continued home 70/30 insulin dosing while on tube feeds
# HTN - normotensive off medication
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraZODone 50 mg PO QHS:PRN insomnia
2. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
3. Omeprazole 20 mg PO DAILY
4. Miconazole Powder 2% 1 Appl TP QID
5. Enoxaparin Sodium 90 mg SC Q12
6. Clopidogrel 75 mg PO DAILY
7. Calcium Carbonate 500 mg PO TID
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
9. Aspirin 81 mg PO DAILY
10. 70/30 10 Units Breakfast
70/30 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Simethicone 40-80 mg PO QID:PRN bloating
RX *simethicone [Gas Relief] 40 mg/0.6 mL 40 mg by mouth four
times a day Refills:*0
3. Enoxaparin Sodium 80 mg SC BID
RX *enoxaparin 80 mg/0.8 mL 80 mg sc twice a day Disp #*30
Syringe Refills:*0
4. Glargine 14 Units Dinner
Insulin SC Sliding Scale using REG Insulin
RX *insulin glargine [Lantus U-100 Insulin] 100 unit/mL AS DIR
14 Units before DINR; Disp #*30 Vial Refills:*0
RX *insulin regular human [Humulin R Regular U-100 Insuln] 100
unit/mL AS DIR Up to 10 Units QID per sliding scale Disp #*30
Vial Refills:*1
5. Miconazole Powder 2% 1 Appl TP TID:PRN rash
RX *miconazole nitrate [Anti-Fungal] 2 % apply to areas of
fungal infection three times a day Disp #*30 Package Refills:*0
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
7. Calcium Carbonate 500 mg PO TID
8. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
9. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
duodenal adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ due to having some blood in your
stool as well as a low red blood cell count. We gave you
multiple units of blood while you continued your radiation
therapy. You also were seen by the interventional radiologists
who changed out your biliary drain an will plan to internalize
it at a later appointment. We also had you work with our
physical therapists who recommend that you go to rehab after
being in the hospital to continue to be stronger. Your
hemoglobin levels have now stabilized and you are ready to be
discharged to rehab.
Please continue to take your medications as prescribed. You will
be sent home on lovenox (a blood thinner) for your history of
stroke with the plan to switch to warfarin once you have an
appointment with a PCP.
Be Well!
-Your ___ Team
Followup Instructions:
___
|
10291942-DS-11 | 10,291,942 | 26,194,093 | DS | 11 | 2176-09-02 00:00:00 | 2176-09-02 14:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
___ line placement ___
History of Present Illness:
As per HPI in H&P by Dr. ___ ___:
"Mr. ___ is a ___ year old male with duodenal adenocarcinoma
and
peritoneal carcinomatosis who presents from home with failure to
thrive.
The patient was recently admitted from ___ with anemia and
melena due to his duodenal tumor. EGD demonstrated for active
bleeding as did a CTA. Tagged RBC was negative as was
colonoscopy. The patient was discharged to rehab where he
believes his lovenox was transitioned to aspirin/Plavix, but he
is not sure.
Two days after coming home from rehab, he noticed to occasional
onset of rigors and chills. He had no fevers. No headache or
vision changes. No chest pain or dyspnea. No n/v/d. No abd pain.
No dysuria. He and his daughter contacted his PCP who obtained
outpatient labs and referred him to the ED for further
evaluation.
In the ED, the initial vital signs were:
T 98.2 TMax 101.4 HR 84 BP 112/74 R 16 SpO2 98% RA
Laboratory data was notable for:
Na 134 Cr 0.7
ALT 177 AST 99 AP349
WBC 5.4 Hgb 9.4 Plt 194
INR 1.3
Lactate 2.1
The patient received:
___ 15:10 IVF LR 1000 mL ___
___ 15:10 IV CefePIME 2 g ___
___ 20:30 PO/NG MetroNIDAZOLE 500 mg
Imaging demonstrated:
___ 15:40 CT Abd & Pelvis With Contrast
1. Interval mild decrease in size and conspicuity of a known
primary duodenal mass with mild surrounding fat stranding,
compatible recent palliative radiation treatment. Previously
described soft tissue deposits/nodularity adjacent and inferior
to the primary lesion are also less distinct and smaller
in size since the prior exam in ___, compatible with
treatment response.
2. Interval replacement of PTBD with a biliary stent with
expected central pneumobilia. Mild intrahepatic biliary
dilatation is similar or minimally decreased since ___.
3. Large stool ball appears impacted in the rectum. Recommend
disimpaction.
4. A couple of hepatic segment 5 hypodense lesions are increased
in size since ___, concerning for metastasis.
5. 9 mm right adrenal nodule is unchanged since the prior study.
6. Stable 3.5 cm infrarenal fusiform abdominal aortic aneurysm
since the prior exam.
ROS: 10 point review of systems discussed with patient and
negative unless noted above"
Past Medical History:
- Stage IV duodenal adenocarcinoma
- MCA CVA in ___ (s/p tPA) almost no residual deficits
(difficulty distinguishing left and right, sometimes difficulty
finding words)
- HTN (no longer an issue, as he has orthostatic hypotension)
- HLD
- IDDM
Social History:
___
Family History:
Father with colon cancer diagnosed in his ___ and he survived
it
after surgery, also had CAD and died of MI. Mother died
following asphyxiation of food. No brothers or sisters.
Physical Exam:
ADMISSION EXAM:
VITALS: BP 118/74 HR 94 R 20 SpO2 97 Ra
GENERAL: Frail, NAD
HEENT: Dry membranes, no lesions
EYES: PERRL, anicteric
NECK: supple
RESP: CTAB, no increased WOB, crackles L hemithorax
___: RRR no MRG
GI: soft, NTND. PEG in place c/d/I. RUQ incision with dried
blood along edges, no erythema or induration
EXT: warm, no edema
SKIN: dry
NEURO: CN II-XII intact
ACCESS: PIV
=================
DISCHARGE EXAM:
___ 1212 Temp: 98,0 PO BP: 104/69 L Lying HR: 72 RR: 18 O2
sat: 99% O2 delivery: RA FSBG: 158
___ 1217 BP: 102/66 L Sitting HR: 103
___ 1221 BP: 91/60 L HR: 116 Standing
GENERAL: lying in bed, answering questions appropriately.
EYES: Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: RRR, no murmur, no S3, no S4.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored on room air
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. G-tube without erythema or tenderness
surrounding. Large linear scar across mid-right abdomen without
drainage, erythema, or tenderness.
GU: No GU catheter
MSK: Moves all extremities, no edema or swelling, muscle wasting
in all extremities
SKIN: No rashes or ulcerations noted
NEURO: alert and oriented, remembers that he has a blood stream
infection and urine infection.
PSYCH: flat affect
PICC in right upper arm
Pertinent Results:
ADMISSION LABS:
___ 12:18PM BLOOD WBC-5.4 RBC-2.92* Hgb-8.4* Hct-26.9*
MCV-92 MCH-28.8 MCHC-31.2* RDW-15.4 RDWSD-51.0* Plt ___
___ 12:18PM BLOOD Neuts-84.3* Lymphs-7.4* Monos-5.5 Eos-1.1
Baso-0.2 Im ___ AbsNeut-4.56 AbsLymp-0.40* AbsMono-0.30
AbsEos-0.06 AbsBaso-0.01
___ 12:18PM BLOOD ___ PTT-24.0* ___
___ 12:18PM BLOOD Glucose-226* UreaN-21* Creat-0.7 Na-134*
K-4.0 Cl-95* HCO3-24 AnGap-15
___ 12:18PM BLOOD Albumin-2.6* Calcium-8.4 Phos-3.0 Mg-1.6
___ 12:18PM BLOOD ALT-177* AST-99* AlkPhos-349* TotBili-0.9
___ 03:33PM BLOOD Lactate-2.1*
___ 12:27PM BLOOD Lactate-2.5*
MICRO:
Urine culture (___):
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
Blood culture (___):
ENTEROCOCCUS SP.
AMPICILLIN------------ S
IMAGING/STUDIES:
CT abd/pelvis with contrast (___):
IMPRESSION:
1. Interval mild decrease in size and conspicuity of a known
primary duodenal mass with mild surrounding fat stranding,
compatible recent palliative radiation treatment. Previously
described soft tissue deposits/nodularity adjacent and inferior
to the primary lesion are also less distinct and smaller
in size since the prior exam in ___, compatible with
treatment response.
2. Interval replacement of PTBD with a biliary stent with
expected central pneumobilia. Small amount of debris is noted
in
the distal tip of the biliary stent. Mild intrahepatic biliary
dilatation is similar or minimally decreased since ___.
3. Large stool ball appears impacted in the rectum. Recommend
disimpaction.
4. A couple of hepatic segment 5 hypodense lesions are increased
in size since ___, concerning for metastasis. There
is
increased hypodensity adjacent to the right portal vein which
may
also represent metastatic involvement.
5. 9 mm right adrenal nodule is unchanged since the prior study.
6. Stable 3.5 cm infrarenal fusiform abdominal aortic aneurysm
since the prior exam.
CXR (___):
IMPRESSION:
No acute intrathoracic process.
TTE ___:
CONCLUSION: There is mild symmetric left ventricular hypertrophy
with a normal cavity size. Normal right ventricular cavity size
with normal free wall motion. The aortic valve leaflets (?#) are
mildly thickened. No mass/vegetation seen, but cannot fully
exclude due to suboptimal image quality. The mitral valve
leaflets appear structurally normal. No mass/vegetation seen,
but cannot fully exclude due to suboptimal image quality. The
pulmonic valve leaflets are not well seen. There is a trivial
pericardial effusion.
IMPRESSION: Very poor image quality. No definite valvular
pathology or pathologic flow identified.
CHEST X-RAY, PICC LINE PLACEMENT ___:
IMPRESSION: The tip of a right PICC is coiled over the right
axilla. Repositioning is
recommended.
___ REPOSITIONING OF PICC ___:
FINDINGS:
1. Basilic vein approach single lumen right PICC reposition with
tip in the distal SVC.
IMPRESSION:
Successful reposition of a right 47 cm basilic approach single
lumen PowerPICC
with tip in the distal SVC. The line is ready to use.
DISCHARGE LABS:
___ 06:15AM BLOOD WBC-7.6 RBC-2.94* Hgb-8.6* Hct-27.8*
MCV-95 MCH-29.3 MCHC-30.9* RDW-16.9* RDWSD-57.6* Plt ___
___ 05:50AM BLOOD Glucose-173* UreaN-27* Creat-0.8 Na-136
K-4.5 Cl-98 HCO3-25 AnGap-13
___ 05:51AM BLOOD Vanco-20.4*
Brief Hospital Course:
Mr. ___ is a ___ yo man with stage IV duodeonal adenocarcinoma
with peritoneal carcinomatosis and possible liver metastases s/p
palliative gastrojejunostomy, palliative XRT, and GJ placement
who presented from home with failure to thrive, and was found to
have Enterococcus bacteremia and MRSA in urine culture.
# Failure to thrive
# Enterococcus bacteremia
# MRSA positive urine culture
The patient had progressive weakness since discharge from the
hospital for recent GI bleeding. Imaging demonstrated increased
hepatic metastasis along with a large stool ball in the rectum
but no biliary obstruction and PTBD in good position. C.
diffICILE from ___ was negative. CXR was clear and the
patient has had no respiratory complaints. He had a fever to
101.4 while in the ED and given cefepime/flagyl on ___. UA
was concerning for UTI, though the patient did not have any
symptoms of cystitis. However, given his history of fatigue and
rigors, he was empirically started on ceftriaxone for UTI while
awaiting culture data. His blood cultures from admission grew
GPCs and he was started on vancomycin on ___. On ___, blood
cultures resulted as Enterococcus sensitive to ampicillin but
urine culture grew MRSA. Antibiotics were narrowed to vancomycin
alone. ID was consulted, who raised concern that the MRSA could
have come from bloodstream at some point, especially since he
had grown had MRSA in biliary abscess culture from ___. ___
was consulted to see if there could potentially be a biliary
source of MRSA still remaining that warranted intervention, but
after reviewing his CT scan, ___ felt that there was no biliary
intervention needed, as there is no evidence of infectious
source or abscess. Enterococcus likely came from GI source with
translocation from given known duodenal adenocarcinoma. TTE on
___ shows no clear vegetation, though poor image quality noted,
but he does not have murmur on exam, so endocarditis seemed less
likely. He refused TEE. Repeat blood cultures were negative
(final). PICC line was placed on ___ and repositioned by ___ on
___, in correct position.
Per ID recommendations, he will continue IV Vancomycin 1000 mg
iv q12 hours (day 1 = ___ through ___, for a total of 2
weeks.
# Orthostatic hypotension: On ___, SBP dropped from 119 to
70 upon standing. He is still orthostatic at times due to
prolonged supine state and resultant deconditioning. His blood
pressure is no longer orthostatic by the time of discharge
although his heart rate did go up. He will need to be observed
with orthostatic precautions with getting out of bed very slowly
setting and spending at least 3 minutes in a sitting position
before attempting to stand.
# Stage IV duodenal adenocarcinoma
# Metastasis to the liver
# Metastasis to the peritoneum
Patient with poor performance status and is currently not a
candidate for chemotherapy. Mild transaminitis may be from
progressive hepatic involvement, though patient is without
synthetic dysfunction. Per Dr. ___ his oncology team,
if he can recover to the point that he is not infected and out
of bed at least 50% of the day, he could benefit from
chemotherapy (which would be at ___. The patient and his
family were amenable to palliative care consult for introduction
to palliative care.
# Stool ball in rectum
# Constipation: He underwent manual disimpaction on ___. He was
started on scheduled Senna BID, Colace BID, bisacodyl PR daily.
For discharge regimen, he was transitioned to MiraLAX daily,
senna and bisacodyl as needed.
# History of MCA CVA (___):
Patient had been treated with enoxaparin with goals to
transition off in setting of recurrent GI bleeds and potential
for thrombocytopenia if he were to receive chemotherapy. He had
no focal neurological deficits on exam. After his recent
hospitalization for GI bleed from the duodenal mass, his
anticoagulation was changed from enoxaparin to aspirin and
Plavix. He was continued on his home aspirin and Plavix during
his hospitalization.
# Hypovolemic hyponatremia: Sodium fluctuates between 132-136,
improved with his clinical improvement and reinitiation of
# Diabetes mellitus with hyperglycemia: He was having
hyperglycemia with BG in 200s consistently, but adequately
controlled after changing tube feeding formula. He was
continued on glargine 14 units QPM (was on 14 units at home)
with Humalog sliding scale.
# Severe protein-calorie malnutrition, with prior duodenal
obstruction: He has a GJ tube in place and nutrition was
following, who changed to Glucerna 1.5 at 105 ml/hr x 14 hours,
plus 100ml free water Q4H. further evaluation of his ability to
reinitiate should be conducted in conjunction with his surgeon,
Dr. ___. She was notified of his discharge to rehab.
# Recent upper GI bleed (from duodenal mass)
# Normocytic anemia: Anemia was stable without evidence of acute
blood loss, as he was not having bowel movements and had
problems with constipation.. Recent RBC scan, EGD, colonoscopy
and CTA were without active bleeding. Chronic anemia is likely
from slow blood loss from duodenal cancer. He was continued on
lansoprazole.
# Chronic malignancy-associated pain: He was continued on home
tramadol 50mg Q6H PRN.
# Hypokalemia: Resolved after repletion
Transitional issues:
Oncology follow-up pending improvement in functional status
Continue discussion regarding reinitiate clinical status,
depending on discussion with surgeon.
Complete 3 more days of IV vancomycin on ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Miconazole Powder 2% 1 Appl TP TID:PRN rash
3. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
4. TraZODone 50 mg PO QHS:PRN insomnia
5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
6. Simethicone 40-80 mg PO QID:PRN bloating
7. Calcium Carbonate 500 mg PO TID:PRN calcium
8. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
9. Glargine 14 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Vancomycin 1000 mg IV Q 12H
Through ___. Glargine 14 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
10. Calcium Carbonate 500 mg PO TID:PRN calcium
11. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
12. Miconazole Powder 2% 1 Appl TP TID:PRN rash
13. Simethicone 40-80 mg PO QID:PRN bloating
14. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
15. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Enterococcus bacteremia
MRSA bacteriuria
Orthostatic hypotension
Stage IV metastatic duodenal adenocarcinoma
Constipation
Diabetes type II
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:
Mr. ___,
You were hospitalized and found to have Enterococcus blood
infection. You also had bacteria (MRSA) found in your urine,
though you had no symptoms of a urinary infection and true
urinary infection with MRSA is unlikely. You were treated with
an IV antibiotic Vancomycin, which you will continue through
___ for a total of 2 weeks. You had a PICC line placed in
your right arm to allow you continue IV vancomycin outside the
hospital.
Followup Instructions:
___
|
10291942-DS-12 | 10,291,942 | 21,168,725 | DS | 12 | 2176-09-10 00:00:00 | 2176-09-10 15:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Weakness, Hypotension
Major Surgical or Invasive Procedure:
___: EGD
___: ___ guided GDA embolization
History of Present Illness:
Mr. ___ is a ___ year old male with stage IV duodenal
adenocarcinoma complicated by recurrent GI bleeding presents
from
home with weakness and anemia.
The patient was recently admitted from ___ with anemia and
melena due to his duodenal tumor. EGD, CTA, tagged RBC scan and
colonscopy were all negative for active bleeding. Therefore, the
etiology of his GI bleeding was thought to be from his duodenal
tumor. The patient was transitioned from lovenox to aspirin
Plavix (for CVA primary prevention).
Two days after coming home from rehab, he noticed to occasional
onset of rigors and chills. He presented to ___ on ___ and was
found to have enterococcus bacteremia which was thought to be
from a GI source. He was discharged on IV vancomycin to complete
a 2 week course on ___. The patient was discharged to ___ on ___ and was feeling better. However on ___,
the
patient noticed the sudden onset of fatigue which had progressed
over the next 2 days. In addition, the daughter noticed that the
patient was receiving tube feeds through his G, rather than his
J
tube. The patient began having melena and labs were checked
which
were concerning for progressive anemia and the patient was sent
to a local hospital where CT imaging was concerning for an SBO.
He was subsequently transferred to ___ for further evaluation.
In the ED, the initial vital signs were:
T 98.3 HR 101 BP 93/56 R 18 SpO2 93% RA
Laboratory data was notable for:
Hgb 6.4->8.3->7.5
WBC 6.7 plt 282
INR 1.5
Normal Chem7 and LFTs
The patient received:
___ 00:27 IV Pantoprazole 40 mg
___ 07:42 IV Ciprofloxacin
___ 11:59 IV MetroNIDAZOLE 500 mg
___ 12:01 IV Pantoprazole 40 mg
___ 15:45 IV CefTRIAXone 1 g
Imaging demonstrated:
___ 00:53 CT Abd & Pelvis With Contrast
1. Findings concerning for disease progression with potentially
slight interval increase in ill-defined wall thickening and
surrounding inflammatory changes about the duodenum in the
region
of the patient's known primary cancer, as well as interval
increase in size of hepatic segment V suspected
metastatic lesion which newly exhibits a connection to a
suspected trace perihepatic hematoma. Given the small size of
this perihepatic fluid collection, it would seem unlikely to
significantly affect the patient's hemoglobin.
2. Rectal stool ball with perirectal inflammatory changes
concerning for stercoral colitis.
3. No evidence of obstruction. Stable positioning of
percutaneous
gastrostomy tube within the distal stomach.
4. Stable pneumobilia in keeping with CBD stent. Persistent main
pancreatic ductal dilatation.
5. Stable infrarenal fusiform abdominal aortic aneurysm
measuring
up to 3.6 cm.
___ 01:08 Chest (Single View)
1. A right-sided PICC line terminates in the low SVC.
2. Mild pulmonary vascular congestion without frank pulmonary
edema.
ECG: Sinus tachycardia. Normal intervals and axis. No ST-T wave
changes
The patient received 2 units of blood with improvement of his
Hgb. He was also seen by GI and underwent EGD which revealed no
active bleeding. They stated that due to his previous work up
(negative tagged RBC scan, CTA and colonoscopy), that his
bleeding is due to his known duodenal CA. They would be unable
pass a duodenoscope to his tumor and in addition, would be
unable
to intervene on a bleeding mass. They therefore recommended
transfusion support and BID PPI. The patient was also seen by
___ surgery who stated there was no surgical intervention
possible and that the patient did not have an SBO.
Upon arrival to ___, the patient and family confirm the above
history. The patient states that he feels extremely weak and
tired. He has been unable to tolerate oral feeding to due what
he
says is a psychological block. He has had no fevers or chills
and
is without headache or vision changes. He has no chest pain,
dyspnea or cough. He has no abdominal pain, nausea or vomiting.
He had previously had constipation but then began having melena
over the last day or so. He denies dysuria.
Past Medical History:
- Stage IV duodenal adenocarcinoma
- MCA CVA in ___ (s/p tPA) almost no residual deficits
(difficulty distinguishing left and right, sometimes difficulty
finding words)
- HTN (no longer an issue, as he has orthostatic hypotension)
- HLD
- IDDM
Social History:
___
Family History:
Father with colon cancer diagnosed in his ___ and he survived
it
after surgery, also had CAD and died of MI. Mother died
following asphyxiation of food. No brothers or sisters.
Physical Exam:
Admission
==========
VITALS: ___ Temp: 97.3 PO BP: 97/63 L Lying HR: 86 RR:
18 O2 sat: 93% O2 delivery: RA
GENERAL: tired, cachectic
HEENT: dry membranes, no lesions
EYES: anicteric, PERRL
NECK: supple
RESP: CTAB, no increased WOB, no wheezing, rhonchi or crackles
___: RRR no MRG
GI: soft, non-tender. GJ tube in place and c/d/I. RUQ surgical
scar intact
EXT: warm, no edema
SKIN: dry
GU: Normal rectal tone, no hard stool or masses in rectal vault.
Significant melena
NEURO: CN II-XII intact
ACCESS: R POC c/d/i
Discharge:
PHYSICAL EXAM:
___ 0709 Temp: 97.9 PO BP: 111/68 HR: 95 RR: 18 O2 sat:
100% O2 delivery: RA
GENERAL: NAD, laying in bed, cachetic
RESP: no respiratory distress, no accessory muscle use
___: Regular rate
GI: soft, non-tender. GJ tube in place, no leakage/drainage, no
erythema
EXT: warm, well perfused
Pertinent Results:
Admission
=========
___ 09:10PM BLOOD WBC-6.3 RBC-2.15* Hgb-6.4* Hct-20.6*
MCV-96 MCH-29.8 MCHC-31.1* RDW-17.0* RDWSD-58.3* Plt ___
___ 09:10PM BLOOD Neuts-66.3 ___ Monos-8.6 Eos-2.1
Baso-0.6 Im ___ AbsNeut-4.18 AbsLymp-1.36 AbsMono-0.54
AbsEos-0.13 AbsBaso-0.04
___ 09:10PM BLOOD ___ PTT-26.2 ___
___ 09:10PM BLOOD Glucose-104* UreaN-38* Creat-0.9 Na-134*
K-4.5 Cl-101 HCO3-23 AnGap-10
___ 09:10PM BLOOD ALT-20 AST-20 AlkPhos-109 TotBili-0.3
___ 09:10PM BLOOD cTropnT-<0.01
___ 06:55PM BLOOD Calcium-8.4 Phos-4.3 Mg-1.7
___ 09:10PM BLOOD Albumin-2.4*
___ 09:19PM BLOOD Lactate-0.9
Micro
======
BCx NGTD
Imaging
========
___ GI Embolization
FINDINGS:
1. Superior mesenteric arteriogram demonstrates no evidence of
active
extravasation, pseudoaneurysm, or arteriovenous fistula.
Retrograde
opacification of the gastroduodenal artery and hepatic artery
via
hypertrophied pancreaticoduodenal arcade is noted.
2. Celiac arteriogram demonstrates aneurysmal dilatation of the
celiac axis with antegrade opacification of the hepatic artery.
Reflux opacification into the gastroduodenal artery.
3. Gastroduodenal arteriogram demonstrates hypertrophy
pancreaticoduodenal arcade with predominant flow arising from
the superior mesenteric artery.
4. Post embolization celiac arteriogram demonstrates stasis
within the
gastroduodenal artery.
___ CT A/P with contrast
No evidence of obstruction. Suspected metastatic lesion within
hepatic segment V has slightly increased in size. Rectal stool
ball with perirectal inflammatory changes could suggest
component of stercoral colitis.
Discharge:
___ 06:00AM BLOOD WBC-7.0 RBC-2.70* Hgb-8.2* Hct-25.5*
MCV-94 MCH-30.4 MCHC-32.2 RDW-17.0* RDWSD-56.9* Plt ___
___ 06:00AM BLOOD Glucose-168* UreaN-23* Creat-0.9 Na-138
K-4.1 Cl-103 HCO3-24 AnGap-11
___ 06:00AM BLOOD Calcium-7.8* Phos-2.9 Mg-2.0
Brief Hospital Course:
___ is a ___ year old man with metastatic duodenal
adenocarcinoma complicated by progressive GI bleeding presents
with weakness and anemia likely from ongoing duodenal tumor
hemorrhage, got ___ guided GDA embo, transitioned to home with
hospice.
ACUTE ISSUES:
=============
#GOALS OF CARE:
Given lack of chemotherapy options, significant complications,
discussed with family and pursing home with hospice,
DNR/DNR/DNH.
#UPPER GI BLEED:
#ACUTE ON CHRONIC ANEMIA: 2 unit Hgb drop with active melena.
EGD without obvious source, could not pass past tumor. Presumed
bleed from tumor. Responded well to 2U pRBC and remained stable
thereafter. PPI IV started. Rad onc consulted but recommended no
role for further radiation given previous radiation for same
issue. ___ consulted and they performed GDA embolization on
___. Hgb at time of discharge was 8.2 and stable.
#STERCORAL COLITIS:
Due to large stool ball in rectum. Patient continued to have
large BMs despite this finding. No stool found on rectal
examination on admission, therefore, patient likely passed stool
ball. He was treated with CTX/flagy initially, but then stopped
given low concern for infection. Started bowel reg.
#FAILURE TO THRIVE:
#SEVERE PROTEIN CALORIE MALNUTRITION:
Patient continues on tube feeds due to self described
psychological block from restarting oral feeding. Patient's
daughter states he was getting fed through his G tube rather
than his J tube at his SNF which may have caused rebleeding from
his duodenal tumor. Resumed tube feeds at time of discharge,
with a plan to taper over to more PO intake if the patient
tolerated them. The family had about 4 weeks of protein shakes
left at home, and nursing educated them on pushing the shakes
into the patient's G-tube without needing a pump (which was not
covered by their insurance).
#DUODENAL CANCER:
#SECONDARY MALIGNANCY OF LIVER:
#SECONDARY MALIGNANCY OF PERITONEUM:
No treatment options. Hospice as above.
#HISTORY OF CVA:
Patient was on ASA/Plavix for secondary prevention. Held on
discharge to prevent further bleeding.
#ENTEROCOCCAL BACTEREMIA: RESOLVED
Finished IV vancomycin for 2 week treatment course on ___
#IDDM:
Held insulin at discharge, not requiring any while in the
hospital. Was
previously on glargine 14U with hISS.
TRANSITIONAL ISSUES:
=========================
[ ] Please use J tube only for tube feeds
[ ] Insulin held at discharge, AM sugars were ~180 and under
while on tube feeds
DNR/DNI/DNH
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. TraZODone 50 mg PO QHS:PRN insomnia
4. Vancomycin 1000 mg IV Q 12H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
3. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
========
Acute blood loss anemia
Upper GI bleed
Secondary
=========
Metastatic pancreatic adenocarcinoma
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:
Hi Mr. ___,
You were admitted for a GI bleed.
You were given blood transfusions, and the source of the bleed
was presumed to be from your tumor. The ___ team did a vascular
procedure to cut the blood supply to your tumor to prevent it
from bleeding further. We discussed with you and your family
that there are unfortunately no further treatment options for
your cancer and you decided to go home on hospice.
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
10291967-DS-23 | 10,291,967 | 20,976,899 | DS | 23 | 2196-12-03 00:00:00 | 2196-12-04 00:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ year-old Male with PMH significant for history of
provoked subsegmental pulmonary embolus (for which he received 6
months of anticoagulation, stopped in ___, diabetes mellitus,
benign prostatic hypertrophy, hyperlipidemia, chronic hematuria
who recently had recurrence of venous thromboembolic disease
with a left lower extremity DVT requiring further
anticoagulation (in ___ for 30-days) who now presents with
recurrent pulmonary embolus in the setting of being off
anticoagulation.
He presented to ___ clinic this afternoon with right-sided chest
discomfort with ambulation, worse with inspiration and coughing.
He had just recently returned from ___ 2-weeks ago. While
in ___ he was diagnosed with symptomatic LLE DVT on ___
and was treated with 1-month of Coumadin therapy. He has since
discontinued anticoagulation. He recently also spent 6-hours in
a car driving back from ___ 2-days prior.
In the ED, initial VS 99.5 69 129/87 28 95% RA. EKG obtained.
CTA with contrast noted pulmonary embolus of the right lower
lobe and lingular segments without right heart strain. CXR was
obtained. Labs were drawn twice and were notable for WBC 6.9,
HCT 44.6%, INR 1.0. Creatinine 0.9. Troponin-T < 0.01.
Urinalysis was positive. He was started on IV heparin infusion
and admitted to Medicine.
On arrival to the floor, he appears comfortabel and his pain has
improved.
Past Medical History:
1. H/o pulmonary embolism; ___: in setting of 8h flight from
___, admitted for anticoagulation. Stopped coumadin early
___ on his own. LLE DVT (in ___ with 30-days of Coumadin)
2. Benign prostatic hypertrophy with h/o hematuria
3. Diabetes Mellitus
4. Hypercholesterolemia
5. ? cognitive disorder
6. left knee arthroscopy ___
7. left rotator cuff repair ___
8. transurethral prostatectomy ___
Social History:
___
Family History:
Mother was diabetic, father passed in ___.
No h/o Cancer or clotting
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: 99.5 69 129/87 18 95% RA
GENERAL: Appears in no acute distress. Alert and interactive.
Well nourished appearing.
HEENT: Normocephalic, atraumatic. EOMI. PERRL.
NECK: supple without lymphadenopathy. JVP at 2-3 cm above
clavicle, at 30 degrees.
___: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort without labored breathing.
ABD: soft, non-tender, non-distended.
EXTR: no cyanosis, clubbing, 2+ peripheral pulses; LLE with 1+
pitting edema to mid-calf. No calf tenderness. No overlying
erythema or skin changes.
NEURO: Alert and oriented x 3. Sensation grossly intact. Gait
normal.
DISCHARGE PHYSICAL EXAM
VITALS: 98.8 98.3 128/58 55 20 93-99% RA
I/Os: ___
FSG: 150
GENERAL: Appears in no acute distress, sitting comfortably in
chair. Alert and interactive. Thin but well nourished appearing.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple. JVP 1-2 cm above clavicle.
___: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort without labored breathing.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing, 2+ peripheral pulses; 1+ pitting
edema on LLE.
NEURO: Alert and oriented x 3. DTRs 2+ throughout, strength ___
bilaterally in upper extremities, sensation grossly intact.
Observed gait normal.
Pertinent Results:
ADMISSION LABS
___ 02:44PM GLUCOSE-106* UREA N-24* CREAT-0.9 SODIUM-139
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-29 ANION GAP-13
___ 02:44PM WBC-6.9 RBC-5.23 HGB-15.4 HCT-44.6 MCV-85
MCH-29.4 MCHC-34.4 RDW-14.5
___ 02:44PM NEUTS-66.9 ___ MONOS-9.5 EOS-1.0
BASOS-0.7
___ 02:44PM PLT COUNT-197
___ 02:44PM ___ PTT-27.3 ___
___ 02:44PM CK(CPK)-69
___ 02:44PM cTropnT-<0.01
DISCHARGE LABS
___ 01:05PM BLOOD PTT-70.0*
ECG (___): Sinus bradycardia. Left axis deviation.
Anterolateral biphasic T waves are non-specific. Compared to
tracing #2 no diagnostic interval change.
ECG (___): NSR @ 61 bpm. LAD and LAFB. QTc 410 msec. R wave
progression abnormal, otherwise no strain. Lateral non-specific
ST changes with TWI lead V1. Otherwise no changes from prior.
URINALYSIS: hazy, large ___, neg Nitr, 30 protein, WBC 82, RBC
149, few bacteria, Epi < 1, gluc 1000
MICROBIOLOGY DATA:
___ Urine culture - pending
IMAGING:
___ BILAT LOWER EXT VEIN - DVT with nonocclusive thrombus
involving the left mid to distal femoral vein and left popliteal
vein. Slow flow, popliteal vein without thrombus noted on the
right.
___ ECHO - The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is ___ mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). 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. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. The pulmonary
artery is not well visualized. There is an anterior space which
most likely represents a prominent fat pad.
Preserved biventricular regional and global systolic function.
Mild aortic regurgitation. Mild dilatation of the aortic root.
Mild pulmonary artery systolic hypertension.
___ CHEST (PA & LAT) - Basilar atelectasis as described
above; right mid-lung opacity better characterized on chest CTA
performed on the same day.
___ CTA CHEST W&W/O C&RECON - PE involving RLL and lingular
segments; no R heart strain
Brief Hospital Course:
Recurrent acute pulmonary embolism - Pt. has history of provoked
pulmonary embolism in ___ treated with 6 months of
anticoagulation. Had symptomatic DVT with only 15 days of
anticoagulation due to hematuria. Now with recurrent
subsegmental PE off anticoagulation; event seems provoked by
recent immobilization. No recent surgery, stroke,
instrumentation or other risk factors. EKG with TWI in lead V1
but no evidence of significant strain, although R-wave
progression is abnormal. Cardiac biomarkers reassuring.
Hemodynamics stable, pain improved and oxygen saturations
adequate. Repeat EKG and TTE are normal - no right heart strain,
bilateral lower extremity US with evidence of clot in LLE so
heparinized and transitioned to ___. Could consider outpatient
inherited thrombophilia work-up, ensure age appropriate
screening for malignancy - due for colonoscopy repeat now; PSA
1.0 in ___.
Chronic hematuria - Prior gross hematuria in the setting of
anticoagulation needs. Has been evaluated by Urology. No
suggestion of glomerular disease in history. Urine cytology
negative in ___ for malignancy. CT imaging in ___ demonstrated
bilateral uncomplicated duplication of the collecting systems on
the left
and on the right without renal calculi. Renal cyst that was
stable. No evidence of renal mass. Prior cytoscopy with Dr.
___ in ___ was reassuring, per the patient. TURP in ___
for BPH symptoms. Evaluated by nephrology in ___, again without
identifiable etiology. A prostatic source has been suspected vs.
atypical anatomy. Continued with hematuria while hospitalized
but had normal urine output and creatinine.
Pyuria - No dysuria. Afebrile without leukocytosis. Review of
record demonstrates similar urinalsyses in the past that showed
sterile pyuria. Consider chronic prostatitis as a source, also
organisms that aren't typically cultured for - sent off urinary
TB, results can be followed up outpatient. Urinary culture
pending.
BPH - Symptoms appear controlled. No evidence of urinary
retention. Not currently on medication.
Diabetes mellitus - HbA1c 6.3% in ___. No reported history of
retinopathy, nephropathy or neuropathy. Creatinine 0.9.
Currently diet-controlled with home glucose monitoring; was kept
on HISS while hospitalized
Hyperlipidemia - continue statin dosing.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Methocarbamol ___ mg PO BID:PRN muscle spasm
3. Pravastatin 40 mg PO HS
4. Aspirin 500 mg PO DAILY
5. Docusate Sodium 100 mg PO DAILY:PRN constipation
6. Naproxen 250 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Docusate Sodium 100 mg PO DAILY:PRN constipation
4. Pravastatin 40 mg PO HS
5. Methocarbamol ___ mg PO BID:PRN muscle spasm
6. Enoxaparin Sodium 60 mg SC Q12H
RX *enoxaparin 60 mg/0.6 mL 60 mg SC EVERY 12 HOURS Disp #*60
Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
1. Recurrent acute pulmonary embolus
2. Deep venous thrombosis
Secondary Diagnosis
1. Chronic hematuria
2. Benign Prostatic Hypertrophy
3. Diabetes Mellitus
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 Internal Medicine Service on ___ 7 at
___ with chest pain that was
due to a blood clot that traveled to your lungs, known as a
pulmonary embolism. You received anticoagulation medication
through an IV and started a new injection medication for
anticoagulation called Lovenox; your pain was managed and you
felt better and were stable at the time of discharge.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
Followup Instructions:
___
|
10292353-DS-3 | 10,292,353 | 24,276,528 | DS | 3 | 2163-03-10 00:00:00 | 2163-03-11 16:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever & chills/1 wk
Major Surgical or Invasive Procedure:
___ ___ placement of 8 ___ drain into hepatic abscess
History of Present Illness:
___ history of poorly controlled diabetes, HTN, and
HLD presents to the emergency room for evaluation of fever
chills
and general malaise. Patient states that he had periumbilical
abdominal pain for one day approximately one week ago that then
resolved without any treatment. Then over the course of the
week
he was unable to leave his house and could barely leave his bed
to go to the bathroom. Has not showered ___ over 1 wk. He was
feeling very lightheaded when he stood up and also c/o fever and
chills. He suspected food poisoning, but had not traveled
anywhere recently or eaten anything suspect. He was not having
any vomiting. He did have loose BMs, but only 1-2/day. They
were
not bloody or acholic. FSBS ___ 460s at the outside hospital
where
a CT showed e/o acute cholecystitis with possible underlying
mass. RUQ US was suspicious for a perforated gallbladder. He
also had an incidental finding of a lung nodule, and this had
been seen on a prior CXR. He was found to have transaminitis
and
elevated alk phos. The surgery team at the OSH felt he was too
complex and recommended transfer to a tertiary care center. wbc
16.9, creatine 2.1 at OSH. Known to have elevated cr/CKD at
baseline.
ROS: + for dyspnea with exertion past several mo, subjective f/c
past week, diarrhea x 1 day and stomach upset/loose stools with
milk products - for wt loss, jaundice, acholic stools, emesis,
bloody/black BMs.
Past Medical History:
PMH: DMT2, lumbar disc herniation, HLD, HTN, right bundle branch
block, last colonoscopy ___ yrs ago per patient no significant
findings due ___ next few years for another
PSH: pedi tonsillectomy
Social History:
___
Family History:
fa died colon ca age ___
Physical Exam:
PE: VS T 99.3 HR 87 BP 174/66 RR 18 SaO2 95% RA
GEN: A&Ox3, NAD, caucasian elderly male
HEENT: PERRL, MMM
CV: RRR, no r/m/g, nl S1/S2
P: CTAB, no respiratory distress
ABD: morbidly obese, nontender abdomen
EXTREM: bilateral ___ edema, e/o chronic venous stasis, no open
wounds, warm and well perfused
LYMPH: no cervical, allixary, inguinal LAD
LABS:
___ 00:24 UA with proteinuria
___ 23:09 Lactate:1.1
___ 22:55
135 104 70 352 AGap=17
5.2 19 1.9
estGFR: 35/42 (click for details)
Ca: 8.7 Mg: 1.7 P: 3.1
ALT: 185 AP: 281 Tbili: 0.5 Alb: 3.0
AST: 53 LDH: Dbili: TProt:
___: Lip: 24
14.8 > 8.8/27.2 < 279
N:82 Band:0 ___ M:8 E:0 ___ Metas: 1 Absneut: 12.14 Abslymp:
1.33 Absmono: 1.18 Abseos: 0.00 Absbaso: 0.00
Hypochr: 1+ Poiklo: 1+ Ovalocy: 1+
Plt-Est: Normal
___: 14.5 PTT: 30.6 INR: 1.3
IMAGING:
OSH RUQ US
? mass ___ the gallbladder versus acute cholecystitis
OSH CT torso
1.3 cm nodule ___ the right apex with periphal calicfaction
subcentimeter subpleural nodules 7.5 mm. Ill defined right lobe
liver fluid collection measuring 5 cm ?liver abscess ___ to
cholecystitis
___ RUQ US
Focused ultrasound ___ the right upper quadrant was performed to
assess the liver and gallbladder given findings on outside
hospital CT and ultrasound. There is a complex irregular fluid
collection within the right hepatic lobe abutting the
gallbladder
which measures approximately 6.5 x 3.3 cm. There is wide open
communication between the gallbladder and this collection
raising
concern for perforated acute cholecystitis with intrahepatic
abscess. No vascularity seen within this collection.
Gallstones
are seen within the neck of the gallbladder. The CBD is
nondilated. Main portal vein is patent. No perihepatic
ascites.
Pertinent Results:
___ 10:55PM BLOOD WBC-14.8*# RBC-2.99* Hgb-8.8*# Hct-27.2*
MCV-91 MCH-29.4 MCHC-32.4 RDW-13.3 RDWSD-44.0 Plt ___
___ 10:55PM BLOOD ___ PTT-30.6 ___
___ 10:55PM BLOOD Glucose-352* UreaN-70* Creat-1.9* Na-135
K-5.2* Cl-104 HCO3-19* AnGap-17
___ 10:55PM BLOOD ALT-185* AST-53* AlkPhos-281* TotBili-0.5
___ 06:15AM BLOOD ALT-122* AST-35 AlkPhos-236* TotBili-0.5
___ 06:15AM BLOOD Calcium-8.9 Phos-4.5 Mg-1.7
___ 06:08AM BLOOD %HbA1c-8.2* eAG-189*
___ 10:27AM BLOOD CEA-5.0* AFP-0.6
___ and ___ Blood cultures:
pending
___ 2:14 pm ABSCESS LIVER ABSCESS.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
WOUND CULTURE (Preliminary):
GRAM POSITIVE COCCUS(COCCI). SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary):
Brief Hospital Course:
___ M with one month h/o RUQ pain, fevers, found to have right
lobe abscess adjacent to the gallbladder. He was pan-cultured
and started on IV antibiotics then underwent ___ drainage on
___. Ultrasound demonstrated an enlarged, distended gallbladder
with complex echogenic internal material, ___ addition to a 6.5 x
6.0 cm hepatic collection adjacent to the gallbladder fossa.
There was visible disruption ___ the gallbladder wall measuring
up to 2.2 cm. The findings were highly
suggestive of perforated cholecystitis with associated liver
abscess. An 8 ___ drain was placed into the collection that
appeared purulent and a sample sent to microbiology. Micro
isolated no pmns, 2+GPC, 2+GNR, 1+GPR and sparse growth GPC. IV
Unasyn continued pending finalization of abscess culture. An MRI
was done to assess whether abscess represented a perforated
cholecystitis or an underlying tumor. MRI was done on ___ that
demonstrated the following:
1. Hepatic abscess ___ direct continuity with a perforated
gallbladder, as
described above. No definite mass is identified. Follow-up
after treatment
is recommended to exclude a subtle underlying lesion which may
be obscured by
the surrounding inflammatory changes.
2. Bland thrombus within the peripheral aspect of the middle
hepatic vein
which courses through the inflamed region.
3. Choledocholithiasis with a 5 mm stone at the ampulla and
several smaller
stones upstream. There is associated mild intra and
extrahepatic biliary duct
dilation.
4. Borderline splenomegaly
Tumor markers were sent off. CEA was elevated at 5.0 and AFP was
0.6. CA ___ was 27.
Upon learing MRI findings, ERCP was consulted and on ___, he
underwent ERCP with the following note:
note of small filling defects ___ the lower bile duct suggestive
of sludge/stone. There was mild diffuse biliary dilation,
including mild saccular dilation of the lower CBD. The cystic
duct was filled with contrast, and the intrahepatics were
well-visualized and only mildly dilated. A sphincterotomy was
performed and a moderate amount of sludge was extracted.
Completion cholangiogram was normal. Otherwise normal ERCP to
___ portion of duodenum.
Post ERCP, he received IV fluid hydration. Labs were improved
and diet was resumed and tolerated.
He was hyperglycemic. Sliding scale insulin was used to control
his glucoses. HgA1c was elevated at 8.2. A ___ consult was
obtained and insulin was adjusted with improved control. At time
of discharge to home, home meds (actos/glipizide)were resumed.
He was instructed to hold his Januvia for a week and f/u with
his PCP for DM management. A Humalog sliding scale was
recommended for home. The ___ DM educator reviewed glucometer
teaching and injection with an insulin pen. He was provided with
scripts for Humalog pen with pen needles, strips, lancets.
A time of discharge, antibiotics were switched to Augmentin for
2 weeks from drain placement. Drain output was averaging 570cc.
___ was arranged to see him at home to assess management.
Of note, he will see Dr. ___ consult)for
evaluation of pulmonary nodules that were noted on OSH CT scan
uploaded on ___ imaging(1.3cm nodule ___ the right apex with
small peripheral calcification and adjacent scarlike opacity,
7.5mm supleural nodule ___ the right lung base, 5mm subpleural
nodule ___ the right middle lobe and 5mm subpleural nodule ___ the
left upper lobe posteriorly).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Simvastatin 80 mg PO QPM
5. Pioglitazone 15 mg PO DAILY
6. GlipiZIDE XL 20 mg PO DAILY
7. Labetalol 300 mg PO BID
8. Lisinopril 40 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Labetalol 300 mg PO BID
2. Allopurinol ___ mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Acetaminophen 650 mg PO TID
do not take more than 2000mg per day
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
6. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 2 by mouth at bedtime Disp #*60
Tablet Refills:*0
7. Multivitamins 1 TAB PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 2 Weeks
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*28 Tablet Refills:*0
10. Aspirin 81 mg PO DAILY
11. GlipiZIDE XL 20 mg PO DAILY
12. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [OneTouch Verio] one ___ times daily
Disp #*1 Box Refills:*5
RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR Up to 17
Units QID per sliding scale Disp #*2 Syringe Refills:*2
RX *lancets [OneTouch Delica Lancets] 33 gauge one ___ times
daily Disp #*1 Box Refills:*5
13. Pioglitazone 15 mg PO DAILY
14. Insulin Pen Needles
32 G, ___ (4mm Nano)
Use to inject insulin 4 times daily
Supply: #100
Refills: 2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hepatic abscess/perforated gallbladder
cholelithiasis
DM, uncontrolled
Lung Nodules
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr. ___ ___ if you have any of the
following: temperature of 101 or chills, nausea, vomiting,
jaundice (yellowing of whites of eyes/skin), abdominal
distension, incision redness/bleeding/drainage, constipation or
diarrhea
Empty abdominal drain when half full and record all output.
Change dry gauze dressing daily and as needed.
Followup Instructions:
___
|
10292353-DS-5 | 10,292,353 | 24,383,845 | DS | 5 | 2163-07-03 00:00:00 | 2163-07-03 21:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old man with recent cholecystitis s/p
open cholecystectomy on ___, HTN, DM, and HLD who presented
with dyspnea on exertion.
He has been being followed closely by his PCP for dyspnea,
which has progressed gradually over the last few weeks to the
point he was getting SOB walking to and from the car. Over the
same period, he noted increased lower leg swelling. He had tried
an increased dose of his chronic furosemide (20 -> 40) earlier
this week as well as an increased dose of labetalol (from 300
BID to ___ BID to ___ BID) but that seemed to make it worse so
it was changed down to 300BID again day prior to admission.
As part of his work up, a d dimer was sent and it came back
elevated to 13,400 at which point he was referred into the ED.
His wife notes that he has gained 20 lbs in 2 weeks (after
losing some weight in the post-surgical period).
He has not had chest pain at any time. He denies a history of
MI, CHF, or every having undergone an ultrasound of the heart or
cardiac cath before. He does not have a cardiologist.
He denies recent viral infection, sick contacts, cough, phlegm,
fevers, urinary symptoms, diarrhea, constipation.
He endorses abdominal distension.
In the ED, initial vitals were: 97.2 74 190/67 16 97% RA
Past Medical History:
PMH: DMT2, lumbar disc herniation, HLD, HTN, right bundle branch
block, last colonoscopy ___ yrs ago per patient no significant
findings due in next few years for another
PSH: pedi tonsillectomy
Social History:
___
Family History:
fa died colon ca age ___
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
Vital Signs: 176 / 78L Lying 97.7 PO L Lying 71 16 97 ra
General: Alert, oriented, no acute distress. Sleeping with bed
at 20 degree tilt.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, neck
supple, JVP elevated to above the mandible. Thick neck.
CV: Regular rate and rhythm, normal S1 + S2, ___ blowing early
systolic murmur heart best at LLSB/apex.
Lungs: bilateral crackles ___ of lung field. No wheezing.
Comfortable appearing on room air.
Abdomen: Soft, non-tender, moderately distended, bowel sounds
present, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ edema to knees. Skin changes over
shins. Negative hoffmans sign, no calf tenderness bilaterally.
Neuro: Symmetric face. Tongue midline. Moves all ext remities.
A&Ox3
Psych: Appropriate affect and mood
Skin: Thick, hyperpigmented changes over bilateral shins with
left>>R.
DISCHARGE PHYSICAL EXAM
==========================
VS: 98.5 PO 155 / 61 71 18 98 RA
General: Alert, oriented, no acute distress. Sitting up in bed
at ~60 degrees
HEENT: NC/AT Sclera anicteric, EOMI grossly
CV: Regular rate and rhythm, normal S1 + S2, ___ blowing early
systolic murmur heart best at LLSB/apex.
Lungs: CTAB, no wheezing or crackles noted today. Comfortable
appearing on room air, in NAD
Abdomen: Soft, non-tender, moderately distended, bowel sounds
present, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 1+ pitting edema to shins and
non-pitting edema to knees. Skin changes over shins c/w chronic
venous insufficiency.
Neuro: CN II-XII grossly intact. responding to questions
appropriately
Psych: Appropriate affect and mood
Pertinent Results:
ADMISSION LABS
========================
___ 05:15PM BLOOD WBC-6.5 RBC-3.01* Hgb-9.0* Hct-27.4*
MCV-91 MCH-29.9 MCHC-32.8 RDW-14.8 RDWSD-48.6* Plt ___
___ 05:15PM BLOOD Neuts-63.2 ___ Monos-8.5 Eos-4.2
Baso-0.6 Im ___ AbsNeut-4.09 AbsLymp-1.50 AbsMono-0.55
AbsEos-0.27 AbsBaso-0.04
___ 11:15AM BLOOD ___ PTT-35.2 ___
___ 05:15PM BLOOD UreaN-56* Creat-1.7* Na-141 K-5.0 Cl-107
HCO3-22 AnGap-17
___ 05:15PM BLOOD ALT-19 AST-25 LD(LDH)-258* AlkPhos-80
TotBili-0.3
___ 05:15PM BLOOD cTropnT-0.05* proBNP-1158*
___ 11:15AM BLOOD CK-MB-6 cTropnT-0.05*
___ 11:15AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.7
___ 05:15PM BLOOD Iron-38*
___ 05:15PM BLOOD ___
___ 08:08AM BLOOD ___
___ 09:00AM BLOOD %HbA1c-5.4 eAG-108
___ 02:56PM BLOOD Triglyc-156* HDL-33 CHOL/HD-3.6
LDLcalc-55
___ 11:15AM BLOOD TSH-2.4
___ 09:00AM BLOOD ANCA-NEGATIVE B
___ 09:00AM BLOOD ___
___ 08:35AM BLOOD PEP-NO SPECIFI IgG-832 IgA-146 IgM-72
IFE-NO MONOCLO
___ 02:56PM BLOOD C3-100 C4-43*
___ 07:41PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 07:41PM URINE RBC-23* WBC-2 Bacteri-FEW Yeast-NONE
Epi-0
___ 07:41PM URINE Hours-RANDOM Creat-39 TotProt-139
Prot/Cr-3.6* Albumin-115.6 Alb/Cre-2964.1*
DISCHARGE LABS
========================
___ 08:52AM BLOOD WBC-6.2 RBC-3.20* Hgb-9.3* Hct-28.8*
MCV-90 MCH-29.1 MCHC-32.3 RDW-14.6 RDWSD-48.4* Plt ___
___ 08:52AM BLOOD Glucose-158* UreaN-48* Creat-1.6* Na-144
K-3.7 Cl-106 HCO3-24 AnGap-18
___ 08:52AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.9
IMAGING
=========================
CTA ___ IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Interval development of small right pleural effusion with
diffuse
ground-glass opacities, most consistent with pulmonary edema.
3. Stable pulmonary nodules.
4. New simple ascites in the upper abdomen.
5. Mediastinal and bilateral hilar lymphadenopathy appears new
over the
interval, and may be reactive. Recommend attention on
follow-up.
L Lower extremity US ___ IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left
lower extremity
veins. Nonvisualized left peroneal veins.
2. Bilateral ___ cysts larger on the right.
Abdominal US ___ IMPRESSION:
1. Patent portal venous system.
2. Borderline splenomegaly measuring 12.8 cm.
3. Minimal fluid within the left lobe of the liver and
gallbladder fossa.
Brief Hospital Course:
___ yo male with h/o diabetes and HTN presenting with dyspnea on
exertion found to have new diastolic heart failure with EF 70%.
He was also found to have nephrotic-range proteinuria.
SPEP/UPEP, as well as immunological studies were sent, which
were negative or pending at time of discharge. He was treated
with IV Lasix, and discharged on an increased dose of 80 mg PO
Lasix daily.
# Dyspnea on exertion/Congestive Heart Failure: Pt presents with
new onset DOE, fatigue, pulmonary edema, and increased ___ edema,
elevated BNP 1158 and EKG ___ with some changes c/w prior
inferior MI. Troponin 0.05 x2. ECHO with preserved EF, signs of
diastolic heart failure and elevated PCWP. Nephrotic syndrome
may also have been contributing to fluid overload. Patient
received diuresis with IV Lasix and lost ~13 kg of fluid.
Dyspnea and lower extremity edema improved. He was discharged on
an increased dose of PO furosemide.
#Nephrotic proteinuria: UA on admission with >100 protein.
Patient may have underlying diabetic nephropathy, but
proteinuria is much increased this admission (protein/Cr ratio =
3.6) from UA in ___, and A1C was 5.4 this admission. ___ be
contributing to volume overload state. New proteinuria is
concerning for ?malignancy, esp. in the setting of possibly
newly reduced cardiac function and lymphadenopathy seen on CTA,
but patient likely does not need to undergo further workup in
house once his edema improves. SPEP an UPEP are negative.
Patient will follow-up with nephrology for repeat UA and further
evaluation as indicated. Patient was started on 25 mg
spironolactone for proteinuria.
# Elevated D Dimer: Pt presented to ED after PCP found elevated
___. However, no sx of chest pain, signs of PE on CTA in ED,
no DVT on LENIs. No symptoms of DVT. High haptoglobin, normal
Bili not consistent with hemolysis. Could be lingering from
recent infection and/or cholecystectomy, though unlikely due to
distant history. Malignancy, renal disease are other
considerations, and patient does have new nephrotic range
proteinuria.
CHRONIC ISSUES:
====================
# DM: continue home medications, ISS.
# HTN: Changed home labetalol to carvedilol, continued
lisinopril 40, started amlodipine 10 mg daily and spironolactone
25 mg PO daily this admission
# HLD: home simvastatin switched to atorvastatin 20 mg PO daily
for amlodipine compatibility
***Transitional issues***:
- Discharged on an increased dose of Lasix at 80 mg daily.
Titrate as needed in outpatient clinic.
- Patient was also started on amlodipine 10 mg daily for high
blood pressure and spironolactone 25 mg daily for proteinuria.
- Labetalol was changed to carvedilol 12.5 mg BID for
cardioprotection
- Simvastatin 80 mg was changed to atorvastatin 20 mg for
compatibility with amlodipine.
- Patient had incidental findings of elevated ___, new
lymphadenopathy on CTA, and borderline splenomegaly. Please make
sure patient is up to date on age appropriate cancer screening.
- Consider workup of coronary artery disease, given findings of
new diastolic dysfunction on ECFHO and presence of risk factors
- Patient should f/u with nephrology to see if proteinuria has
resolved. If not, may need renal biopsy.
# CODE: Full
# CONTACT: wife ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. GlipiZIDE XL 20 mg PO DAILY
5. Labetalol 300 mg PO BID
6. Lisinopril 40 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Simvastatin 80 mg PO QPM
9. Vitamin D 1000 UNIT PO DAILY
10. HumaLOG KwikPen (insulin lispro) Other 15 SUBCUTANEOUS PER
SLIDING SCALE UP TO 4 TIMES DAILY
11. Viagra (sildenafil) 50 mg oral prn
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
RX *atorvastatin 20 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*0
3. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Spironolactone 25 mg PO DAILY
RX *spironolactone [Aldactone] 25 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
5. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP DAILY to
shins
RX *triamcinolone acetonide 0.025 % apply to both legs daily
Refills:*0
6. Furosemide 80 mg PO DAILY
RX *furosemide 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Allopurinol ___ mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. GlipiZIDE XL 20 mg PO DAILY
10. HumaLOG KwikPen (insulin lispro) Other 15 SUBCUTANEOUS PER
SLIDING SCALE UP TO 4 TIMES DAILY
11. Lisinopril 40 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Viagra (sildenafil) 50 mg oral prn
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Diastolic heart failure with ejection fraction 70%
Proteinuria
Secondary diagnoses:
Diabetes
HTN
HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure treating you at ___!
Why was I admitted to the hospital?
You were admitted to the hospital because you had trouble
breathing and you had swelling in your legs.
What happened while I was admitted?
-We found out that your heart was having trouble filling up
-There was protein in your urine, so you were seen by the kidney
doctors and should follow up with them at the appointment below
-Because you had a lot of extra fluid in your lungs and legs, we
gave you a diuretic medicine to get the fluid off you body, and
your breathing and the leg swelling improved
What should I do when I come home?
-Please take your medications as directed
-Please follow-up with your primary care doctor and with the
kidney doctors
-___ we increased the dose of your diuretic medicine, please
call your doctor if you start feeling lightheaded when you stand
up or walk around
-Please weigh yourself daily and call your doctor if you gain
more than 3 pounds
It was a pleasure taking care of you and we wish you the best!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10292353-DS-7 | 10,292,353 | 26,396,106 | DS | 7 | 2165-04-13 00:00:00 | 2165-04-16 11:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bradycardia, SDH, Syncope
Major Surgical or Invasive Procedure:
Date of Implant: RA lead revision on ___, RV lead implantation
on
___
Indication: syncope/2:1 AVB
Device info:
Device ___ Azure XT ___ MRI ___ Implanted:
___
Atrial ___ 4076 CapSureFix® Novus MRI BBL ___
Implanted: ___
RV ___ 4076 CapSureFix® Novus MRI BBL ___ Implanted:
___
History of Present Illness:
Mr. ___ is a ___ man with HFpEF, HTN, T2DM, stage
III/IV CKD, pHTN, severe OSA, and previously known RBBB who
presents as a transfer from for further evaluation after
syncopizing in setting of bradycardia with resultant SDH.
The patient states that over the past week he has experienced
intermittent episodes of dizziness with minimal activity. Today
he was gardening with his wife when he again developed dizziness
and subsequently syncopized falling onto the grass. He was
initially taken to an OSH where CT head demonstrated a small
subdural hemorrhage and ECG was concerning for complete heart
block. He was subsequently transferred to ___ for both
neurosurgical and EP evaluation.
In the ED, initial VS were: T97.3, HR 48, BP 155/51, RR16, 96%
on
RA.
Exam notable for: normal mentation with fully intact neurologic
examination; bradycardic but euvolemic and warm on exam. ECG
demonstrated 2:1 AV conduction with prolonged PR interval to
240,
ventricular rate 38 bpm, sinus rate 72 bpm, RBBB, QTc 398.
Labs showed troponin 0.05, Cr 2, bicarb 17, K 5.2, Mg 1.7. OSH
head CT showed small falcine SDH.
Consults:
- Neurosurgery recommended observation with repeat of head CT in
AM to monitor small SDH.
- Trauma Surgery foud no additional injuries on exam and
recommended no further workup from a trauma perspective.
- Cardiology felt no indication for temp wire with rec to make
patient NPO for likely PPM. Also rec sending Lyme titers and
obtaining ECHO.
Transfer VS were: T98, HR 38, BP 148/54, RR 16, 100% on RA.
On arrival to the floor, patient denies any current symptoms
(including dizziness, lightheadedness, palpitations, chest pain,
or shortness of breath). He states that he has been recently
gardening, but denies any known tick exposure or new rashes. He
has experienced some diarrhea over the past few weeks and feels
he may have been slightly dehydrated.
Past Medical History:
-HFpEF
-RBBB
-HTN
-T2DM
-stage III/IV CKD; hx of nephrotic/nephritic syndrome
-OSA
- Cholecystitis s/p open cholecystectomy (___)
- S/p tonsillectomy
Social History:
___
Family History:
Father died colon ca age ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: T98.1, BP 168/62 HR 54, RR 17, 97% RA
GENERAL: pleasant obese man laying in bed in NAD.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: bradycardic regular, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, 1+ edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: chronic venous stasis changes in bilateral ___ otherwise
no
rashes or other lesions
DISCHARGE PHYSICAL EXAM
========================
Vital signs: 24 HR Data (last updated ___ @ 747)
Temp: 98.5 (Tm 99.6), BP: 164/76 (143-165/69-76), HR: 84
(61-84), RR: 17 (___), O2 sat: 99% (85-99), O2 delivery: Ra,
Wt: 270.9 lb/122.88 kg
Fluid Balance (last updated ___ @ ___
Last 8 hours No data found
Last 24 hours Total cumulative -790ml
IN: Total 940ml, PO Amt 940ml
OUT: Total 1730ml, Urine Amt 1730ml
GENERAL: pleasant man laying in bed in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, II/IV murmur best heard at apex, III/IV systolic
murmur best heard at RUSB, left pacemaker pocket with dressing
in
place, non tender to palpation, no hematoma noted
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, non pitting edema in
bilateral lower extremities
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, CN2-12
grossly intact
SKIN: chronic venous stasis changes in bilateral ___ otherwise
no
rashes or other lesions
Pertinent Results:
Admission Labs
===============
___ 11:12PM BLOOD WBC-6.8 RBC-3.08* Hgb-9.3* Hct-28.5*
MCV-93 MCH-30.2 MCHC-32.6 RDW-14.8 RDWSD-49.7* Plt ___
___ 11:12PM BLOOD ___ PTT-32.1 ___
___ 11:12PM BLOOD Glucose-229* UreaN-83* Creat-2.0* Na-143
K-5.3 Cl-110* HCO3-17* AnGap-16
___ 11:12PM BLOOD ALT-32 AST-49* AlkPhos-118 TotBili-0.5
___ 11:12PM BLOOD Albumin-3.6 Calcium-8.5 Phos-4.0 Mg-1.7
Discharge labs
===============
___ 07:35AM BLOOD WBC-7.1 RBC-3.23* Hgb-9.6* Hct-31.4*
MCV-97 MCH-29.7 MCHC-30.6* RDW-14.9 RDWSD-52.6* Plt ___
___ 07:35AM BLOOD Glucose-180* UreaN-40* Creat-1.4* Na-151*
K-4.5 Cl-118* HCO3-19* AnGap-14
MICRO
======
___ 7:35 am Blood (LYME)
**FINAL REPORT ___
Lyme IgG (Final ___: NEGATIVE BY EIA.
(Reference Range-Negative).
Lyme IgM (Final ___: NEGATIVE BY EIA.
(Reference Range-Negative).
Negative results do not rule out B. burg___ infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody.
IMAGING
========
___ CT Head
1. Mild thickening of the falx may represent a component of
small volume
subdural hemorrhage. Comparison with prior imaging is
recommended, after
images are up loaded into PACS.
2. There is no other evidence of hemorrhage and no evidence of
infarction.
3. Mildly prominent ventricles and sulci are age appropriate.
4. Multifocal paranasal sinus inflammatory disease.
___ Carotid Ultrasound
FINDINGS:
RIGHT:
The right carotid vasculature has moderate heterogeneous
atherosclerotic
plaque.
The peak systolic velocity in the right common carotid artery is
163 cm/sec.
The peak systolic velocities in the proximal, mid, and distal
right internal
carotid artery are 109, 118, and 86 cm/sec, respectively. The
peak end
diastolic velocity in the right internal carotid artery is 19
cm/sec.
The ICA/CCA ratio is 0.72.
The external carotid artery has peak systolic velocity of 129
cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has moderate heterogeneous
atherosclerotic
plaque.
The peak systolic velocity in the left common carotid artery is
182 cm/sec.
The peak systolic velocities in the proximal, mid, and distal
left internal
carotid artery are 101, 120, and 83 cm/sec, respectively. The
peak end
diastolic velocity in the left internal carotid artery is 29
cm/sec.
The ICA/CCA ratio is 0.65.
The external carotid artery has peak systolic velocity of 185
cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
Moderate heterogeneous atherosclerotic plaque involving both
internal carotid
arteries with estimated 40-59% stenosis of each internal carotid
artery.
___ TTE
The left atrial volume index is mildly increased. The right
atrium is mildly enlarged. There is normal left
ventricular wall thickness with a normal cavity size. There is
normal regional left ventricular systolic
function. Quantitative 3D volumetric left ventricular ejection
fraction is 69 %. 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 valve leaflets (3) appear
structurally normal. There is no aortic
valve stenosis. The increased velocity is due to high stroke
volume. There is trace aortic regurgitation.
The mitral leaflets are mildly thickened with no mitral valve
prolapse. There is moderate mitral annular
calcification. There is minimal mitral stenosis from the
prominent mitral annular calcification. There is
trivial mitral regurgitation. Due to acoustic shadowing, the
severity of mitral regurgitation could be
UNDERestimated. The tricuspid valve leaflets appear structurally
normal. There is mild to moderate
[___] tricuspid regurgitation. There is moderate pulmonary
artery systolic hypertension. There is a trivial pericardial
effusion.
IMPRESSION: Normal biventricular cavity sizes, regional/global
systolic function. Mild functional mitral stenosis.
Mild-moderate tricuspid regurgitation. Moderate pulmonary artery
systolic hypertension.
Compared with the prior TTE (images reviewed) of ___ ,
minimal functional mitral stenosis is now identified and the
estimated pulmonary artery systolic pressure is now higher.
___ CXR
In comparison with the study ___, the right atrial lead
now appears well
placed. The other lead extends into the right ventricle. No
evidence of
pneumothorax.
Brief Hospital Course:
Mr. ___ is a ___ man with HFpEF, HTN, T2DM, stage
III/IV CKD, OSA, and previously known RBBB who presented as a
transfer from OSH for evaluation after syncopizing in setting of
bradycardia with resultant SDH.
ACUTE ISSUES:
===============
# Symptomatic Bradycardia with AV 2:1 block
# Cardiogenic Syncope:
Patient with symptoms of dizziness for the past week and
syncopal
episode. EKG with bradycardia with AV 2:1 block iso known
conduction system disease. His carvedilol was held and patient
was empirically started on ceftriaxone for possible lyme disease
though this was stopped after lyme serologies were negative. He
was seen by EP and patient had pacemaker placed. Course was
complicated by atrial lead dislodgement which was subsequently
replaced without issue. Patient was given vancomycin while
inpatient and discharged to complete 3 day course of Keflex. He
will follow up with EP in device clinic.
# SDH: After fall patient found to have small falcine SDH on CT
head without neuro changes. Repeat head CT was stable. Seen by
neurosurgery felt didn't require any further monitoring or
follow up. He was restarted on ASA, without issues.
#Chronic Normocytic Anemia: Prior iron studies suggestive of ACD
likely from CKD. In review of chart patient has not followed up
for colonoscopy screening and is overdue. At time of discharge
Hgb was 9.6.
CHRONIC ISSUES:
===============
# HFpEF: Held home Lasix while patient was NPO. No evidence of
volume overload on exam and Cr actually improved with holding
Lasix. Therefore he was restarted only on am 40mg Lasix at
discharge with the thought that he may need less diuretics. He
will follow up with his PCP as an outpatient. Patient does not
have outpatient cardiologist so he will be set up with on prior
to discharge for follow up.
# T2DM: held oral agents while inpatient. He was restarted prior
to discharge.
# HTN: Held carvedilol d/t bradycardia and other
antihypertensives prior to pacemaker placement. Amlodipine and
lisinopril were restarted prior to discharge.
# HLD: continued home statin
# CKD:
Followed by Dr. ___. Baseline Cr 2. Cr improved to 1.4 with
holding Lasix during admission. As detailed above, patient
restarted on lower dose of Lasix at discharge.
# OSA: Used CPAP during admission, pt reports not using at home.
# Primary prevention: Continued atorvastatin and ASA
# Gout: continued home allopurinol
Transitional Issues
====================
[] Patient discharged on reduced dose of Lasix. Please monitor
volume status and titrate diuretic as needed
[] Patient discharged off carvedilol, consider restarting if
needed for better blood pressure control
[] Hypernatremic to 150 day of d/c ___ hypovolemia; please check
Cr and sodium on ___ at clinic visit. If increasing would
consider decreasing Lasix dose, encouraging PO intake. PCP ___:
___
[] Please encourage patient to follow up for colonoscopy for age
appropriate cancer screening, especially iso anemia
#Discharge Weight: 122.8kg/270.9Lb
#Discharge Cr: 1.4, Na 150
#CONTACT: ___: wife
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Carvedilol 25 mg PO BID
6. GlipiZIDE XL 5 mg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. sildenafil 50 mg oral prior to sex
___. Furosemide 40 mg PO QAM
11. Calcitriol 0.25 mcg PO DAILY
12. Furosemide 20 mg PO QPM
13. Sodium Bicarbonate 650 mg PO BID
14. Triamcinolone Acetonide 0.025% Cream 1 Appl TP HS
Discharge Medications:
1. Cephalexin 500 mg PO Q6H post pacemaker Duration: 2 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth q6hr Disp #*8
Capsule Refills:*0
2. Furosemide 40 mg PO QAM
3. Allopurinol ___ mg PO DAILY
4. amLODIPine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 20 mg PO QPM
7. Calcitriol 0.25 mcg PO DAILY
8. GlipiZIDE XL 5 mg PO DAILY
9. Lisinopril 10 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. sildenafil 50 mg oral prior to sex
___. Sodium Bicarbonate 650 mg PO BID
13. Triamcinolone Acetonide 0.025% Cream 1 Appl TP HS
14. HELD- Carvedilol 25 mg PO BID This medication was held. Do
not restart Carvedilol until you follow up with your pcp
15. HELD- Furosemide 20 mg PO QPM This medication was held. Do
not restart Furosemide until you followup with your PCP
___:
Home
Discharge Diagnosis:
Primary Diagnosis
===================
Syncope ___ bradycardia
Traumatic ___
Secondary Diagnosis
===================
Chronic Heart Diastolic Failure
Type 2 diabetes
HTN
HLD
CKD
OSA
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you passed out at home.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- Your heart rate was found to be very slow which likely caused
you to pass out
- You had a pacemaker placed to keep your HR at a safe rate
- The lead of the pacemaker became displaced and this had to be
replaced
- You were also found to have a very small bleed in your brain
from the fall. This was monitored and was stable
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Your dry weight is 270.9Lb
- You will follow up with EP for a check of your pacemaker
- You also will see a new cardiologist to help with your heart
failure and pacemaker.
- You should take Keflex for two more days (until ___
- Please only take 40mg of Lasix in the morning. This is a
reduction in your dose.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10292548-DS-3 | 10,292,548 | 24,067,979 | DS | 3 | 2119-07-27 00:00:00 | 2119-07-29 12:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right lower quadrant pain
Major Surgical or Invasive Procedure:
___: laparoscopic appendectomy
History of Present Illness:
___ G3P1 at 15w5d gestation with a history of ulcerative colitis
currently on mesalamine and prednisone taper, admitted to
medical
service overnight with RLQ and epigastric pain. Pt was initially
evaluated by the Acute Care Surgery team 7 weeks ago for RLQ
pain
and loose stools. An MRI at the time showed a normal appendix
and
no evidence of colitis. Pt reports that, due to persistent
symptoms, she was eventually started on prednisone for a
presumed
ulcerative colitis flare. Her symptoms subsided for the most
part, although she continued to notice an occasional slight RLQ
pain with certain movements. Her steroid regimen was tapered,
and
she is currently taking 12.5mg daily.
Yesterday, following lunch, the pt noticed vague abdominal pain,
predominantly in the epigastrium and RLQ. This progressed in
severity and was eventually accompanied by mild nausea. She
otherwise denies fevers, chills, emesis, change in stool
frequency, dysuria, or vaginal bleeding. She presented to an
OSH
and was then transferred overnight to ___ for further workup.
She underwent RUQ ultrasound and pelvic / OB ultrasound without
identifiable abnormality. She was admitted to the medical
service
for pain control and further workup.
This morning the pt underwent MRI A/P, which demonstrated
findings consistent with acute appendicitis.
Past Medical History:
-Ulcerative colitis (last c-scope ___ w/ proctitis) on
mesalamine and prednisone
-Hypertension
-Lactose intolerance
-GERD
Social History:
___
Family History:
NC
Physical Exam:
On Admission:
Vitals: 98.6 81 109/63 18 97%RA
GEN: NAD. Alert, oriented x3.
HEENT: No scleral icterus. Mucous membranes moist.
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, obese. Tender to palpation RLQ, particularly over
McBurney's point. Mild tenderness over epigastrium as well. No
R/G.
EXT: Warm with trace ___ edema.
Pertinent Results:
___ 09:13AM BLOOD WBC-17.5* RBC-4.25 Hgb-12.0 Hct-35.9*
MCV-85 MCH-28.3 MCHC-33.4 RDW-13.8 Plt ___
___ 03:30AM BLOOD WBC-15.2* RBC-4.27 Hgb-11.9* Hct-36.0
MCV-84 MCH-27.8 MCHC-32.9 RDW-13.4 Plt ___
___ 03:30AM BLOOD Neuts-82.3* Lymphs-14.0* Monos-2.8
Eos-0.8 Baso-0.1
___ 09:13AM BLOOD Glucose-107* UreaN-6 Creat-0.6 Na-139
K-4.0 Cl-106 HCO3-23 AnGap-14
___ 03:30AM BLOOD Glucose-121* UreaN-5* Creat-0.6 Na-137
K-3.8 Cl-103 HCO3-22 AnGap-16
___ 09:13AM BLOOD ALT-10 AST-14 LD(LDH)-218 AlkPhos-57
TotBili-0.5
___ 03:30AM BLOOD ALT-9 AST-13 AlkPhos-59 TotBili-0.3
___ 09:13AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.0
___ MRI Abdomen: 1. Uncomplicated appendicitis with mural
edema at the base and dilation of the appendix towards the tip.
2. No abnormally dilated or thickened small or large loops to
indicate active colitis at this time.
Brief Hospital Course:
Ms. ___ was admitted to the ___ service on ___ following
laparoscopic appendectomy for acute appendicitis. Reader is
referred to the operative report from that date for further
details. She tolerated the procedure well and was extubated in
the OR. Following an uneventful stay in the PACU, she was
transferred to the floor for further monitoring. Her diet was
advanced postop without issue, and she endorsed good pain
control with tylenol. She remained afebrile throughout the
remainder of her hospital stay, was ambulating without
assistance, and was endorsing normal bowel and bladder function.
She felt well and was without evidence of obstetric
complications throughout her postoperative period. She was
deemed stable for discharge home on ___. She was advised to
schedule follow up with her OB within a week following
discharge, and is to follow up in ___ clinic for routine
postoperative check. She verbalized understanding and agreement
with these arrangements.
Medications on Admission:
-Mesalamine 2.4g BID
-Pantoprazole 40mg daily
-Prednisone 12.5mg daily
-Vitamin D3 1000u daily
Discharge Medications:
1. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Six (6)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
3. prednisone 5 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the Acute Care Surgery service because of
acute appendicitis.
You were taken to the operating room for a laparoscopic
appendectomy on ___. You tolerated this procedure well and
there were no complications.
You should drink plenty of fluid and eat your regular diet.
You may continue to walk as often as tolerated. Do not lift
objects greater than 5 pounds for at least ___ weeks.
You should take Tylenol for pain and use warm compresses for
comfort. Do not take narcotic medications, as these may have
adverse effects on your fetus.
You should follow up with your obstetrician following discharge
from the hospital.
You should call the ___ clinic or seek immediate medical
attention if you develop fevers, chills, difficulty eating food,
nausea, vomiting, diarrhea, or any symptoms which are concerning
to you.
Followup Instructions:
___
|
10292574-DS-6 | 10,292,574 | 27,802,882 | DS | 6 | 2170-06-24 00:00:00 | 2170-06-26 08:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Isosorbide Mononitrate / Amiodarone
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ w/PMH of Afib (c/b chronic pain) who complains of
pain atypical from her usual Afib. She says she had an episode
of palpitations on ___ x4h that resopnded to 25 PO metoprolol
per PCP ___. Afterwards she has had persistent
retrosternal pleuritic pain that radiated to her left shoulder.
Today she says she feels pain only on inspiration and it's not
associated to shortness of breath or other symptoms.
In the ED, initial vitals were 97.6 110 116/95 18 99%.
She arrived to the ER with c/o chest discomfort during
inspiration. EKG performed. Pt in Afib with rate of 135. Given
total of 10mg IVP Lopressor and pulse currently 55. Pt with c/o
chest pain now and trop of 1.9. She triggered on arrival for
Afib in rate of 120s w/SBPs in the ___ which downtrendd to ___.
She was given bolus of normal saline and 2.5 IV metoprolol. She
then converted to sinus ryhtm with her heart rate in the ___.
INR 4.7, Trop 1.9, ASA given.
___ 07:50 IV Metoprolol Tartrate 5 mg
___ 07:50 IVF 1000 mL NS 1000 mL
___ 08:05 IV Metoprolol Tartrate 5 mg
___ 09:22 PO Aspirin 324 mg
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. Hypertension.
2. Hyperlipidemia.
3. Paroxysmal atrial fibrillation, anticoagulated, followed by
Dr. ___.
4. Ophthalmic zoster ___.
5. Osteoporosis.
6. Right eye glaucoma.
7. Left eye cataract.
PAST SURGICAL HISTORY: ___, polypectomy of the colon.
Social History:
___
Family History:
Her father died when he was ___ years old of MI. She also has a
couple of sisters who also suffer from coronary artery disease.
Physical Exam:
Admission PE:
VS: T= 98 BP= 96/60 HR= 57 RR= 18 O2 sat= 95% RA
GENERAL: In NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Severe kyphosis. Resp were unlabored, no accessory muscle
use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 1+ ___ 1+
Left: DP 1+ ___ 1+
Discharge PE:
VSS, HR in ___, BPs ___
Exam otherwise unremarkable.
No ___ edema
Pertinent Results:
Admission Labs:
___ 07:50AM BLOOD WBC-11.1*# RBC-3.94* Hgb-12.7 Hct-38.4
MCV-98 MCH-32.3* MCHC-33.1 RDW-13.4 Plt ___
___ 07:50AM BLOOD Neuts-85.8* Lymphs-7.4* Monos-5.6 Eos-0.8
Baso-0.4
___ 07:50AM BLOOD ___ PTT-45.7* ___
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD Glucose-150* UreaN-32* Creat-1.1 Na-137
K-4.4 Cl-101 HCO3-23 AnGap-17
___ 07:50AM BLOOD CK(CPK)-1022*
___ 07:50AM BLOOD CK-MB-21* MB Indx-2.1 ___
___ 01:00PM BLOOD TSH-0.054*
___ 01:00PM BLOOD T4-6.9
NOTABLE LABS
___ 07:50AM BLOOD cTropnT-1.90*
___ 01:00PM BLOOD CK-MB-14* cTropnT-1.96*
___ 06:55PM BLOOD CK-MB-9 cTropnT-2.26*
___ 07:20AM BLOOD CK-MB-5 cTropnT-2.65*
___ 07:00AM BLOOD CK-MB-3 cTropnT-3.29*
DISCHARGE LABS
___ 07:00AM BLOOD WBC-8.1 RBC-3.66* Hgb-11.8* Hct-35.7*
MCV-98 MCH-32.2* MCHC-33.0 RDW-13.4 Plt ___
___ 07:00AM BLOOD ___
___ 07:00AM BLOOD Glucose-94 UreaN-40* Creat-1.0 Na-141
K-3.8 Cl-107 HCO3-26 AnGap-12
IMAGING:
ECHO ___:
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. Overall left ventricular systolic function
is mildly depressed (LVEF= 45-50%) secondary to apical and
distal anterior, anteroseptal, and inferior hypokinesis. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are mildly thickened.
Mild to moderate (___) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of ___,
regional wall motion abnormalities are new. There is more
tricuspid regurgitation and pulmonary artery systolic pressure
is higher.
Brief Hospital Course:
BRIEF SUMMARY STATEMENT: ___ year old female with a history of
HTN, atrial fibrillation diagnosed in ___, rate controlled, who
was admitted on ___ due to pleuritic chest pain unusual
compared to the discomfort she feels due to afib. Initially
worked up as NSTEMI however EKG and ECHO findings more
consistent with myopericarditis. Her CP improved on colchicine
and she was discharged with close follow-up.
ACTIVE ISSUES
==============
# ATYPICAL CHEST PAIN: Pt. presented with CP somewhat atypical
for her as it had more of a pleuritic and positional character
in nature. There was evidence of troponin elevation yet CK-MB
remained practically normal. The initial EKGs showed pattern
suggestive of diffuse ST segment elevation with PR depression in
several leads. Additionally, her focal wall motion
abnormalities on TTE were not consistent with her EKG changes.
As such, it was thought her presentation were most consistent
with having myopericarditis. Pt. was started on colchicine with
dramatic improvement.
CHRONIC ISSUES
===============
# Atrial fibrillation: Pt. was in sinus rhythm on admission.
She also was bradycardic. As such, her home metoprolol was not
uptitrated. She was continued on coumadin.
# HTN: Pt. with stable hypotension on admission. As such, her
amlodipine was discontinued. She was continued on lisinopril
and HCTZ.
# Depression: Continued on fluoxetine.
TRANSITIONAL ISSUES
======================
# Colchicine: Initiated on BID dosing for ___ months
# Medication Changes: We discontinued pt's amlodipine as her
blood pressures were low. If need more BP control, would
recommend uptitrating her lisinopril. Simvastatin was d/c'ed and
she was started on atorvastatin 40. We also started the pt. on
aspirin 81 daily. These changes were made as pt. is likely high
risk for CAD.
# Code: Full
# Contact: ___ (son, HCP, ___ Alternate
is daughter in law ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO HS
2. Acetaminophen 1000 mg PO Q8H:PRN pain
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Bisacodyl 5 mg PO EVERY OTHER DAY constipation
5. Warfarin 4 mg PO 6X/WEEK (___)
6. Hydrochlorothiazide 12.5 mg PO 3X/WEEK (___)
7. travoprost 0.004 % ophthalmic once daily
8. Simvastatin 20 mg PO QPM
9. Fluoxetine 10 mg PO DAILY
10. Amlodipine 2.5 mg PO HS
11. Vitamin D 1000 UNIT PO DAILY
12. Warfarin 2 mg PO 1X/WEEK (SA)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Bisacodyl 5 mg PO EVERY OTHER DAY constipation
3. Fluoxetine 10 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. travoprost 0.004 % ophthalmic once daily
6. Warfarin 4 mg PO 6X/WEEK (___)
7. Warfarin 2 mg PO 1X/WEEK (SA)
8. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
10. Colchicine 0.6 mg PO BID
RX *colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*3
11. Hydrochlorothiazide 12.5 mg PO 3X/WEEK (___)
12. Lisinopril 10 mg PO HS
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Myopericarditis
SECONDARY DIAGNOSES
====================
Atrial fibrillation
Hypertension
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you while you were at ___
___.
You were admitted for chest pain. We discovered that you had
irritation to your heart that was consistent with
pericarditis-myocarditis. You were started on a medication
called colchicine to help treat and prevent this from recurring.
You were also started on a daily baby aspirin and a different
statin, atorvastatin. Please stop your simvastatin and
amlodipine. You should follow up with your primary care
physician and cardiologist for management going forward.
Thank you and all the best,
Your ___ Team.
Followup Instructions:
___
|
10292598-DS-13 | 10,292,598 | 27,780,489 | DS | 13 | 2163-06-11 00:00:00 | 2163-06-12 17:57:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / adhesive tape / Tegaderm /
vancomycin
Attending: ___.
Chief Complaint:
Transferred from ___ ED with hypotension and
concern for wound infection.
Major Surgical or Invasive Procedure:
Right breast tissue expander removal ___
R breast abscess washout site ___
History of Present Illness:
Ms. ___ is a ___ with hx R breast invasive ductal carcinoma
(s/p neoadjuvant chemotherapy, mastectomy with tissue expander
___, on doxorubicin/cyclophospamide) now transferred from
___ ED with hypotension and concern for wound
infection.
She was seen ___ plastic surgery clinic ___ when her 600 cc
tissue expander was filled with 60 cc of normal saline, bringing
the total volume to 180 cc. The medial aspect of the wound was
noted to be erythematous without concern for frank cellulitis or
purulent drainage. A 1.5 cm necrotic area was debrided ___ the
office, along with a 0.7 cm area lateral to this wound. The
wound was closed with nylon sutures.
Since that time, she has been feeling lightheaded and dizzy with
poor po intake and urine output. Febrile to 102 last week, also
endorses shaking chills. ___ measured her blood pressure as
70/40, and she was transported by ambulance ___ to ___
___.
At the ___ ED she was hypotensive with an SBP ___
the
___, also febrile to 103.3F. Labs notable for Cr 5.5 and lactate
5.6. She was found to be neutropenic with a WBC of 1.4. Sodium
was 126. She was given 5L of fluid and started on vanc (did not
receive zosyn) with improvement ___ her blood pressure into the
___. She was subsequently transferred to ___ for further
management. En route she was started on norepinephrine for low
blood pressure.
___ the ___ ED, initial vitals notable for T 102, HR 112, BP
111/58, 100%RA. Labs notable for Na 132, Bicarb 14 (Gap16), BUN
52, Cr 5.4 (baseline ~0.9), WBC 1.4, H/H 8.7/25.7, Plt 51. Her
lactate improved to 1.5. A foley catheter was inserted and a UA
showed 19WBCs, 86RBCs, negative leuks, negative nitrites.
Patient given 5mg IV morphine, 2g Cefepime, 1L NS, 4mg Zofran
and 1g tylenol. Given improvement ___ her SBP was improved to
90-100's and norepinephrine was stopped, however only
transiently and was restarted. She continued to be febrile with
fevers to 101. She was seen by plastic surgery who thought
surgical infection was localized and are planning to take
patient to OR tonight for expander removal and washout.
On arrival to MICU, patient ___ NAD, afebrile on 0.15 norepi with
BPs stable ___ 100s systolic.
Past Medical History:
ONCOLOGIC HISTORY:
-___: screening mammogram revealed numerous calcifications ___
the right breast and called back for diagnostic imaging.
Diagnostic ___ revealed pleomorphic calcs ___ the right ___ at the junction of the anterior middle thirds behind
and
slightly below and lateral to the nipple spanning an area of 4 x
3 x 3.2 cm. She then underwent ultrasound, which showed an
irregular hypoechoic mass containing calcifications measuring
1.7
x 1 x 1.3 cm. ___ addition, on ultrasound scanning, there was a
0.7 x 0.5 cm mass at 12 o'clock, 4 cm from the nipple, which
also
had a few faint calcifications. Her right axilla was scanned,
which showed a single lymph node, which appeared normal. Core
needle biopsy performed at
the 9 o'clock position and the 12 o'clock position. The
pathology of these two sites revealed at the 9 o'clock position,
invasive ductal carcinoma, grade 2, HER2 positive (FISH ratio
7.7), ER positive, LVI present. At the 12 o'clock position, it
revealed breast parenchyma with foci of lymphovascular invasion.
-___: Breast MRI revealed biopsy proven cancer ___ the
slightly outer central right breast measuring 2.5cm ___ maximum
dimension with suspected satellite areas of disease which spans
a total area of 7cm x 6.2cm x 4.5cm. The area of concern on
the
prior ultrasound of ___ at 12 o'clock
corresponds to a 1 cm lesion with irregular margins and washout
kinetics concerning for a satellite area of malignancy. Two
suspicious lymph nodes ___ the right axilla for which right
axillary ultrasound with possible fine needle aspiration is
recommended. Two probable benign foci on the left which can be
re-evaluated ___ one year by MRI.
-___: FNA of right axillary node was positive for
malignant
cells
-___: initiated neoadjuvant chemotherapy with Taxol,
Herceptin, and Pertuzumab which will be followed by dose-dense
Adriamycin & Cytoxan.
- ___ week 10 taxol, also received herceptin/pertuzumab
PAST MEDICAL HISTORY:
Hypothyroidism
Hypertension
Social History:
___
Family History:
Mother ___ ___ HEART DISEASE
PANCREATIC CANCER
Father ___ ___ ___ DISEASE
PACE MARKER
Sister Living ___ HYPERTENSION
HYPERLIPIDEMIA
Physical Exam:
On admission:
Physical Exam:
Vitals- T 98.9, HR 95, BP 105/58, RR 12, 95%RA
General: Alert, oriented, significant discomfort
HEENT: Sclera anicteric, dry MM, oropharynx clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi appreciated anteriorly, exam limited by pain
CV: Regular rate and rhythm, no murmurs/rubs/gallops
Abdomen: soft, non-tender, non-distended, hypoactive bowel
sounds, no rebound tenderness or guarding, no organomegaly
GU: + foley
Skin: R 10cm incision with sutures ___ tact, tender to palp,
warm, no noted fluctuance
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On discharge:
VS: Tmax 99.0, Tc 99.0, BP 124-148/60-80, HR 79-82, RR 18, SpO2
93-99%RA
GEN: A&Ox3, NAD, hair loss
HEENT: PERRLA. MMM. blister right lower lip. no JVD. neck
supple.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: Decreased breath sounds on R up to mid lung field;
otherwise clear, good air entry, good respiratory effort
Chest: Dressing over right chest wall c/d/i, non-tender to
palpation, sutures removed.
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no ___
sign
Extremities: wwp, 2+ ___ edema to thigh. DPs, PTs 2+.
Skin: papularmacular rash on R flank, back, under bra line on R,
and on LLE, bilateral arms; itchy; healing
Neuro: A&Ox3. CNs II-XII grossly intact. Moving all extremities.
Pertinent Results:
On admission:
___ 07:20PM BLOOD WBC-1.4*# RBC-2.83*# Hgb-8.7*# Hct-25.7*#
MCV-91 MCH-30.9 MCHC-34.0 RDW-15.2 Plt Ct-51*#
___ 07:20PM BLOOD Neuts-67 Bands-10* Lymphs-16* Monos-4
Eos-0 Baso-2 ___ Metas-1* Myelos-0
___ 07:20PM BLOOD ___ PTT-29.2 ___
___ 07:20PM BLOOD Glucose-89 UreaN-52* Creat-5.4*# Na-132*
K-4.5 Cl-102 HCO3-14* AnGap-21*
___ 07:20PM BLOOD ALT-29 AST-27 LD(LDH)-165 AlkPhos-86
TotBili-2.6*
___ 05:13AM BLOOD Calcium-6.4* Phos-5.3*# Mg-1.4*
___ 07:20PM BLOOD Lactate-1.5
___ the interim:
___ 05:13AM BLOOD Glucose-134* UreaN-53* Creat-5.3* Na-133
K-4.3 Cl-105 HCO3-15* AnGap-17
___ 03:11AM BLOOD Glucose-94 UreaN-47* Creat-3.6* Na-134
K-3.8 Cl-105 HCO3-19* AnGap-14
___ 06:04AM BLOOD Glucose-97 UreaN-46* Creat-2.7* Na-140
K-4.2 Cl-110* HCO3-20* AnGap-14
___ 05:44AM BLOOD Glucose-89 UreaN-36* Creat-2.1* Na-141
K-4.8 Cl-110* HCO3-23 AnGap-13
___ 05:44AM BLOOD Glucose-83 UreaN-29* Creat-2.0* Na-141
K-4.8 Cl-110* HCO3-25 AnGap-11
___ 05:15AM BLOOD Glucose-96 UreaN-20 Creat-1.6* Na-138
K-4.4 Cl-108 HCO3-25 AnGap-9
___ 05:47AM BLOOD Glucose-91 UreaN-18 Creat-1.7* Na-141
K-4.4 Cl-110* HCO3-24 AnGap-11
___ 06:00AM BLOOD Glucose-85 UreaN-20 Creat-1.8* Na-142
K-4.4 Cl-109* HCO3-24 AnGap-13
___ 06:06AM BLOOD Glucose-87 UreaN-17 Creat-1.6* Na-142
K-4.2 Cl-109* HCO3-23 AnGap-14
___ 05:30AM BLOOD Glucose-88 UreaN-17 Creat-1.8* Na-143
K-4.2 Cl-109* HCO3-24 AnGap-14
___ 05:29AM BLOOD Glucose-88 UreaN-18 Creat-1.9* Na-141
K-4.5 Cl-107 HCO3-23 AnGap-16
___ 05:52AM BLOOD Glucose-90 UreaN-18 Creat-2.0* Na-141
K-4.5 Cl-107 HCO3-22 AnGap-17
On discharge:
___ 06:09AM BLOOD WBC-7.4 RBC-2.66* Hgb-8.3* Hct-24.2*
MCV-91 MCH-31.2 MCHC-34.3 RDW-17.0* Plt ___
___ 06:09AM BLOOD Neuts-74.5* Lymphs-13.7* Monos-4.5
Eos-6.9* Baso-0.4
___ 06:09AM BLOOD Glucose-90 UreaN-12 Creat-1.8* Na-143
K-4.2 Cl-109* HCO3-22 AnGap-16
___ 06:09AM BLOOD Calcium-8.6 Phos-4.8* Mg-1.9
Microbiology:
___ Blood cultures x 2: Negative
___ Urine culture:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ MRSA screen:
MRSA SCREEN (Final ___:
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
___ R breast wound swab:
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT
PRESENT ___
this culture..
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ and ___ Blood cultures: No growth.
___ Lower lip swab:
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
YEAST, PRESUMPTIVELY NOT C. ALBICANS. SPARSE GROWTH.
___ Lower lip viral culture:
___ 2:55 pm SKIN SCRAPINGS
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary):
No Herpes simplex (HSV) virus isolated.
VARICELLA-ZOSTER CULTURE (Preliminary): RESULTS PENDING.
___ R breast washout culture:
___ 7:20 pm TISSUE Site: CHEST RIGHT CHEST WOUND.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
Reported to and read back by ___ ___ @ 12:46
___.
NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. SPARSE
GROWTH.
sensitivity testing performed by Microscan. MEROPENEM
<=1 MCG/ML.
ENTEROCOCCUS SP..
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
NON-FERMENTER, NOT PSEUDOMONAS
AERUGINOSA
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R
CEFEPIME-------------- 8 S
CEFTRIAXONE----------- <=4 S
CIPROFLOXACIN--------- <=0.5 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- <=1 S
LINEZOLID------------- 2 S
MEROPENEM------------- S
PENICILLIN G---------- =>64 R
PIPERACILLIN/TAZO----- <=8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=2 S
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Imaging and other studies:
ECG (___):
Sinus tachycardia. Borderline low generalized QRS voltage. Minor
non-specific repolarization changes. No previous tracing
available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
110 128 88 314/401 67 18 57
CXR (___):
IMPRESSION:
Left lung is clear. Peribronchial opacification developing ___
the right lower lobe could be asymmetric edema, or early
pneumonia. CT careful followup advised. Normal
cardiomediastinal and hilar silhouettes. No pleural effusion.
Catheter of the left central venous infusion port ends ___ the
region of the superior cavoatrial junction. No pneumothorax.
TTE (___):
The left atrium and right atrium are normal ___ cavity size. Mild
symmetric left ventricular hypertrophy with normal cavity size,
and global systolic function (biplane LVEF = 59 %). The
estimated cardiac index is normal (>=2.5L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved regional and global
biventricular systolic function.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
CXR (___):
IMPRESSION:
Previous mild pulmonary edema has resolved. Consolidation at the
right lung base persists and is still accompanied by moderate
size subpulmonic pleural effusion. Small left pleural effusion
unchanged. Upper lungs clear. Heart size top-normal.
The patient could not cooperate for standard positioning of the
right cubitus radiograph to look for layering right pleural
effusion.
Brief Hospital Course:
___ with hx of R invasive ductal carcinoma (s/p neoadjuvant
chemotherapy, mastectomy with tissue expander) presented with
septic shock from a MRSA soft tissue and breast device
infection.
#Septic shock: Tissue expander placed ___ and she had
started a nother cycle of doxo/cyclophosphamide on ___. On
presentation surgical site erythematous with purulent drainage.
Plastic surgery service explanted R tissue expander on ___.
She was initially started on Vanc/Zosyn. OR cultures grew MRSA.
No blood cultures were positive. She presented borderline
neutropenic and received neupogen. She was resucitated with 12L
crystalloid and levophed gtt. Plastic surgery service came by
daily to debride wound. She required levophed for 5 days to
maintain MAPs>60. Given the persistence of her shock, a TTE was
performed to r/o cardiac etiologies. Her EF was preserved. Her
port, which had remained ___ place during her treatment, was not
deemed to be infected. Site was clean/dry/intact. Zosyn was
de-escalated to Augmentin, per ID. Vancomycin was continued, and
patient underwent repeat washout on ___, with closure of the
site. Site was closed with Nylon sutures, and 2 JP drains were
left to suction. Starting ___, Vancomycin and Augmentin were to
continue for an additional 2 weeks. New culture data from ___
washout led to a switch from Augmentin to Moxifloxacin. On ___,
drug rash was noted (also + eosinophilia without evidence of
DRESS) and attributed to Vancomycin. Vancomycin was switched to
Linezolid PO. Linezolid and Moxifloxacin were continued until
the end of the 2 week course ___ until the end of the day
on ___. For her rash, Sarna Lotion and hydrocortisone cream
along with PO Hydroxyzine provided some relief.
#Acute renal failure: Presented with a Cr of 5.4 from a baseline
of .9. Spun urine showed ATN. Likely pre-renal from her septic
shock. Improved, as did her urine output, with IVF and blood
pressure support. Patient's new creatinine baseline was
determined to be 1.6-1.8. After her initial period of sepsis,
her blood pressure normalized, and she became hypertensive to
the 170s on the floor. Her home Losartan was resumed with good
tolerance. Her creatinine initially rose ___ the setting of her
eosinophilic rash with initial concern for DRESS; however, she
was found to be only pre-renal, and urine was spun without
evidence of increased WBCs or casts. Creatinine returned to 1.8
with maintenance fluid and increased PO intake.
# Right lung effusion/possible PNA: Noted on CXR, infiltrate
complicated by parapneumonic effusion on R. However, remained
afebrile and saturated well on RA throughout her stay on the
Oncology floor. Due to her clinical stability, the decision was
made not to drain her R-sided effusion. Blood cultures from ___
and ___ demonstrated no growth to date. Patient never spiked a
fever on the floor during her post-ICU course, and never had a
productive cough. She was continued on Linezolid and
Moxifloxacin as above.
# Breast cancer - Per outpatient notes, plan for 4 cycles of
Cytoxan/Adriamycin and then for her to have postmastectomy
radiation (planning scheduled for late ___. She was given
Herceptin ___ ___, which is to continue q3weeks.
CHRONIC ISSUES:
#HTN - Initally, patient's home Losartan and Metoprolol were
held ___ the setting of hypotension and sepsis. However,
post-stabilization, she was hypertensive with SBPs to the
160s-170s. Her home Metoprolol XL 50 mg qday was re-started.
Losartan was initially resumed given acceptance of new
creatinine baseline of 1.6-1.8; once creatinine started to rise
again (to 2.0). There was initial concern for AIN, but urine
sediment was examined without evidence of casts/ increased WBCs.
Creatinine once again stabilized without steroids/ with only
maintenance IVF to 1.8. Patient was resumed and continued on her
home Losartan for BP control.
#HLD - Patient's Atorvastatin was initially held ___ the setting
of sepsis/ hemodynamic instability; after stabilization, this
medication was resumed.
#Hyperthyroid - Last TSH was low on ___. Patient was continued
on her pre-admission Levothyroxine dose 112mcg. TSH was
re-checked prior to discharge and was found to be high at 21.
This should be re-checked off antibiotics, and dose adjusted per
her PCP as an outpatient.
#GERD - Patient was continued on her home Omeprazole.
#Primary Prophylaxis: Patient was continued on a multi-vitamin.
Aspirin was discontinued ___ while the patient was placed
on HSQ, but was re-started upon discharge.
#Other issues: Patient was severely deconditioned upon
admission, but was fully functional with ___ after clinical
stabilization.
TRANSITIONAL ISSUES:
- Patient completed a 2 week course with Linezolid and
Moxifloxacin for her implant infection/ R breast abscess.
- Patient has reached a new creatinine baseline of 1.6-1.8.
Losartan was resumed this admission after stabilization from
sepsis. Consideration can be given to switching this to
Amlodipine as an outpatient.
- Patient's TSH was checked per her request this admission and
was elevated at 21. Please re-check ___ 4 weeks, and re-address
dosing of Levothyroxine.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 112 mcg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. dolasetron 100 mg oral Daily:PRN nausea from chemotherapy
4. Ondansetron 8 mg PO Q8H:PRN nausea from chemotherapy
5. Losartan Potassium 25 mg PO DAILY
6. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
7. Diphenoxylate-Atropine 2 TAB PO Q6H:PRN diarrhea
8. Prochlorperazine 10 mg PO Q6H:PRN nausea from chemotherapy
9. Lorazepam 0.5 mg PO Q6H:PRN nausea from chemotherapy
10. Metoprolol Succinate XL 50 mg PO DAILY
11. pegfilgrastim 6 mg/0.6mL subcutaneous For chemotherapy
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Aspirin 81 mg PO DAILY
15. nitrofurantoin macrocrystal 50 mg oral QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Levothyroxine Sodium 112 mcg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. 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
8. dolasetron 100 mg ORAL DAILY:PRN nausea from chemotherapy
9. Lorazepam 0.5 mg PO Q6H:PRN nausea from chemotherapy
10. Ondansetron 8 mg PO Q8H:PRN nausea from chemotherapy
11. pegfilgrastim 6 mg/0.6mL subcutaneous For chemotherapy
12. Prochlorperazine 10 mg PO Q6H:PRN nausea from chemotherapy
13. Diphenoxylate-Atropine 2 TAB PO Q6H:PRN diarrhea
14. Acetaminophen 650 mg PO Q6H:PRN pain
15. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
18. Bisacodyl 10 mg PR QHS:PRN constipation
19. Sarna Lotion 1 Appl TP TID:PRN itchy rash
20. HydrOXYzine 25 mg PO TID:PRN itching
RX *hydroxyzine HCl 25 mg 1 tablet by mouth three times a day
Disp #*21 Tablet Refills:*0
21. Losartan Potassium 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right breast Methicillin Resistant Staph Aureus abscess
Acute Tubular Necrosis
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 to the ICU for low blood pressure and
infection of your right breast implant. You were treated with IV
fluids, medications to increase your blood pressure,
antibiotics, and removal of the infected implant. Your vital
signs improved and you were transferred to the general oncology
floor.
Antibiotics were continued and you did not develop any further
signs of infection. You did develop a drug rash as a reaction to
one of the previous antibiotics which was resolving at the time
of discharge. You may apply lotions of your choice to your rash
at home.
Because of low blood pressure, your kidney function acutely
worsened but gradually improved with the above therapies. Your
kidney numbers have reached a new baseline.
You also had a radiation planning session while you were here.
Once again, it was a pleasure being a part of your care, and we
wish you all the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10292730-DS-22 | 10,292,730 | 20,918,790 | DS | 22 | 2140-01-09 00:00:00 | 2140-01-12 12:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ultram / methyldopa
Attending: ___
Major Surgical or Invasive Procedure:
Cardiac catheterization
Direct current cardioversion
Right heart catheterization
attach
Pertinent Results:
ADMISSION LABS:
___ 04:51PM BLOOD WBC-5.3 RBC-3.94 Hgb-10.8* Hct-34.4
MCV-87 MCH-27.4 MCHC-31.4* RDW-15.8* RDWSD-49.8* Plt ___
___ 04:51PM BLOOD Neuts-59.4 ___ Monos-8.3 Eos-0.4*
Baso-0.6 Im ___ AbsNeut-3.14 AbsLymp-1.63 AbsMono-0.44
AbsEos-0.02* AbsBaso-0.03
___ 04:51PM BLOOD Plt ___
___ 07:00AM BLOOD ___ PTT-31.0 ___
___ 04:51PM BLOOD Glucose-115* UreaN-26* Creat-1.4* Na-145
K-4.8 Cl-110* HCO3-19* AnGap-16
___ 04:51PM BLOOD ALT-7 AST-14 AlkPhos-88 TotBili-0.3
___ 04:51PM BLOOD proBNP-2201*
___ 04:51PM BLOOD cTropnT-<0.01
___ 07:00AM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:51PM BLOOD Albumin-4.2 Calcium-10.1 Phos-3.2 Mg-2.1
Iron-81
___ 04:51PM BLOOD calTIBC-317 Ferritn-76 TRF-244
PERTINENT STUDIES:
___ Video Capsule Endoscopy Report:
PROCEDURE INFORMATION AND FINDINGS
1) Capsule images started in the small bowel. No evaluation of
the esophagus or stomach.
2) Nonspecific erythema in the duodenum
3) Several nonbleeding angioectasias in the mid jejunum
4) Three lymphangiectasias in the mid jejunum
5) Nonspecific erythema in the mid ileum. No evidence of active
bleeding.
SUMMARY AND RECOMMENDATIONS
Summary:
1) Capsule images started in the small bowel. No evaluation of
the esophagus or stomach.
2) Nonspecific erythema in the duodenum
3) Several nonbleeding angioectasias in the mid jejunum
4) Three lymphangiectasias in the mid jejunum
5) Nonspecific erythema in the mid ileum. No evidence of active
bleeding.
Recommendations:
1) If clinically bleeding, could consider single balloon
enteroscopy for treatment of jejunal angioectasias. Unclear
given delayed start of capsule if they would be amenable to push
enteroscopy.
___ CT Abd and Pelvis W/O Contrast:
No substantial change in appearance or size of a wedge-shaped
hypodensity of the spleen, likely reflecting infarct. No
interval expansion, hematocrit level or perisplenic free fluid
to suggest hematoma.
___ CT Chest W/O Contrast:
1. Mucous plugging of segmental bronchi in the bilateral lower
lobes, more
extensive on the right. Mild linear and bandlike atelectasis in
the bilateral lower lobes, right greater than left.
2. Areas of wedge-shaped hypoattenuation in the spleen,
suspicious for
infarcts. Splenic masses are also in the differential. This
could be better characterized with contrast enhanced CT or MRI
of the abdomen.
3. Cardiomegaly. Moderate coronary calcifications.
___ CT Abd/Pelvis W/O Contrast:
New wedge-shaped defect within the spleen with intermediate
density. This is nonspecific and could represent a hematoma or
infarct. Contrast enhanced CT abdomen or abdominal ultrasound
can be performed for further characterization.
RHC ___:
At entry, the mean RA was 10, RV ___ PA 65/___, mean PCW 16
mm Hg. Using an assumed oxygen consumption of 125 mL/min/m2 and
arterial oxygen saturation imputed from finger oxymetry,
the calculated cardiac index was 2.7 L/min/m2. The PVR was 414
dynes-sec/cm5 (5.2 ___. Using mean arterial pressure imputed
from
left brachial NIBP, the estimated SVR was 1361 dynes-sec/cm5.
There was no oxymetric evidence of significant intracardiac
shunting (right-to-left or left-to-right).
Please see the paper chart for printouts of the hemodynamic
waveforms.
1. Moderate pulmonary hypertension.
2. Mildly elevated mean PCW consistent with mild left
ventricular
diastolic heart failure (acute on
chronic).
3. Mild right ventricular diastolic dysfunction.
4. No oxymetric evidence of significant intra-cardiac shunting.
EKG ___: Sinus bradycardia with LBBB
EKG ___: Sinus bradycardia with LAD and LBBB
EKG ___: A-fib with RVR, LAD
EKG ___: A-fib with RVR, LAD
EKG ___: Unchanged from prior
EKG ___: Unchanged from prior
EKG ___: Unchanged from prior
EKG ___: Unchanged from prior
EKG ___: S/p TEE and DCCV: NSR
CXR ___:
New moderate pulmonary edema. Worsened bilateral pleural
effusions and adjacent consolidations consistent with
compressive
atelectasis.
TEE ___:
No thrombus in the left atrium/left atrial appendage. Mild
spontaneous echo contrast in the left atrium/ left atrial
appendage. Moderate aortic stenosis. Mild mitral regurgitation.
Mild tricuspid regurgitation.
U/S Aorta and Branches ___:
1. Limited examination due to patient movement. Within this
limitation, no
visualized dissection in the proximal or mid aorta.
2. Distended gallbladder. Gallbladder wall edema is
nonspecific,
could be
from third spacing and distention could be from NPO. Correlate
clinically.
CXR ___:
1. Interval improvement in pulmonary edema. No focal
consolidation or
pneumonia. Mild right basilar atelectasis.
2. Stable moderate cardiomegaly.
CXR ___:
Compared to chest radiographs since ___ most recently ___ and ___. Mild pulmonary edema is new. Moderate
cardiomegaly is chronic. Small pleural effusions are likely. No
pneumothorax.
Chronic deviation of the upper trachea suggests that enlargement
of the right thyroid lobe has been present since at least ___.
Coronary angiogram ___:
The ___ Obtuse Marginal, arising from the proximal segment, is a
medium caliber vessel. There is a 70% RCA: The Right Coronary
Artery, arising from the right cusp, is a large caliber vessel.
There is a 30% stenosis in the proximal segment. The Right
Posterior Descending Artery, arising from the distal segment, is
a medium caliber vessel. There is a 70% stenosis in the proximal
segment.
Renal Ultrasound ___:
Intrarenal arteries show normal waveforms with sharp systolic
peaks and continuous antegrade diastolic flow. The resistive
indices of the right intra renal arteries range from 0.63-0.78.
The resistive indices on the left range from 0.67-0.73.
Bilaterally, the main renal arteries are patent
with normal waveforms. The peak systolic velocity on the right
is
28 centimeters/second. The peak systolic velocity on the left is
40.5 centimeters/second. Main renal veins are patent bilaterally
with normal waveforms.
No evidence of significant renal artery stenosis.
CXR ___:
Mild cardiomegaly with vascular congestion and small pleural
effusions. No focal consolidation. Leftward deviation of the
trachea at the thoracic inlet which may be due to
right-sided thyroid enlargement. Consider dedicated thyroid
ultrasound if not already performed.
TTE ___:
Mild symmetric left and right ventricular hypertrophy with
normal
cavity size and regional/global biventricular systolic function.
Moderate aortic stenosis with mildly thickened leaflets.
Moderate
mitral and tricuspid regurgitation. Severe pulmonary
hypertension (PASP 74). The visually estimated left ventricular
ejection fraction is 60%.
KUB ___
Mild colonic stool burden with a nonobstructive bowel gas
pattern.
Degenerative changes of the spine and bilateral hips, and
sacroiliac joints as
above.
DISCHARGE LABS:
___ 06:15AM BLOOD WBC-8.4 RBC-3.11* Hgb-8.5* Hct-27.7*
MCV-89 MCH-27.3 MCHC-30.7* RDW-16.1* RDWSD-49.8* Plt ___
___ 06:15AM BLOOD Glucose-101* UreaN-19 Creat-1.6* Na-141
K-5.2 Cl-107 HCO3-21* AnGap-13
___ 06:15AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.3
Brief Hospital Course:
TRANSITIONAL ISSUES
===================
DISCHARGE WEIGHT: 146 lbs
DISCHARGE Cr: 1.6
DISCHARGE DIURETIC: Held
[] Consider restarting lisinopril once kidney function improves,
would likely need to decrease/stop amlodipine when doing so.
[] Furosemide held on discharge given recent ___ and reduced PO
intake this admission. Continue to monitor volume status and
consider restarting as outpatient as diet improves.
[] Consider nephrology follow up for CKD.
[] Discharged on Plavix/Warfarin given recent ___ and concerns
for GI bleeding and ability to reverse warfarin if needed. If
Hgb and creatinine remains stable, consider switching to
Plavix/Apixaban for more evidence-based
anti-platelet/anti-coagulation regimen.
[] Patient was referred to ___ for INR
monitoring on discharge, continue to adjust dose as needed,
would recommend conservative INR goal given GI bleed this
admission.
[] Please recheck a BMP and CBC at PCP follow up.
[] Outpatient ultrasound of thyroid given tracheal deviation
noted on chest x-ray.
[] Continue pantoprazole 40MG BID due to concern for GI bleeding
on Plavix/Warfarin.
[] Home gabapentin dose decreased due to decreased renal
function and AMS this admission, if back pain returns/persists
consider increased if renal function remains stable.
[] Patient's Code status was reversed for procedures this
admission, at discharged remained DNR/DNI which she was
previously. Continue outpatient discussions about the level of
invasive procedures / rehospitalizations that she is comfortable
with going forward.
CODE STATUS: DNR/DNI
HCP: ___, Phone number: ___
CCU COURSE
==========
She was admitted to the CCU overnight given respiratory distress
with brief need for BiPAP which was quickly weaned off. CXR was
consistent with pulmonary edema, felt to be ___ flash pulmonary
edema in setting of poorly controlled HTN and OSA. In the CCU
she received IV diuresis and was started on antihypertensives.
Her respiratory status was stable and she was called back out to
the floor.
Brief hospital course:
___ female past medical history of HFpEF (EF 60%)
poorly-controlled HTN, severe pHTN, tricuspid regurgitation,
mitral regurgitation, HLD presenting initially with volume
overload concerning for HFpEF exacerbation. Was successfully
diuresed with 2 days of IV diuretics and then transitioned to
her home diuretic dose, however then had episodes of unremitting
chest pain with flat troponin trend and was found to have
new-onset atrial fibrillation with RVR. Patient underwent
coronary angiogram, s/p DES to PDA, with 70% stenosis of OM1
that is to be medically managed. On HD#8, patient underwent
successful DCCV and remained in sinus rhythm at discharge. Due
to worsening SOB, was taken for RHC which showed severely
elevated pulmonary artery pressures and elevated wedge, was then
diuresed and discharged in stable condition.
Active Issues
=============
___ female past medical history of HFpEF (EF 60%)
poorly-controlled HTN, severe pHTN, tricuspid regurgitation,
mitral regurgitation, HLD who presented initially with volume
overload concerning for HFpEF exacerbation, had new-onset A-fib
with RVR and troponin elevation concerning for type II NSTEMI
complicated by post-MI unstable angina, s/p coronary angiogram
with DES to PDA (___) and s/p TEE DCCV with conversion to sinus
rhythm, with recent brief CCU stay for acute worsening SOB
thought to be due to flash pulmonary edema, found to have new
leukocytosis and ___ with course further complicated by upper GI
bleed.
#CORONARIES: 70% OM1, 30% RCA, 70% PDA
#PUMP: 60% (___)
#RHYTHM: Sinus
Active Issues
=============
#HFpEF exacerbation
#Severe pulmonary hypertension
#Severe tricuspid regurgitation
#Severe mitral regurgitation
Patient previously on oral diuretics and euvolemic on exam, with
LVEDP around 12 as measured in cath lab suggesting patient is
euvolemic. TTE on this admission shows preserved LVEF with
restrictive-type filling pattern and severe pulmonary
hypertension, likely group II. RHC with evidence for moderately
severe pulmonary hypertension with mild elevation of left and
right heart filling pressures and preserved cardiac index with
moderate increase in pulmonary vascular resistance. Her home
lisinopril was changed to amlodipine in the setting of ___, and
her home direutic was held due to ___ and decreased
PO intake. Carvedilol was also stopped due to bradycardia after
starting amiodarone.
#Chest pain
#Epigastric pain
#Type II NSTEMI
#Unstable angina
Patient with recurrent episodes of SOB, epigastric pain/pressure
and nausea, now resolved. Abdominal exam benign. Troponin T
trend flat, EKG remains unchanged. S/P DES to PDA, 70% stenosis
in OM1 to be medically managed. Abdominal U/S negative for
mesenteric ischemia or aortic dissection. Chest pain now
improved. She was discharged on Plavix/Warfarin due to concern
for splenic infarct and GI bleed as mentioned elsewhere.
#Anemia
#UGB
Patient noted to have hemoglobin of 6.9 on ___. In addition,
had loose dark stools that were guaiac positive. Likely a slow
AVM upper GI bleed due to current anticoagulation vs gastric or
duodenal stress ulcer. Per GI, patient and family did not not
want endoscopic procedures. In, addition CT A/P ___ noted
possible splenic hematoma, concern that anemia could be from
possible expanding hematoma, however repeat CT ___: No
substantial change in appearance or size of a wedge-shaped
hypodensity of the spleen, likely reflecting infarct. No
interval expansion, hematocrit level or perisplenic free fluid
to suggest hematoma. Now S/p 2 units PRBC. Hgb appropriately
increased to 8.4, however downtrended to 7.3. S/p EGD ___,
noted patchy erythema and few punctate erosions of the mucosa in
the stomach with no active bleeding consistent with erosive
gastritis, multiple cold forceps biopsies were performed for
histology in the stomach antrum and stomach body. Repeat
hemoglobin 6.5 ___. S/p unprepped pill capsule endoscopy,
notable for small angiotectasias, continue to monitor
clinically, if she rebleeds would undergo EGD versus ___
depending on presentation. OK for regular diet at this point.
Hgb 7.3 ___ down from 8.3, improved on recheck in afternoon,
currently stable today. Normal VitB12 and folate levels.
#New onset A-fib with RVR
CHADS2VASC of 4 without prior diagnosis of atrial fibrillation.
Likely trigger due to labile BP, with worsening rate control.
Given worsening rate control, now s/p TEE and DCCV w conversion
to SR and rates in ___. S/p Amio load and initially was
converted without anticoagulation and developed a splenic
infarct. Started heparin and bridge to warfarin due to patient's
high bleed risk and easier reversal of Warfarin.
___ on CKD-improved
Per chart review, baseline Cr 1.4-1.9, admission creatinine 1.4.
Cr peaked this admission at 3.4. Etiology likely multifactorial.
Prerenal causes include hypovolemia from decreased PO intake and
upper GI bleed. Unlikely to be cardiorenal as patient is not
clinically volume overloaded. Could be due to contrast induced
nephropathy from recent cath on ___. However, creatinine then
downtrended to baseline. Now elevated. Renal US w/o hydro, and
slowly improved with supportive care, likely multifactorial in
the setting of possible pneumonia, splenic infarct, and
hypotension in the setting of diuresis.
#Hypertension
Initially with labile BP with SBP ranging from 140s-220s
requiring nitro gtt, now with SBP in 130s. Renal U/S without
evidence of RAS. Difficult to control BP in CCU, with SBP in
170s. Discharged on Amlodipine 10MG as discussed elsewhere.
#Dyspnea
#Asthma
Patient intermittently complaining of dyspnea throughout
hospitalization, using oxygen for comfort though satting 99% on
RA. Reports improvement in SOB and wheezing with PRN
ipratropium/albuterol inhaler. Euvolemic on exam with improved
vascular congestion on CXR. Trop T trend flat, EKG now in sinus
rhythm. CXR with mild hyper-inflation, likely ___ asthma. CXR
___ w improved pulm edema and no obvious signs consolidation.
Discharge on home medications.
Chronic/Resolved Issues
=======================
#Leukocytosis, Concern for aspiration penumonia
Patient remains afebrile and hemodynamically stable.
Leukocytosis felt likely to be due to splenic infarct,
especially with noted left flank pain on ___. No dysuria, new
cough w sputum production. Endorsing dark liquid diarrhea, which
has been present for over one week, when C dif was checked and
negative. C dif recheck ___ negative. Has stable dry cough with
some phlegm production. Has had intermittent emesis throughout
admission likely ___ pill burden dysuria. Repeat CXR (port) ___
- difficult to exclude PNA. CT Chest ___: Mucous plugging of
segmental bronchi in the bilateral lower lobes, more extensive
on the right. Mild linear and bandlike atelectasis in the
bilateral lower lobes, right greater than left. CXR ___: There
is no focal consolidation, pleural effusion or pneumothorax. The
cardiac silhouette is enlarged. UA bland. C dif negative. S/p 1
dose of Vancomycin ___, does not require additional dose due to
___. Plan to complete 5 day empiric antibiotics for possible
pneumonia. Sputum culture- contaminated. S/P 5 day course of
CefTAZidime 1 g IV Q24H for possible HAP with slow resolution of
her leukocytosis.
#Diabetes mellitus type 2: Held metformin, insulin sliding scale
while in house. Restarted metformin on discharge
#Hyperlipidemia: Changed home Simvastatin to Atorvastatin 80mg
#GERD: Changed home omeprazole to pantoprazole
#Chronic back pain: Decreased home gabapentin given decreased
renal function this admission
#Gout: Continued allopurinol
~Attending Attestation
Patient seen and agree with summary as documented. 35 minutes
spent in discharge time.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. CARVedilol 25 mg PO BID
3. Gabapentin 400 mg PO BID
4. Lisinopril 20 mg PO DAILY
5. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
6. mometasone-formoterol 100-5 mcg/actuation inhalation BID
7. Omeprazole 40 mg PO DAILY
8. Simvastatin 40 mg PO QPM
9. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Severe
10. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
11. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral BID
12. cod liver oil 1,250-135 unit oral DAILY
13. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 1
tab oral DAILY
14. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Atorvastatin 80 mg PO QPM NSTEMI
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
4. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
RX *polyethylene glycol 3350 [GlycoLax] 17 gram/dose 17 g by
mouth once a day Refills:*0
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [Senokot] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
8. Warfarin 1 mg PO DAILY16 Duration: 1 Dose
Please take at night as directed by the ___
___.
RX *warfarin 1 mg 1 tablet(s) by mouth at bedtime Disp #*60
Tablet Refills:*0
9. Gabapentin 100 mg PO BID:PRN back pain
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
11. Allopurinol ___ mg PO DAILY
12. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral BID
13. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 1
tab oral DAILY
14. cod liver oil 1,250-135 unit oral DAILY
15. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
16. mometasone-formoterol 100-5 mcg/actuation inhalation BID
17. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Severe
18. HELD- Furosemide 40 mg PO DAILY This medication was held.
Do not restart Furosemide until Follow up with your
PCP/Cardiologist
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis
=================
HFpEF exacerbation
Secondary diagnosis
===================
Hypertensive urgency
Type II NSTEMI
Unstable Angina
Atrial fibrillation
Diabetes mellitus type 2
Hyperlipidemia
Asthma
GERD
Gout
CKD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
============================
DISCHARGE WORKSHEET TEMPLATE
============================
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
Thank you for allowing us to be involved in your care, we wish
you all the best!
- Your ___ Healthcare Team
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because of shortness of breath, high blood
pressure, and chest pain
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were admitted to the hospital because you had been feeling
short of breath and you were found to have fluid on your lungs.
This was felt to be due to a condition called heart failure,
where your heart does not pump hard enough and fluid backs up
into your lungs. You were given a diuretic medication through
the IV to help get the fluid out.
- You were also found to have elevated blood pressure, and were
given medication bring the blood pressure down.
- You had a procedure to fix a blockage in one of the arteries
in the heart
- You had a shock to your heart to convert your heart back into
a normal rhythm
- You were started on blood thinners to reduce your risk of
blood clot from your heart rhythm and you had some bleeding in
your intestines. You were started on the lowest possible dose of
blood thinner with improve in your bleeding.
- You improved considerably and were ready to leave the hospital
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- Your weight at discharge is 146 lbs. Please weigh yourself
today at home and use this as your new baseline
- Please weigh yourself every day in the morning. Call your
doctor if your weight goes up or down by more than 3 lbs in a
day or 5Ibs in a week.
Followup Instructions:
___
|
10292870-DS-8 | 10,292,870 | 20,283,882 | DS | 8 | 2182-09-23 00:00:00 | 2182-09-24 12:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Break-through seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old man with a history of a low grade glioma
s/p resection complicated by refractory seizures despite AED
adherence leading to left temporal lobectomy on ___. Since
___, he has continued his AED regimen of LACOSamide 200 mg
BID, lamotrigine 250 mg BID, clobazam 10 mg BID, and lorazepam 1
mg PRN.
He recently had follow-up with both the neurosurgical team and
with the Epilepsy team and was found to have a stable exam.
However, he was noted to have a post-surgical left temporal
hygroma with CT imaging demonstrating possible dural
communication. He was asymptomatic at this time and the decision
was made to continue to watch him.
Three days ago, he developed a piercing headache, sharp through
his left temporal region. This has been constant, if not
steadily
worsening ever since. His pain is not positional. No photophobia
or phonophobia. He has had no recent sicknesses, endorses no
neck
stiffness, and has been adherent with his AED regimen.
Yesterday evening, he suddenly had a generalized tonic clonic
seizure, without his typical aura. Per his wife, he was noted to
be sitting on the couch and suddenly fall, with tongue biting
but
without incontinence. Unlike his seizures prior to his surgical
resection, this seizure was without any aura. The episode lasted
less than 1 minute followed by the patient going limp then
thrashing in non-rhythmic way (total event lasted ~ 3 minutes).
Wife was particularly concerned at the duration of his
post-ictal
state, which lasted ~ 15 minutes and was characterized by
nonsensical speech. W Specifically, wife notes that he was
disoriented to year ("1817") and president and that ee had
trouble speaking in full-sentences. Wife says that it is
atypical
for him to have such a prolonged post-ictal state. His typical
period of aphasia with his prior semiology lasted for 1 minute.
Wife gave him 1 mg ativan when she thought it was safe for him
to
take PO. Although they typically don't call after he has
seizures, wife concerned as this was his first seizure since his
surgical resection on ___.
On ___ reports having a headache for the past 3 days
that he describes as left-sided and piercing, as if directly
piercing into surgical site. He has been adherent with his AEDs
and has not had any recent sicknesses or change in his pattern
of
sleep. On chart review, in last follow-up was on ___ with
Dr. ___ was noted to have fluid collection over
surgical site. He did not have a headache at this time. CT
demonstrated increased size of fluid collection at craniotomy
site. MRI brain without and with gadolinium was recommended to
evaluate whether there is direct communication with cystic area
at the left middle cranial fossa, and integrity of the dura.
Past Medical History:
-Left frontotemporal brain tumor, ganglioglioma on pathology
from OSH, s/p subtotal resection in ___
-Symptomatic epilepsy
Non-AED Medications
-Melatonin 3mg qhs for insomnia
Social History:
___
Family History:
No family history of epilepsy. No other brain tumors in
family, though lung ca, breast ca, and father w/ CABG @ ___.
Physical Exam:
EXAM ON ADMISSION:
=================
Vitals: T97.7 HR75 RR18 101/63
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Visual acuity
___ bilaterally. Fundoscopic exam revealed no papilledema,
exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
EXAM ON DISCHARGE:
==================
Unchanged
Pertinent Results:
LABS:
___ 05:30AM BLOOD WBC-11.1* RBC-4.03* Hgb-12.7* Hct-37.2*
MCV-92 MCH-31.5 MCHC-34.1 RDW-12.5 RDWSD-42.4 Plt ___
___ 05:30AM BLOOD Neuts-54.9 ___ Monos-7.8 Eos-2.8
Baso-0.5 Im ___ AbsNeut-6.08 AbsLymp-3.72* AbsMono-0.86*
AbsEos-0.31 AbsBaso-0.05
___ 05:30AM BLOOD Glucose-102* UreaN-14 Creat-0.9 Na-141
K-4.1 Cl-103 HCO3-23 AnGap-15
___ 05:30AM BLOOD ALT-27 AST-18 AlkPhos-47 TotBili-0.3
___ 05:30AM BLOOD Albumin-4.1 Calcium-9.4 Phos-4.1 Mg-2.2
MRI with and without contrast ___:
FINDINGS:
Postoperative change anterior left temporal lobectomy. Adjacent
postoperative changes.
T2 signal abnormality, cephaly malacia cystic changes of the
anterior left
temporal lobe near the surgical margin, extending into the
posterior left sub insula, left para hippocampal gyrus is more
prominent compared to prior, may be sequela postsurgical
ischemic changes, underlying inflammatory or infectious process.
Remnant left hippocampus is atrophic and not FLAIR
hyperintense.
Well-defined extracranial fluid collection seen deep to the
temporalis muscle. This measures approximately 8.6 x 7.8 x 2.7
cm (AP by SI by TV) in maximum ___, similar to the prior
examination. There is extension of collection intracranially,
with its extension extending extra axially
underneath the left temporal lobe. No associated restricted
diffusion.
Postsurgical volume loss of the left hippocampal formation is
similar to the prior examination, with persistent asymmetric
decreased size of the left mammillary body. No frank abnormal
signal seen within the left mammillary body or residual
hippocampus.. There is interval volume loss left hemisphere.
The ventricles and sulci are otherwise grossly unchanged and
unremarkable in appearance. There is no evidence for acute
intracranial hemorrhage or
infarction. No abnormal enhancement is seen. The dural venous
sinuses remain patent.
The paranasal sinuses and mastoid air cells are clear. The
globes are
unremarkable bilaterally.
IMPRESSION:
1. Postsurgical change anterior left temporal lobectomy.
2. Extracranial fluid collection, with apparent connection to
extra-axial
space at the left middle cranial fossa.. No restricted
diffusion.
3. Interval worsened parenchymal abnormality anterior temporal
lobe, extending into sub insula, with cystic changes, may be
sequela of ischemia.
Inflammatory, infectious process is probably less likely.
Brief Hospital Course:
Mr. ___ is a ___ year old man with history of complex partial
seizures, occasionally with secondary generalization, in setting
of glioma now s/p resection x2 with post surgical complication
of hygroma. He was admitted for workup of a seizure breakthrough
event that was not a typical seizure, as it did not begin with
an aura or start with a simple etiology followed by secondary
generalization. Imaging notable for hygroma on left with
possible intracranial communication, representing potential site
for dural membrane irritation or abscess formation, which could
be epileptogenic. His seizure breakthrough event may be
concerning in the setting of a new symptomatic headache and his
known hygroma.
Non-con head CT at outside hospital was without significant
change in his post-surgical hygroma. MRI w and wo contrast
showed an extracranial fluid collection, with apparent
connection to extra-axial space at the left middle cranial
fossa. There was no restricted diffusion. There was also
interval worsening in the parenchymal abnormality anterior
temporal lobe, extending into subinsula, with cystic changes
thought to be the sequela of ischemia, less likely inflammatory,
infectious process. Dr. ___ neurosurgery reviewed the
images and did not think this represented infection. They
recommended outpatient follow-up with Dr. ___ the
patient will arrange.
His breakthrough seizure was treated with an increase in the
dose of his clobazam from 10 mg BID to 10mg qAM and 15 mg qPM.
He was monitored on this increased regimen and remained seizure
free without adverse effects or notable drowsiness.
Transitional Issues:
- follow-up with Dr. ___ as arranged prior to admission
- follow-up with neurosurgery
- follow-up AED levels (collected on admission)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LACOSamide 200 mg PO BID
2. LamoTRIgine 250 mg PO BID
3. Clobazam 10 mg PO BID
4. LORazepam 1 mg PO ONCE:PRN seizure
Discharge Medications:
1. Clobazam 10 mg PO QAM
2. Clobazam 15 mg PO QHS
RX *clobazam [Onfi] 10 mg ___ tablet(s) by mouth as directed
Disp #*75 Tablet Refills:*1
3. LACOSamide 200 mg PO BID
4. LamoTRIgine 250 mg PO BID
5. LORazepam 1 mg PO ONCE:PRN seizure
Discharge Disposition:
Home
Discharge Diagnosis:
Breakthrough seizure
Subgaleal fluid collection
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 a breakthrough seizure. The
cause of this was not clear as you had no signs of infection and
you did not miss doses of your medications. We increased the
dose of your Clobazam at night time to help better control your
seizures.
Medication changes:
INCREASE Clobazam to 10mg in the morning and 15mg at night
CONTINUE Lamotrigine 250mg twice a day
CONTINUE Lacoasmide 200mg twice a day
You were evaluated by neurosurgery who recommended an MRI of the
brain to see if there was any fluid collection in the brain. It
did not appear that this was the case. The fluid collection
seems to be outside the brain. You should call Dr. ___ office
to discuss plans for follow-up.
You should follow-up with Dr. ___ at the appointment listed
below.
I did discuss the findings with you on the MRI - the possibility
of a connection of the fluid collection outside of your brain
with the inside of your brain, that there were some changes in
the left temporal lobe (new compared to the prior MRI done post
operatively) which is suggestive of some
ischemic changes, and the slight enlargement of the ventricles.
We did reconsult the neurosurgeons and they did not feel there
was anything urgent and asked you followup with Dr. ___.
It was a pleasure taking care of you,
Your ___ Neurologists
Followup Instructions:
___
|
10292987-DS-11 | 10,292,987 | 24,281,722 | DS | 11 | 2113-11-21 00:00:00 | 2113-11-23 09:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / Penicillins / Ceclor / clindamycin / ibuprofen /
Erythromycin Base / naproxen
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with a history of
polycythemia ___, hypertension and chronic pain who is
presenting with altered mental status. She was in her usual
state of health the morning of admission when her wife left her
at home. In the afternoon, the patient's wife found her
confused, lethargic, and having vomited. Otherwise, the patient
is unable to provide much history; however, she did have some
pain with palpation of her right upper quadrant. Neither the
patient nor her wife can remember any trauma to her left leg
(though she had a recent fall with a fracture of her left
humerus).
In the ED, initial VS were: 102.9 108 189/81 16 98%. She was
noted to have a large area of erythema and tenderness to
palpation of the left lower extremity that was marked which
involved a large portions of her calf as well as her distal
thigh. She was given Tylenol 1g, Vancomycin 1g IV, levofloxacin,
and Zofran. CT scan of her abdomen showed a small gallbladder,
making cholecystitis unlikely although not completely excluded;
with hyperdense contents which suggest stones or sludge. Fatty
liver and splenomegaly: although splenomegaly is not specific,
concern is raised for steatohepatitis or cirrhosis. Marked fatty
replacement of pancreas. Large right adnexal cyst; ultrasound
assessment recommended when appropriate. RUQ ultrasound was
unable to be completed due to significant patient discomfort.
.
On arrival to the MICU, the patient was somewhat agitated. She
became more calm in the presence of her wife, but still removed
an IV and needed to be restrained. Vitals T 97.9 HR 109 BP
124/51 RR 16 97% on room air.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
1. Hypertension
2. Degenerative disc disease
3. chronic pain
4. Polycythemia ___ followed by ___
Social History:
___
Family History:
Not known. The patient's mother and father are
deceased. She has three brothers, six sisters and two
daughters.
She is estranged from all family members and does not know their
medical history.
Physical Exam:
Admission to MICU exam:
General: Oriented x 2 (person, place), agitated
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not appreciated due to habitus, no LAD
CV: S1, S2, ___ SEM heard best at upper sternal border
Lungs: Clear to anterior auscultation bilaterally
Abdomen: Soft, non-tender, obese, bowel sounds present, striae
Ext: Warm, well perfused
Skin: Left lower leg with significant erythem from just below
the knee to foot, especially on medial side.
Neuro: CNIII-XII intact, ___ strength upper/lower extremities,
sppech incoherent but intelligible
Call out to Medicine Exam:
GENERAL - Chronically ill appearing ___ F who appears older
than her stated age. She has an odd affect with tangential
thinking. She is lethargic but arousable, oriented to person,
place and time. Inattentive and unable to do months of the year
in reverse
HEENT - NC/AT, EOMI, sclerae anicteric, Adentulous, MMM, OP
clear
NECK - supple, no ___, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilaterally, moving air well and symmetrically
HEART - S1 S2 clear and of good quality, tachycardic, ___ SEM
RUSB
ABDOMEN - NABS, Obese, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, 2+ peripheral pulses (radials, DPs). Chronic
venous stasis skin changed on bilateral ___. Left lower leg with
significant erythema from knee to groing along medial aspect
tracking in a linear pattern along medial aspect of thigh. Warm
to touch.
NEURO - Awake but lethargic, A&Ox3, Facial asymmetric but CNs
II-XII grossly intact, muscle strength ___ throughout, sensation
grossly intact throughout. Speech slurred at times though
adentulous may be contributing. Tangential thought processes
Pertinent Results:
Trends:
___ 06:38PM BLOOD WBC-29.7* RBC-7.68*# Hgb-17.3* Hct-57.0*
MCV-76* MCH-22.2* MCHC-29.3* RDW-18.7* Plt ___
___ 05:18AM BLOOD WBC-21.5* RBC-7.26* Hgb-16.0 Hct-54.8*
MCV-76* MCH-22.1* MCHC-29.2* RDW-19.0* Plt ___
___ 06:38PM BLOOD Neuts-89.7* Lymphs-6.6* Monos-2.6 Eos-0.4
Baso-0.7
___ 05:18AM BLOOD ___
___ 06:38PM BLOOD Glucose-109* UreaN-8 Creat-0.7 Na-135
K-3.9 Cl-94* HCO3-27 AnGap-18
___ 05:18AM BLOOD Glucose-126* UreaN-8 Creat-0.7 Na-137
K-3.8 Cl-97 HCO3-27 AnGap-17
___ 06:38PM BLOOD ALT-23 AST-43* AlkPhos-205* TotBili-1.2
___ 05:18AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.2
___ 04:12PM BLOOD Lactate-2.8*
___ 05:47AM BLOOD Lactate-1.8
___ 10:00PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 10:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
Discharge Labs:
___ 08:20AM BLOOD WBC-17.3* RBC-7.24* Hgb-15.7 Hct-55.3*
MCV-77* MCH-21.6* MCHC-28.3* RDW-19.1* Plt ___
___ 08:20AM BLOOD Neuts-86* Bands-0 Lymphs-6* Monos-4 Eos-3
Baso-1 ___ Myelos-0
___ 08:20AM BLOOD Glucose-152* UreaN-10 Creat-0.8 Na-139
K-4.1 Cl-99 HCO3-30 AnGap-14
___ 08:20AM BLOOD TSH-0.24*
BCx pending:
Imaging:
CT abd/pelvis w/:
IMPRESSION:
1. Mostly decompressed gallbladder which makes cholecystitis
unlikely,
although hyperdense contents could be seen with stones or
sludge.
2. Fatty infiltration of the liver.
3. Marked fatty infiltration of the pancreas, which can be seen
as a
manifestation of chronic pancreatic inflammation, although other
etiologies
such as cystic fibrosis could generate such an appearance.
4. Mild-to-moderate splenomegaly including small infarcts.
Splenomegaly in
association with fatty liver may raise concern for
steatohepatitis or
cirrhosis with portal hypertension as the etiology for
splenomegaly, although the appearance is not entirely specific.
5. Large right adnexal cyst. Although no complex features are
apparent based on CT imaging, particularly based on size and the
limitations of CT
assessment, when clinically appropriate, evaluation with
ultrasound is
recommended. If the lesion is not accessible to visualization
with
ultrasound, then MR is recommended.
6. Mild left inguinal lymphadenopathy, likely reactive;
correlation with
physical findings involving the left lower extremity is
recommended.
___ ___
IMPRESSION: No evidence of deep vein thrombosis either right or
left lower
extremity.
CT ___ ___:
IMPRESSION:
1. Findings above of subcutaneous edema and circumferential skin
thickening,
which in the right clinical setting may represent cellulitis.
2. No focal fluid collections to suggest abscess. No
subcutaneous emphysema.
3. Scattered degenerative changes of the left lower extremity.
CXR ___:
FINDINGS: In comparison with the study of ___, there is
little change.
Continued low lung volumes most likely account for the
prominence of the
cardiac silhouette. No pneumonia, vascular congestion, or
pleural effusion.
Brief Hospital Course:
Ms. ___ is a ___ y/o female with a history of polycythemia
___, hypertension and chronic pain who presented with altered
mental status and cellulitis. Treated with IV antibiotics in
the MICU with improvement in MS and cellulitis and transferred
to ward on HD2.
# Cellulitis. Non-purulent, no necrosis on CT. Tx initially
with Vancomycin/Levofloxacin given allergy profile (anaphylaxis
to PCNs and Clindamycin). Levofloxacin d/ced on HD2 as pt.
improved. ___ was negative for DVT. Although cephalosporin
regimen would be most optimal, due to severe reaction type and
potential crossreactivity, vancomycin was selected for
treatment. In preparation for discharge antibiotics changed to
Bactrim 2DS tabs PO BID to complete 5 more days for total ___ltered mental status. Toxic-metabolic encephalopathy
secondary to the patient's left leg cellulitis. Head CT not
suggestive of hemorrhage. UA negative. CT abdomen demonstrated
no site of infection. Utox/Stox negative. Improved with
treatment of cellulitis. Initially held sedating medications but
restarted prior to discharge with improvement in mental status.
# LFTs: Isolated ALP elevation associated with slightly elevated
T.Bili to 1.2 from 0.5. AST also elevated but ALT flat would
suspect mitochondrial dysfunction. Tox screen only positive for
Methadone so ingestion less likely especially while rising in
MICU. In ED patient complained of RUQ pain and nausea consitent
with cholecystitis. RUQ ultrasound incomplete/limited given
patient agitation. CT scan could not definitely rule out
cholecystitis. Patient has habitus and epidemiology for
cholelithiasis but with improved mental status she has no RUQ
pain ___ sign on exam with improvement in mental status so
did not pursue a second RUQ US. Fever curve also improved on
only Vancomycin without GNR or anaerobic coverage.
# Tachycardia: Sinus tachycardia to 120s consistently in the
MICU. Initially thought related to sepsis but did not improve
with downtrend of fever curve or improvement in cellulitis.
Volume status euvolumic and patient with good urine output.
Tachycardia did dip to ___ when wife is around and so there may
be a psychologic component. Patient with chronic pain on
Methadone so pain may be contributing as well. Outpatient HRs in
___ per record. Low likelihood for PE without hypoxia,
tachypnea, chest pain and LENIs negative for DVT. Tachycardia
resolved prior to discharge.
# Hypertension: Chronic, Lisinopril recently restarted with
resolution of sepsis but she remained hypertensive. Amlodipine
started prior to discharge. Asymptomatic on floor. TSH checked
and was low. Continued Lisinopril 40mg PO BID and added
Amlodipine 5 mg PO/NG DAILY to augment BP control. Day of
discharge she became hypotensive and orthostatic which, per
patient's wife, usually happens when increasing BP meds.
Amlodipine was discontinued, and lisinopril to 40mg po daily and
patient discharged after BPs stabilized.
# Anxiety: Continued home regimen of Ativan.
# DJD/chronic pain: Continue methadone but tizanidine and
gabapentin were initially held in setting of delirium but
restarted prior to discharge
# P. ___. Stable. Plavix was continued.
# Incidentalomas: Splenic infarcts likely PCV related in
addition to splenomegaly. Large right adenexal cyst can be
worked up as outpatient
TRANSITIONAL ISSUES:
- Follow up incidentalomas, patient should have adenexal cyst
monitored as an outpatient
- Better control of hypertension is essential in this patient
- Careful with BP meds given profound orthostasis when starting
CCB
- CODE STATUS: Presumed Full
- CONTACT: Wife and HCP ___ ___
Medications on Admission:
- lisinopril 40 mg PO BID
- methadone 20 mg PO QID
- methadone 10 mg PO Daily
- tizanidine 4 mg PO TID
- tizanidine 2 mg PO BID
- gabapentin 600 mg PO Q4H
- lorazepam 0.5 mgPO Q4H as needed for anxiety
- Plavix 75 mg Tablet PO once a day
- Colace 100 mg PO twice a day as needed for constipation
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) dose PO BID (2
times a day).
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. methadone 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
5. methadone 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day) for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
7. gabapentin 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
8. tizanidine 4 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. tizanidine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
Please check chemistry panel including sodium, potassium,
creatinine on ___ and fax results to Dr. ___
___.
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
Encephalopathy
Polycythemia ___
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure treating you during this hospitalization. You
were admitted to ___ because of
confusion and an infection in the skin of your thigh. You were
initially admitted to the ICU because of concern for sepsis and
you were treated with IV antibiotics with improvement in mental
status and skin infection. You were switched to by mouth
medications with continued improvement in skin infection
clearing. Your mental status also improved back to baseline. You
should have a blood lab checked on ___, which will be faxed
to your doctor and discuss the results when you see Dr. ___
on ___. Some of your medications may need to be adjusted
further.
The following changes to your medications were made:
- START Bactrim 2 DS tablets twice daily until ___
- DECREASE your lisinopril to 40mg tabs, 1 tab daily
- No other changes were made, please continue taking your home
medications as previously prescribed
Followup Instructions:
___
|
10292987-DS-12 | 10,292,987 | 23,356,448 | DS | 12 | 2113-11-26 00:00:00 | 2113-11-26 17:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / Penicillins / Ceclor / clindamycin / ibuprofen /
Erythromycin Base / naproxen
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with h/o polycythemia ___, hypertension
and DDD recently admitted from ___ for cellulitis
presented to the ED due to falls at home and found to have acute
renal failure. During previous admission, pt was initially
admitted to the MICU and treated with IV
vancomycin/levofloxacin. She improved and levofloxacin was
discontinued. She was transferred to the floor and transitioned
to PO Bactrim (due to allergies to penicillins and clindamycin).
Antihypertensives were intially held due to concern for sepsis.
She was initially restarted on amlodipine 5mg but this was
discontinued and she was advised to restart her home lisinopril.
Since discharge, she states she has felt very lethargic. Pt's
wife notes she has had very little PO fluid intake. Also c/o
"leg weakness" leading to 2 mechanical falls today (landed on
her knees, no head strike or LOC). Her wife brought her to the
ED for further evaluation.
.
In the ED initial vitals were T 97.1 HR 78 BP 70/40 RR 16 O2 sat
92%RA. She was triggered for hypotension, received 2L IV NS and
her SBP improved to 110s. Labs were notable for new renal
failure (creat 5.7, was normal on discharge 2 days ago), HCO3
19, Phos 7.1. Post-void bladder scan showed 82cc residual. UA
showed 11 WBCs, few bac, 279 hyaline casts. Renal service was
consulted and recommended d/c lisinopril and bactrim, obtain
renal/bladder U/S. She was admitted to medicine for further
evaluation.
.
On arrival to floor, vitals were 98.2 141/75 100 18 95% RA.
Currently she states she is comfortable. C/o chronic L arm pain
___ old fracture, otherwise denies pain. Denies chest pain,
SOB, palpitations.
.
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. Degenerative disc disease
3. chronic pain
4. Polycythemia ___
___ History:
___
Family History:
Not known. The patient's mother and father are deceased. She
has three brothers, six sisters and two daughters. She is
estranged from all family members and does not know their
medical history.
Physical Exam:
VS - 98.2 141/75 100 18 95% RA
GENERAL - Chronically ill appearing ___ F who appears older
than her stated age. Awake and alert, engages in conversation.
HEENT - NC/AT, EOMI, sclerae anicteric, Adentulous, MMM, OP
clear
NECK - supple, no JVD
LUNGS - CTA bilaterally, no wheezes/rhonchi/rales
HEART - S1 S2 clear and of good quality, tachycardic, ___ SEM
RUSB
ABDOMEN - NABS, Obese, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, 2+ peripheral pulses (radials, DPs). Chronic
venous stasis skin changes on bilateral ___. Left lower leg with
mild erythematous area on thigh/knee, non-tender, not warm
NEURO - Awake A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout. Gait
assessment deferred
Pertinent Results:
Admission Labs:
___ 01:20PM BLOOD WBC-24.8* RBC-6.28* Hgb-13.6 Hct-48.2*
MCV-77* MCH-21.6* MCHC-28.2* RDW-19.5* Plt ___
___ 01:20PM BLOOD Glucose-95 UreaN-40* Creat-6.5*# Na-129*
K-5.9* Cl-92* HCO3-19* AnGap-24*
___ 02:40PM BLOOD Calcium-8.0* Phos-7.1*# Mg-2.1
Discharge Labs:
___ 06:15AM BLOOD WBC-15.5* RBC-6.06* Hgb-13.5 Hct-47.2
MCV-78* MCH-22.3* MCHC-28.6* RDW-20.1* Plt ___
___ 06:15AM BLOOD Glucose-42* UreaN-10 Creat-0.9 Na-129*
K-4.4 Cl-92* HCO3-28 AnGap-13
___ 06:15AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.8
Urine Studies:
___ 02:45PM URINE Color-AMBER Appear-Hazy Sp ___
___ 02:45PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-2* pH-5.5 Leuks-TR
___ 02:45PM URINE RBC-0 WBC-11* Bacteri-FEW Yeast-NONE
Epi-1
___ 02:45PM URINE CastHy-279*
___ 02:45PM URINE AmorphX-OCC
___ 02:45PM URINE Mucous-OCC
___ 02:45PM URINE Eos-NEGATIVE
___ 02:45PM URINE Hours-RANDOM UreaN-172 Creat-167 Na-77
K-19 Cl-13
Micro:
___ 2:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
LEFT HUMERUS RADIOGRAPH PERFORMED ON ___
COMPARISON: ___.
CLINICAL HISTORY: Status post fall, pain, question fracture.
FINDINGS: Two views of the left humerus were provided. Patient
is known to have an impacted left humeral neck fracture which
appears grossly stable from prior exam. No new fractures are
seen.
ECHO ___:
The left atrium is mildly dilated. 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 diameters of aorta at the sinus,
ascending and arch levels are normal. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. The left ventricular inflow pattern suggests impaired
relaxation. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal global and regional
biventricular systolic function. No pathologic valvular disease
identified. Mild tricuspid regurgitation.
Brief Hospital Course:
Primary Reason for Hospitalization:
___ with h/o polycythemia ___, hypertension and DDD recently
admitted from ___ for cellulitis presented to the ED
due to falls at home and found to have acute renal failure.
Active Issues:
# Acute renal failure: Pt's renal function was normal during
prior hospitalization and on discharge 2 days prior to
admission, re-presented with Creat 5.7. Initially concerning
for AIN given recent therapy with Bactrim, however FeNa and
FeUrea were c/w pre-renal etiology. She endorsed poor PO intake
at home and had hypotension during her previous admission and in
the ED on day of this admission, so she likely had mixed
pre-renal/ATN renal failure. Her home lisinopril and Bactrim
were held and her creatinine rapidly improved with IV fluids.
On discharge her creatinine was 0.9.
# Hypotension: Pt was hypotensive with BP 70/40 on arrival to
ED, responded well to IV fluids. Most likely ___ poor PO intake
(pt's wife attests to very little PO fluid intake over past 2
days). She was being treated for cellulitis since previous
admission which had significantly improved and had no other s/sx
infection so there was low suspicion for sepsis. Her home
lisinopril was held and she received IV fluids. Her BP
gradually increased during admission and her lisinopril was
restarted at a reduced dose (decreased from 40mg daily to 20mg
daily).
# Fungal rash: Pt had erythematous intertriginous rash on R
breast, improved with miconazole powder.
# Cellulitis: Pt was recently hospitalized for cellulitis,
treated with PO Bactrim (day 1 = ___. Bactrim was stopped due
to renal failure as above, and she was switched to IV
vancomycin. She completed her 7 day course of antibiotics
during hospitalization.
# Hyponatremia: Pt had hyponatremia on admission, remained
stable at 129-133. Unclear etiology, may be hypovolemic
hyponatremia ___ poor PO intake (Na initially improved with
aggressive fluid repletion then decreased once on PO fluids
only). She was asymptomatic. She will have Chem-7 drawn as
outpatient prior to her PCP appointment to ___ her Na level.
Chronic Issues:
# DJD/chronic pain: Stable. She is on an odd pain medication
regimen at home (takes methadone, tizanidine, and gabapentin in
5 divided doses per day). Her home regimen was reduced during
hospitalization due to renal failure. She was resumed on her
home regimen at discharge.
Transitional Issues:
- Medication changes: Stopped bactrim, decreased lisinopril to
20mg daily, started miconazole powder for fungal rash.
- She is scheduled to ___ with her PCP ___ 1 week.
- ___ Na (will have outpt labs drawn prior to PCP appt on ___
- Full code
Medications on Admission:
- lisinopril 40 mg PO daily
- methadone - takes 90mg daily total in 5 divided doses:
___
- tizanidine 4 mg PO TID - takes 16mg daily in 5 divided doses:
___
- gabapentin PO - takes 5 times daily: ___
- Plavix 75 mg Tablet PO once a day
- Bactrim DS 2 tablets PO BID (started ___
Discharge Medications:
1. miconazole nitrate 2 % Powder Sig: One (1) application
Topical twice a day as needed for rash.
Disp:*1 QS* Refills:*0*
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. methadone 10 mg Tablet Sig: Nine (9) Tablet PO Daily: In 5
divided doses.
5. tizanidine 2 mg Tablet Sig: Eight (8) Tablet PO daily: In 5
divided doses.
6. gabapentin 600 mg Tablet Sig: Six (6) Tablet PO daily: In 5
divided doses.
7. Outpatient Lab Work
Please check complete metabolic panel.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Acute Kidney Injury
Secondary: Cellulitis, Hypertension, L humeral neck fracture,
polycythemia ___.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted after sustaining a fall at home. When you
arrived in the ED you were found to have low blood pressure and
kidney injury. After giving you a large amount of fluids, your
blood pressure increased and your kidneys recovered. We also
continued antibiotics to treat the cellulitis on your left leg.
We have made the following changes to your medications:
STOP Bactrim 2DS tablets BID - you have finished your antibiotic
course for your skin infection
START miconazole powder 2% twice daily to your rash
DECREASE lisinopril to 20mg daily
We encourage you to follow up with your PCP during the
appointment time listed below to ensure your blood pressure is
adequately controlled. We also encourage you to drink plenty of
fluids while at home. Please note you have been given a
prescription to get lab work performed before your follow up
visit with your primary care doctor.
It has been a pleasure taking care of you at ___ and we wish
you a speedy recovery.
Followup Instructions:
___
|
10292987-DS-16 | 10,292,987 | 21,097,340 | DS | 16 | 2115-03-16 00:00:00 | 2115-03-17 17:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / Penicillins / Ceclor / clindamycin / ibuprofen /
Erythromycin Base / naproxen / Hibiclens
Attending: ___.
Chief Complaint:
cellulitis
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ lady with a PMH significant for obesity,
polycythemia ___, and recent HbA1c of 8.2 (___) who
presents with right lower extremity pain, erythema, and swelling
x1 day. Ms. ___ was recently admitted ___ for right
lower extremity cellulitis and was treated with 10 days of IV
vancomycin, chosen beacuse of multiple severe antibitic
allergies. Her symptoms resolved on that regimen. Then one day
prior to admission, Ms. ___ began to have pain, redness, and
swelling in her right lower leg. She reports this was similar
to her presentation in ___, though not as severe. She reports
no open lesions, bug bites, or any other obvious source of
infection. She denies fever, but does report some chills. She
is physically active, has no history of clots, does not smoke,
and is not on any hormonal treatments. Doppler U/S of RLE
showed no evidence of clot. She was started on IV vanc.
Past Medical History:
PAST MEDICAL HISTORY:
1. HTN
2. Degenerative disc disease
3. Polycythemia ___
4. HbA1c 8.2 (___)
PAST SURGICAL HISTORY
1. BTL
2. ___
PAST OB HISTORY
G2P2002
Vaginal: 2
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.5F, 122/76, 58, 20, 96% RA
General: Alert, oriented, no acute distress
HEENT: MMM, oropharynx clear, neck supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds
R LL: 2+ pitting edema; signs of chronic venous stasis; warm,
erythematous area from ankle to knee; no open lesions; no
discharge
L LL: 1+ pitting edema; signs of chronic venous stasis; no
warmth or erythema
B/L feet: onychomycosis on all toenails b/l; significant dryness
and fissuring of soles and between toes; no ulcerations or open
lesions
DISCHARGE PHYSICAL EXAM:
VS: Tm 98.2, HR 65, BP 128/57, RR 18, SpO2 98% on RA.
GENERAL: sitting up in chair with wife at bedside in NAD
LUNGS: Clear to auscultation b/l with no wheezes or crackles
HEART: RRR; II/VI systolic murmur
ABDOMEN: obese, soft, nontender, nondistended, normoactive bowel
sounds
Right ___: eryethema extending circumferentially from ankle to
mid-calf. Some warmth over area. No open lesions or discharge.
Pertinent Results:
Admission labs:
___ 09:00PM BLOOD WBC-25.6* RBC-6.89* Hgb-14.1 Hct-48.5*
MCV-70*# MCH-20.5*# MCHC-29.1* RDW-19.4* Plt ___
___ 09:00PM BLOOD Neuts-86.6* Lymphs-7.9* Monos-2.4 Eos-2.4
Baso-0.6
___ 09:00PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+
Macrocy-OCCASIONAL Microcy-3+ Polychr-OCCASIONAL
Spheroc-OCCASIONAL Ovalocy-OCCASIONAL Target-OCCASIONAL
___ 06:15AM BLOOD ___ PTT-34.8 ___
___ 09:00PM BLOOD Glucose-226* UreaN-10 Creat-0.9 Na-138
K-6.4* Cl-98 HCO3-25 AnGap-21*
___ 06:15AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.0
Other results:
___ RLE Doppler U/S:
IMPRESSION: No right lower extremity DVT. Calf veins not seen.
Discharge Labs:
___ 06:10AM BLOOD WBC-23.3* RBC-6.90* Hgb-14.8 Hct-49.8*
MCV-72* MCH-21.4* MCHC-29.6* RDW-19.2* Plt ___
___ 06:10AM BLOOD %HbA1c-7.9* eAG-180*
___ 06:10AM BLOOD Glucose-123* UreaN-8 Creat-0.8 Na-138
K-4.6 Cl-98 HCO3-30 AnGap-15
Brief Hospital Course:
Ms. ___ is a ___ lady with a PMH significant for
polycythemia ___, HbA1c ___, and multiple drug
allergies who presented with RLE cellulitis and was treated with
antibiotics.
# Cellulitis: Mild cellulitis of right lower extremity. This is
her third episode of cellulitis in the past year. Poor foot
hygeine and impaired healing due to chronic venous stasis and
possibly underlying diabetes likely are cause of repeated
episodes. Given severe allergies to multiple antibiotics,
elevated Cr when on Bactrim, and interaction of linezolid with
methadone, Ms. ___ was started on IV vancomycin on ___,
which she has tolerated well in the past. She was discharged on
a 10-day course of linezolid ___ q12hrs. We discussed the
minimal risk of serotonin syndrome when using linezolid and
methadone concurrently and stressed to the patient the
importance of returning to care should she develop any symptoms.
# Elevated HbA1c: HbA1c in ___ was 8.2. Pt. denies any
dificulties with elevated glucose when outpatient, though her
glucose levels have been signficantly elevated during this
admission and her PCP explains they have had ongoing discussion
about her glucose control. She was started on a regular insulin
sliding scale while inpatient and advised to follow-up with her
PCP for further management, likely including ACEi and metformin.
# Polycythemia ___: Pt. had significant vaginal bleeding
related to uterine prolapse when on anticoagulation previously.
She also has an anaphlyactic allergy to ASA. Pt. declined
heparin SC and lovenox while in house due to persistent vaginal
bleeding. We discussed risk of not being on anticoagulation
especially given diagnosis of polycytemia ___, and pt. willing
to accept them and continue to hold prophylaxis. We recommend
follow-up with outpatient hematologist for reassessment of
risks/benefits of anticoagulation.
# Hypertension: Pt. hypertensive with SBP around 200 on
admission. Once settled on the floor, pt. remained normotensive.
However, durng periods of agitation, pt. again became
hypertensive to SBP 180s. On discharge, she was again
normotensive.
# Leukocytosis: Likely related to PV.
# Dejenerative disc disease: Continued on home pain medications
of gabapentin, methadone, and acetaminophen.
# Transitional issues
- f/up with PCP regarding blood glucose control
- f/up with PCP regarding episodes of hypertension and
possibility of restarting ACEi
- f/up with hematologist to discuss restarting anticoagulation
for prophylaxis given PV
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO 6X/DAY
hold for excessive sedation
2. Methadone 30 mg PO TID
hold for excessive sedation or RR < 12
3. Tizanidine 4 mg PO QID
4. Multivitamins 1 TAB PO DAILY
5. Terbinafine 1% Cream 1 Appl TP BID
to feet
Discharge Medications:
1. Gabapentin 600 mg PO 6X/DAY
2. Methadone 30 mg PO TID
3. Multivitamins 1 TAB PO DAILY
4. Terbinafine 1% Cream 1 Appl TP BID
5. Tizanidine 4 mg PO QID
6. Linezolid ___ mg PO Q12H Duration: 10 Days
Please stop med and call PCP should you develop agitation,
confusion, sweating, or new symptoms.
RX *linezolid [Zyvox] 600 mg 1 tablet(s) by mouth every 12 hours
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Cellulitis
Secondary diagnoses:
Polycythemia ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were
admitted for a skin infection of your right lower leg. We placed
you on intravenous vancomycin, a strong antibiotic, and your
exam improved. We then switched you to an oral antibiotic called
Linezolid that you will take for 10 days.
Your blood sugar was also high and you were placed on insulin
while hospitalized.
Followup Instructions:
___
|
10293329-DS-18 | 10,293,329 | 23,150,464 | DS | 18 | 2134-12-06 00:00:00 | 2134-12-09 17:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
Zyprexa / Risperdal / Abilify / Saphris
Attending: ___.
Chief Complaint:
right flank pain, nephrolithiasis completed
Major Surgical or Invasive Procedure:
___: right ureteral stent placement
History of Present Illness:
___ y/o female with prior history of nephrolithiasis never
requiring intervention p/w right flank pain similar to prior
episodes of stone passage, since resolved. Imaged and found to
have an obstructing 0.7 cm right proximal ureteral stone. Her UA
is positive for few bacteria and yeast but she has no clinical
signs/symptoms of systemic infection and no urinary symptoms to
suggest UTI. Either discharge home on PO antibiotics or OR today
for attempt at definitive stone procedure would be clinically
appropriate; will admit for further monitoring and management.
Past Medical History:
PMH/PSH:
- stroke
- CAD/NSTEMI
- hypothyroidism
- migraine headaches
- psychotic disorder, prior psychiatric admissions
FH:
no FH of GU malignancy or stone disease
copied from ___ d/c summary:
-HYPOTHYROIDISM
-MIGRAINE HEADACHES
-PARANOID DELUSIONS
-H/O MYOCARDIAL INFARCTION ___ - NSTEMI - vasospasm vs.
intramyocardial bridging. Cath ___: distal LAD vasospasm
versus chronic disease. The LMCA, LCX, and RCA had no
angiographically significant disease. The LAD appeared to be a
twin system with spasm versus chronic disease in the distal
pole. TTE ___: focal hypokinesis of the distal septum, inferior
wall, lateral wall, and apical cap (EF relatively preserved at
55%).
Peripheral artery disease
Seasonal allergies
Denies h/o head injuries or seizure
Social History:
___
Family History:
Aunt w/ hypothyroidism. Patient has 2 cousins with bipolar
disorder
Physical Exam:
WdWn female, NAD, AVSS
Interactive, cooperative
Abdomen soft, Nt/Nd
voided urine bloody
Lower extremities w/out edema or pitting and no report of calf
pain
Pertinent Results:
___ 10:50PM BLOOD WBC-11.8*# RBC-5.21* Hgb-14.4 Hct-45.1*
MCV-87 MCH-27.6 MCHC-31.9* RDW-13.2 RDWSD-41.5 Plt ___
___ 10:50PM BLOOD Neuts-89.7* Lymphs-6.4* Monos-3.2*
Eos-0.0* Baso-0.3 Im ___ AbsNeut-10.54* AbsLymp-0.75*
AbsMono-0.38 AbsEos-0.00* AbsBaso-0.03
___ 10:50PM BLOOD Glucose-124* UreaN-16 Creat-1.0 Na-141
K-4.1 Cl-100 HCO3-25 AnGap-20
___ 10:10PM URINE Color-RED Appear-Cloudy Sp ___
___ 10:10PM URINE RBC->182* WBC-27* Bacteri-FEW Yeast-MOD
Epi-0
___ 10:10 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
Ms. ___ was admitted to Dr. ___ urgent decompression
given her presenting complaints. She was taken to the OR from
the ED where she underwent ureteral stent placement and
cystoscopy. She tolerated the procedure well and recovered in
the PACU before transfer to the general surgical floor. See the
dictated operative note for full details. She was hydrated with
intravenous fluids and received appropriate perioperative
prophylactic antibiotics and gradually converted to oral pain
medications. She was later discharged after voiding and
ambulating several times. At discharge Ms. ___ pain was
controlled with oral pain medications, she was tolerating
regular diet, ambulating without assistance, and voiding without
difficulty. She was explicitly advised to follow up as directed
as the indwelling ureteral stent must be removed and or
exchanged and definitive management of the stones addressed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benztropine Mesylate 1 mg PO Q6H:PRN extrapyramidal symptoms,
restlessness
2. lurasidone 100 mg oral DAILY
3. LORazepam 0.5 mg PO QHS:PRN anxiety, insomnia
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Simvastatin 40 mg PO QPM
6. Levothyroxine Sodium 100 mcg PO DAILY
7. MethylPHENIDATE (Ritalin) 10 mg PO DAILY
8. Apixaban 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
4. Phenazopyridine 100 mg PO TID:PRN urinary discomfort
Duration: 3 Days
5. Tamsulosin 0.4 mg PO DAILY
6. Benztropine Mesylate 1 mg PO Q6H:PRN extrapyramidal
symptoms, restlessness
7. Levothyroxine Sodium 100 mcg PO DAILY
8. LORazepam 0.5 mg PO QHS:PRN anxiety, insomnia
9. lurasidone 100 mg oral DAILY
10. MethylPHENIDATE (Ritalin) 10 mg PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Simvastatin 40 mg PO QPM
13. HELD- Apixaban 10 mg PO DAILY This medication was held. Do
not restart Apixaban until ___
Discharge Disposition:
Home
Discharge Diagnosis:
obstructing right proximal ureteral stone
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You may continue to periodically see small amounts of blood in
your urine.
-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.
Please do not take your doses of apixaban tomorrow, ___. You
may resume it on ___.
-If prescribed; complete the full course of antibiotics (Bactrim
for five days)
-You may be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that some narcotic pain medication also contains
Tylenol
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery.
Followup Instructions:
___
|
10293329-DS-19 | 10,293,329 | 27,308,394 | DS | 19 | 2136-09-16 00:00:00 | 2136-09-16 16:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
Zyprexa / Risperdal / Abilify / Saphris
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ female who presented to ER with back pain
for 18 hours. Started in the ___ her lower
back and radiated to her groin. NOW HAVING NO BACK/ABDOMINAL
PAIN. Also Endorses gross hematuria, fruit punch colored without
clots. Denies fevers, chills, HA, CP, SOB, dysuria.
Has history of stones requiring procedures. Most recent was ESWL
in ___ ___.
WBC 15, no bands
Cr 1 (baseline 0.9)
UA 100 wbc, few bact, no nitr, no yeast
Past Medical History:
PMH/PSH:
- stroke
- CAD/NSTEMI
- hypothyroidism
- migraine headaches
- psychotic disorder, prior psychiatric admissions
FH:
no FH of GU malignancy or stone disease
copied from ___ d/c summary:
-HYPOTHYROIDISM
-MIGRAINE HEADACHES
-PARANOID DELUSIONS
-H/O MYOCARDIAL INFARCTION ___ - NSTEMI - vasospasm vs.
intramyocardial bridging. Cath ___: distal LAD vasospasm
versus chronic disease. The LMCA, LCX, and RCA had no
angiographically significant disease. The LAD appeared to be a
twin system with spasm versus chronic disease in the distal
pole. TTE ___: focal hypokinesis of the distal septum, inferior
wall, lateral wall, and apical cap (EF relatively preserved at
55%).
Peripheral artery disease
Seasonal allergies
Denies h/o head injuries or seizure
Social History:
___
Family History:
Aunt w/ hypothyroidism. Patient has 2 cousins with bipolar
disorder
Physical Exam:
WdWn male, NAD, AVSS
Interactive, cooperative
Abdomen soft, Nt/Nd
Flank pain: None
Lower extremities w/out edema or pitting and no report of calf
pain
Pertinent Results:
___ 10:25AM BLOOD WBC-6.6 RBC-3.95 Hgb-10.9* Hct-34.5
MCV-87 MCH-27.6 MCHC-31.6* RDW-13.4 RDWSD-42.9 Plt ___
___ 07:29PM BLOOD WBC-14.9* RBC-5.16 Hgb-14.1 Hct-44.5
MCV-86 MCH-27.3 MCHC-31.7* RDW-13.2 RDWSD-41.2 Plt ___
___ 10:25AM BLOOD Glucose-84 UreaN-12 Creat-0.8 Na-141
K-3.7 Cl-105 HCO3-27 AnGap-9*
___ 07:29PM BLOOD Glucose-106* UreaN-15 Creat-1.0 Na-140
K-5.4 Cl-99 HCO3-25 AnGap-16
Urine culture: Pending
US retroperitoneal ___
IMPRESSION:
1. 3 mm obstructing left UVJ stone with absence of left
ureteral jet.
2. Multiple nonobstructing bilateral renal calculi.
3. Probably a combination of hydronephrosis and multiple
parapelvic cysts in
the bilateral kidneys, left worse than right, although difficult
to
definitively delineate on ultrasound. Overall, findings are
stable compared
to ultrasound from ___ and CT from ___.
Brief Hospital Course:
Patient was admitted to the Urology service under Dr. ___
observation. No complications were encountered overnight and by
the morning the patient's flank pain had subsided. A follow up
US was obtained which demonstrated the left UVJ stone still in
place. Her labs were normal with a WBC of 6 and a creatinine of
0.8. She was discharged for a trial of medical expulsive therapy
and to follow up with Dr. ___ in the office. She was discharged
on antibiotics. Urine culture is still pending at this time but
patient did not demonstrated any significant signs of infection
during her stay.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
2. lurasidone 100 mg oral DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Apixaban 5 mg PO BID
5. Simvastatin 40 mg PO QPM
6. MethylPHENIDATE (Ritalin) 10 mg PO DAILY
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Benztropine Mesylate 1 mg PO BID
Discharge Medications:
1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
2. Sulfameth/Trimethoprim DS 1 TAB PO BID UTI
3. Tamsulosin 0.4 mg PO QHS
4. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
5. Apixaban 5 mg PO BID
6. Benztropine Mesylate 1 mg PO BID
7. Levothyroxine Sodium 100 mcg PO DAILY
8. lurasidone 100 mg oral DAILY
9. MethylPHENIDATE (Ritalin) 10 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Left UVJ stone
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 the stone.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-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. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-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
Followup Instructions:
___
|
10293407-DS-8 | 10,293,407 | 28,135,848 | DS | 8 | 2196-12-05 00:00:00 | 2196-12-05 20:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Left Thoracentesis (___)
History of Present Illness:
HPI:
___ ___ with metastatic non-small cell lung
cancer to the spine (C4D1 ___ as of ___, last XRT
___ presents for evaluation of dyspnea. The patient has had
worsening dyspnea with exertion for the past ___ days, such that
she is short of breath after using the bathroom or taking a
shower. She denies fevers, chills, nausea, vomiting, chest pain.
She denies any pleuritic discomfort. Denies any orthopnea, PND.
She endorses generalized fatigue and malaise. Denies any focal
weakness or sensory deficit.
She has had odynophagia, attributed to XRT, causing poor PO
intake but no oral ulcers. Denies any melena or bright blood per
rectum, urinary symptoms, hematuria.
ED course:
11:41 0 99.0 112 123/78 18 97%
Today 15:59 0 98.0 77 133/99 18 98% RA
Today 15:59 0 98.0 77 133/99 18 98% RA
ED eval: opacity in left lung base likely PNA. Will admit for
dyspnea, likely pneumonia, rule out pulmonary embolism
meds
15:33 CefePIME 2 g IV ONCE
15:33 Vancomycin 1000 mg IV ONCE
Review of Systems: As per HPI. All other systems negative.
Past Medical History:
Oncologic History:
(Please see OMR for full details.)
DIAGNOSIS:
1. Stage IV ___ TNM) nonsmall cell lung cancer (adenocarcinoma
with EGFR activating mutation: delE___)
2. Relapse with T790M mutation in exon 20
TREATMENT:
1. Started first line erlotinib as part of clinical trial ___
___ on ___.
___. Erlotinib 150 mg/day from ___ to ___.
B. Erlotinib 100 mg/day from ___ to ___
C. Erlotinib 50 mg/day from ___ to ___
- disease progression on ___
- repeated biopsy
- C1D1 ___ with continued erlotinib
- C2D1 ___ held due to Shingles
2. Carboplatin + pemetrexed with concurrent erlotinib
A. C1D1 on ___
- C2D1 on ___ held due to shingles
PMH/PSH:
1. Hyperglycemia
2. Hyperlipidemia
3. Osteopenia
4. Carpal tunnel syndrome
Social History:
___
Family History:
No family history of cancer
Physical Exam:
Admission Physical Exam:
T98.1, 132/45, HR 105, 18, 97%RA
GEN: NAD
HEENT: PERRL, EOMI, slightly dry MM, oropharynx clear, no
cervical ___: CTAB, though decreased breath sounds bibasilar.
CV: tachy with regular rhythm, no m/r/g, nl S1 S2. JVP<7cm
ABD: normal bowel sounds, non-tender, not distended, no
organomegaly or masses
EXTR: Warm, well perfused. No edema. 2+ pulses.
NEURO: alert and orientedx3, motor grossly intact
.
Discharge Physical Exam:
Vitals - 98.8 98.5 ___ 580/400+
GENERAL: NAD, resting comfortably in bed
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB, decreased breath sounds at the bases
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: well perfused
Pertinent Results:
Admission Labs:
___ 12:27PM ___ PTT-27.8 ___
___ 12:27PM NEUTS-81.5* LYMPHS-9.0* MONOS-7.2 EOS-2.0
BASOS-0.3
___ 12:27PM WBC-4.5 RBC-3.20* HGB-9.9* HCT-31.0* MCV-97
MCH-30.9 MCHC-31.9 RDW-15.7*
___ 12:27PM CK(CPK)-79
___ 12:27PM estGFR-Using this
___ 12:27PM GLUCOSE-227* UREA N-9 CREAT-0.6 SODIUM-134
POTASSIUM-6.1* CHLORIDE-100 TOTAL CO2-26 ANION GAP-14
___ 12:33PM LACTATE-2.3* K+-5.9*
.
Discharge Labs:
___ 06:30AM BLOOD WBC-4.1 RBC-3.31* Hgb-9.8* Hct-31.9*
MCV-96 MCH-29.5 MCHC-30.6* RDW-15.9* Plt ___
___ 06:30AM BLOOD Glucose-124* UreaN-16 Creat-0.5 Na-138
K-3.8 Cl-102 HCO3-27 AnGap-13
___ 06:30AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9
.
Microbiology:
# Blood Cultures (___): Pending.
# Pleural Fluid Culture (___): No growth
.
Imaging/Studies:
# CXR (___): 1. New small to moderate left pleural effusion.
2. Stable appearance of known right loculated pleural effusion
and pleural
thickening. Known right pulmonary mass and multiple pulmonary
nodules better assessed on CT.
# CTA Chest (___): 1. No evidence of central pulmonary
embolism.
2. Interval development of large left pleural effusion and
adjacent
compressive atelectasis, likely contributing to the patient's
symptoms.
3. Increased size of dominant right infrahilar lesion
reflecting progression of disease. 4. Stable to mildly
increased osseous metastases.
# CXR (___): Following thoracentesis, small left pleural
effusion is smaller today than it was on ___. There is no
pneumothorax. Chronic moderate right pleural effusion and severe
basal atelectasis distal to right hilar mass R unchanged. Heart
is top-normal size,
# CXR (___): As compared to the previous radiograph, no
relevant change is seen. The extent of the known bilateral
pleural effusions is constant. Moderate cardiomegaly without
overt pulmonary edema. Areas of atelectasis at both lung bases
but no evidence of pneumonia. No pneumothorax.
Brief Hospital Course:
___ with metastatic non-small cell lung cancer to the spine
(C4D1 ___ as of ___, last XRT ___ who presented
with worsening dyspnea on exertion, found to have LLL effusion.
#Left Lower Lobe Effusion: She was found to have a moderate size
pleural effusion on CTA and CXR. No pulmonary embolism was seen.
She was started on broad spectrum antibiotics for empiric
coverage of pneumonia. She remained afebrile without
leukocytosis making an infectious causes like pneumonia less
likely. The antibiotics were then discontinued. Given her
history of non-small cell lung cancer, a malignant effusion was
the most likely etiology. Interventional pulmonology was
consulted to perform a thoracentesis. The pleural fluid was sent
for gram stain, culture and cytology. The gram stain revealed
few WBCs and no growth was observed on culture. Cytology was
pending at the time of discharge and will be followed up when
she sees her oncologist as an out patient. Her SpO2 remained in
the high 90's while walking with physical therapy and she felt
her symptoms had improved.
#Non-small cell lung cancer with mets to the spine: She is
receiving pemetrexed/carboplatin, erlotinib, and radiation.
Lorazepam, Zofran, Compazine, and her home doses of extended
release morphine were continued.
#Dysphagia: Radiation-related: Improved with viscous lidocaine.
#Hyperkalemia: Her potassium was noted to be 6.0 on admission.
No EKG changes were observed and she remained asymptomatic.
Resolved with kayexalate. Her CPK was within normal limits.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Morphine Sulfate ___ 30 mg PO Q4H:PRN pain
3. Naproxen 500 mg PO DAILY:PRN pain
4. Morphine SR (MS ___ 60 mg PO Q12H
5. Erlotinib 50 mg PO DAILY
6. Dexamethasone 4 mg PO Q12H
7. Lorazepam 0.5 mg PO BID:PRN nausea
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Lactulose 30 mL PO BID:PRN constipation
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Lorazepam 0.5 mg PO BID:PRN nausea
3. Morphine SR (MS ___ 60 mg PO Q12H
4. Morphine Sulfate ___ 30 mg PO Q4H:PRN pain
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Dexamethasone 4 mg PO Q12H
8. Erlotinib 50 mg PO DAILY
9. Lactulose 30 mL PO BID:PRN constipation
10. Naproxen 500 mg PO DAILY:PRN pain
11. Cepastat (Phenol) Lozenge 2 LOZ PO Q2H:PRN sorethroat
RX *phenol [Cepastat] 14.5 mg 1 Lozenge Q2H Disp #*70 Lozenge
Refills:*0
12. Lidocaine Viscous 2% 15 mL PO TID:PRN throat pain
RX *lidocaine HCl [Lidocaine Viscous] 20 mg/mL 15ml three times
a day Refills:*0
13. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) Apply patch to
affected area daily Disp #*30 Patch Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Pleural Effusion (likely a malignant effusion)
Secondary: Non-small cell lung cancer, dysphagia, hyperkalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You came to the hospital after having increasing
shortness of breath while walking. You were found to an
increased amount of fluid in your left lung. The fluid was
drained out of the left lung and it was sent to the lab for
evaluation. You also had a sore throat that improved with oral
lidocaine and lozenges.
Thank you for allowing us to take part in your care.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10293587-DS-2 | 10,293,587 | 21,547,743 | DS | 2 | 2161-05-09 00:00:00 | 2161-05-09 22:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy ___
Flexible sigmoidoscopy ___
History of Present Illness:
Ms. ___ is a pleasant ___ year old lady with a PMH significant
for IBD (UC vs Crohns dx ___ year ago w/ brb stools), multiple
sclerosis Dx in her ___ on long standing prednisone complicated
by degenerative joint disease s/p bilateral hip replacement
severe depression, suicidal ideation and anxiety p/w BRBPR.
Per patient, she has had complicated course of disease to have
blood streaked stools. This then progressed to worsening pain,
bloating, diarrhea (>6 BMs per day), with some blood at end of
diarrhea episodes. 9 days prior she started herself on a
prednisone taper, which she states she had leftovers from
previous flare in ___. She took for 8 days, one day at 40mg,
then self-tapered, which she says initially helped her sx but
they have now worsened. Pt reports eating well prior to 3 weeks
ago but then was not watching what she eats. She had 2 episodes
of vomiting over the past 3 weeks. Reports associated weakness,
fatigue, denies shortness of breath, chest pain, fevers, chills.
Yesterday, she had 6 episodes of bloody, watery, diarrhea and
was
concerned. She called her gastroenterologist who advised her to
come to the ED. Patient reports multiple over-the-counter
medications including "natural supplements" recently but no
additional changes in medication. Denies any NSAID use, and
recently was on amoxicillin ppx a couple months ago prior to
dental procedure. She was scheduled to have colonoscopy ___.
Please see GI note from ___ for more information about her IBD
hx. But in brief, had not had GI symptoms until ___ when she
had nonbloody diarrhea with routine colonoscopy revealing
adenoma, but otherwise normal c-scope. Had symptoms a few months
later of painless hematochezia and received flex sig which noted
diffuse inflammation thoughtout left side of colon and given
diagnosis of UC and placed on steroid taper and lialda. Pt
unable
to tolerate lialda and had worsening symptoms again in ___
and was admitted to ___ for UC flare, treated with steroids and
mesalamine. She continued to have GI sx and presented to ___
clinic on ___.
In the ED, initial vitals: Pain 4 Temp 98.0 HR 116 BP 107/74 RR
17 O2sat 100% RA
- Exam notable for: mild diffuse TTP, greatest RLQ/LLQ. Liquid
stool on exam with poss mixed gross blood - hemoccult pos.
- Labs notable for:
K:4.4
Lactate:1.2
CRP: 9.5
5.0 - 12.8/38.9 - 323
- Imaging notable for: N/A
- GI was consulted who recommended:
- no steroids right now
- rule out c diff and send stool cultures
- NPO at midnight for flex sig in AM.
- 2 enemas: one in AM and one when on call to endoscopy unit
- avoid narcotics and NSAIDs
- CRP in AM
- please give pharmacologic dvt ppx
- Pt given: N/A
- Vitals prior to transfer: Pain 0, Temp 98.3, HR 93, BP 100/61,
RR 16, O2sat 100% RA
On the floor, patient reports symptoms including abdominal pain
and BM are improved as she has not eaten the whole day. Has some
lower abdominal crampy pain. No nausea, vomiting, chest pain,
shortness of breath.
Past Medical History:
___ - Arthroscopy shoulder
___ cholecystectomy
ESWL kidney
Total hip replacement Fall of ___ left and right
Social History:
___
Family History:
Mother - died from cholangiocarcinoma
Father - ___ Ca
Brother - Multiple psychiatric problems
Paternal ___ cousin - ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VITALS: 98.3 99/58 92 18 99% RA
General: anxious appearing in NAD
HEENT: Sclerae anicteric, dry MM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, nondistended, mildly tender in lower quadrants.
+BS
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: AOx3, moving all extremities with purpose
DISCHARGE PHYSICAL EXAM:
===========================
VITALS: 97.6 119/76 85 16 99 Ra
General: Well developed woman, not appearing to be in any
physical distress, but perseverating over many details of her
care.
AAOx3.
HEENT: Normocephalic, atraumatic. EOMI. MMM. No lymphadenopathy.
Cardiac: Regular rate & rhythm. Normal S1/S2. No murmurs, rubs,
or gallops.
Pulmonary: Clear to auscultation bilaterally. Breathing
comfortably on room air.
Abdomen: Normal in appearance. Soft, mildly tender to palpation
diffusely. Non-distended.
Extremities: Warm, well perfused, non-edematous.
Pertinent Results:
ADMISSION LABS:
===================
___ 03:35PM BLOOD WBC-5.0# RBC-4.46 Hgb-12.8 Hct-38.9
MCV-87 MCH-28.7 MCHC-32.9 RDW-12.9 RDWSD-40.3 Plt ___
___ 03:35PM BLOOD Neuts-57.7 ___ Monos-11.8 Eos-1.6
Baso-0.6 Im ___ AbsNeut-2.88# AbsLymp-1.39 AbsMono-0.59
AbsEos-0.08 AbsBaso-0.03
___ 06:20AM BLOOD ___ PTT-26.8 ___
___ 03:35PM BLOOD Glucose-90 UreaN-16 Creat-0.8 Na-137
K-7.0* Cl-98 HCO3-25 AnGap-14
___ 03:35PM BLOOD ALT-24 AST-75* LD(LDH)-762* AlkPhos-89
TotBili-0.3
___ 03:35PM BLOOD Calcium-9.5 Phos-5.1* Mg-2.4
___ 03:35PM BLOOD CRP-9.5*
___ 03:45PM BLOOD Lactate-1.2 K-4.4
PERTINENT LABS:
===================
___ 06:30AM BLOOD GGT-298*
___ 06:35AM BLOOD VitB12-619
___ 06:30AM BLOOD Hapto-226*
___ 05:50AM BLOOD Triglyc-174* HDL-65 CHOL/HD-3.0
LDLcalc-93
___ 07:05AM BLOOD 25VitD-32
___ 06:30AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG IgM HAV-NEG
___ 07:05AM BLOOD IgG-670* IgA-106 IgM-67
___ 06:30AM BLOOD HCV Ab-NEG
___ 06:30AM BLOOD HBV VL-NOT DETECT
___ 07:05AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
DISCHARGE LABS:
===================
___ 07:00AM BLOOD WBC-7.7 RBC-4.61 Hgb-13.4 Hct-41.8 MCV-91
MCH-29.1 MCHC-32.1 RDW-13.4 RDWSD-43.6 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-83 UreaN-22* Creat-0.8 Na-142
K-4.2 Cl-97 HCO3-29 AnGap-16
___ 07:00AM BLOOD Calcium-9.3 Phos-5.3* Mg-2.4
___ 07:00AM BLOOD CRP-1.8
MICROBIOLOGY:
===================
___ 10:06 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
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 O157:H7 found.
IMAGING:
===================
MRCP
1. Findings suspicious for 0.6 cm ampullary mass with mild
upstream
intrahepatic and extrahepatic biliary duct dilatation.
2. No choledocholithiasis.
PATHOLOGY
===================
FLEXIBLE SIGMOIDOSCOPY
Colonic mucosal biopsies, two specimens:
1. Sigmoid:
- Chronic moderately active colitis.
2. Rectum:
- Chronic mildly active colitis.
Note: No granulomas or dysplasia are seen.
AMPULLARY MUCOSAL BIOPSIES
- Duodenal mucosa, within normal limits
Brief Hospital Course:
___ w/ hx of recently-diagnosed IBD, depression, anxiety who
presented with 3 weeks of bloody diarrhea likely secondary to
IBD flare now s/p flexible sigmoidoscopy showing primarily
distal inflammation with biopsies consistent with active
colitis. Her hospital course was also notable for transaminitis
of unclear etiology, possibly secondary to drug induced liver
injury secondary to other the counter supplements. Repeat
sigmoidoscopy showed overall improvement in flare and so patient
was discharged with plan for steroid taper without additional
immunosuppressants.
#Ulcerative colitis
Patient presented with bloody diarrhea and abdominal pain
secondary to IBD flare (suspected UC). She underwent flexible
sigmoidoscopy ___ which showed distal inflammation and
biopsies consistent with active colitis. Infectious stool
studies were negative. C. diff was negative. She was started on
cortifoam enemas BID, per GI recommendations. However, this did
not adequately control her symptoms. She was started on IV
methylprednisolone with improvement; however, her symptoms
worsened again with transition to PO prednisone. She underwent a
second flexible signmoidoscopy which showed overall improvement
of UC lesions, and so was not started on additional
immunosuppression. Discharged with plan for steroid taper as
outlined below. To follow up with GI as an outpatient.
# Acute transaminitis
Patient had up-trending AST/ALT and alk phos with elevated GGT,
concerning for mixed hepatocellular and cholestatic pattern. She
does have known history of fatty liver disease, felt secondary
to non-alcoholic fatty liver disease and prior long standing
ETOH use. Her acutely worsened LFTs during admission may have
been secondary to drug induced liver injury from digestive
enzyme supplements and/or apple cider bitters supplements, which
she started taking over the last few weeks. Liver injury
secondary to imipramine was also considered. She was taken off
this for a few days, and LFTs downtrended. However, she was
re-challenged with imipramine and LFTs did not worsen again
after imipramine was re-started. ___, anti-smooth muscle
antibody, and anti-mitochondrial antibody were negative. Viral
hepatitis antibodies and HBV viral load were negative. She had
an MRCP that was notable for an ampullary mass; however,
subsequent endoscopic ultrasound did not demonstrate the mass
again. Biopsies from the EUS were consistent with normal
duodenal mucosa. The "mass" seen on MRCP may have been a
prominent ampulla. Her LFTs had downtrended at discharge.
# Major depressive disorder
# Anxiety
Patient noted that she has failed multiple anti-depressants in
the past for various side effects and ineffectiveness. She has a
history notable for SI. Given that she has become paranoid on
systemic steroids in the past, psychiatry was consulted when
systemic steroids were started this admission. Per psych
recommendations, she was started on Seroquel along with
steroids, and her mood remained stable. She was continued on her
home clonazepam and imipramine. Her home buspirone was stopped
per psych recommendations. She was advised to continue
seroquel as an outpatient while on the steroids, and to discuss
this with her outpatient providers.
===================
TRANSITIONAL ISSUES
===================
[] Steroid taper plan:
- 60 mg PO daily (___)
- 50 mg PO daily ___ - ___
- 40 mg PO daily ___ - ___
- 30 mg PO daily (___)
- 20 mg PO daily until further plan delineated by outpatient GI
[] Home buspirone was stopped per psych recommendations.
[] Over the counter supplements were discontinued.
[] Started Seroquel to be continued while on systemic steroids.
Please discontinue this when steroid taper is complete.
[] Please re-check LFTs at outpatient follow up to ensure
normalizing.
[] Please continue to counsel patient to avoid OTC supplements
due to concern for liver toxicity.
[] Please check finger stick blood sugar at next visit while on
steroids
[] Consider repeat EUS/EGD in 3 months.
[] Consider colorectal surgery outpatient appointment for
discussion of colectomy as a possible therapeutic options, as
appropriate if patient is amenable.
ADVANCED CARE PLANNING
#Code status: Full (presumed)
#Emergency contact: Friend ___ - ___
___ contact ___ (___)
Phone: ___
Other Phone: ___
Greater than ___ hour spent on care on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MethylPHENIDATE (Ritalin) 10 mg PO BID
2. Imipramine 150 mg PO QHS
3. ClonazePAM 1 mg PO QHS
4. Cholestyramine 4 gm PO QOD
5. BusPIRone 10 mg PO BID:PRN anxiety
6. Baclofen 10 mg PO TID
7. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
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 capsule(s) by mouth daily Disp
#*30 Capsule Refills:*0
3. PredniSONE 40 mg PO DAILY Duration: 7 Doses
Start: After 50 mg DAILY tapered dose
This is dose # 3 of 4 tapered doses
RX *prednisone 10 mg 4 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
4. PredniSONE 30 mg PO DAILY Duration: 7 Doses
Start: After 40 mg DAILY tapered dose
This is dose # 4 of 4 tapered doses
RX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*21 Tablet
Refills:*0
5. PredniSONE 20 mg PO DAILY
This is the maintenance dose to follow the last tapered dose
RX *prednisone 10 mg 2 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
6. PredniSONE 60 mg PO DAILY Duration: 5 Doses
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
This is dose # 1 of 4 tapered doses
RX *prednisone 10 mg 6 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. PredniSONE 50 mg PO DAILY Duration: 7 Doses
Start: After 60 mg DAILY tapered dose
This is dose # 2 of 4 tapered doses
RX *prednisone 10 mg 5 tablet(s) by mouth daily Disp #*35 Tablet
Refills:*0
8. QUEtiapine Fumarate 25 mg PO QHS
RX *quetiapine 25 mg 1 tablet(s) by mouth at night Disp #*30
Tablet Refills:*0
9. Ramelteon 8 mg PO QHS:PRN insomnia
Should take 30 minutes before bedtime
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth at night Disp
#*30 Tablet Refills:*0
10. Ranitidine 150 mg PO BID
RX *ranitidine HCl [Acid Control (ranitidine)] 150 mg 1
tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0
11. Simethicone 40-80 mg PO QID:PRN gas pain
RX *simethicone 80 mg ___ tablet Oral every ___ hours Disp
#*120 Tablet Refills:*0
12. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
13. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
14. Baclofen 10 mg PO TID
15. BusPIRone 10 mg PO BID:PRN anxiety (this was on her
medication list, but patient will be called and asked to stop
this medication)
16. Cholestyramine 4 gm PO QOD
17. ClonazePAM 1 mg PO QHS
18. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
19. Imipramine 150 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses
==================
IBD
Acute Transaminitis
Secondary diagnoses
====================
Major depressive disorder
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you had bloody
diarrhea and abdominal pain.
What happened while I was in the hospital?
===========================================
- You had a procedure called a flexible sigmoidoscopy which
showed inflammation in your colon.
- You were treated with steroid enemas to help reduce the pain
and inflammation in your colon. Unfortunately, these did not
control your symptoms well enough.
- You were started to IV steroids, which helped your symptoms.
You were then switched to an oral steroid called prednisone.
- You were started on Seroquel while on the steroids to help you
feel less restless.
- Your liver enzymes were also high in the hospital. This may
have been caused by your over-the-counter supplements. This
improved while you were in the hospital.
- You had two imaging studies called an MRCP and an endoscopic
ultrasound to get a better look at your liver. The biopsies from
this procedure showed normal tissue, which was reassuring.
What should I do when I go home?
=================================
- Please follow up with your primary care doctor ___ Dr. ___
in ___ weeks.
- Please stop taking the digestive enzymes and apple cider
bitters supplements. Please also avoid other over-the-counter
supplements since some of these can cause liver injury.
- Please take the prednisone taper as described in the
medications below.
We wish you all the best,
Your ___ Team
Followup Instructions:
___
|
10293741-DS-21 | 10,293,741 | 29,334,389 | DS | 21 | 2176-09-12 00:00:00 | 2176-09-13 06:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"Weakness."
Major Surgical or Invasive Procedure:
- None.
History of Present Illness:
___ with history of laryngeal CA c/b parastomal infection and
fistula formation with G-tube placement p/w lightheadedness,
weakness, DOE and poor G-tube feedings. Patient reports feeling
lightheaded and weak upon standing and walking. No vertigo type
symptoms. No visual changes. No numbness in extremities. Family
reports that patient should be getting 240 of fluids prior to
feedings, but has only been able to get 120 because he feels
full and no longer tolerates the fluids. Reports increased DOE
upon walking and needs to rest more frequently. He fell at home
three weeks ago, but did not strike his head or lose
consciousness. No CP. No f/c. No n/v/d. Last BM was 3 days ago
and normal. No BRBPR/melena. Patient was seen by ___ today and
noted to have SBPs to ___ and sent to ED for further evaluation.
.
In the ED, initial vs were: 97.6 75 97/71 18 97% ra.
Orthostatics were positive. Labs notable for positive UA. Hct
was stable from baseline. CXR was unremarkable. Blood/urine
cultures were taken. Patient was given CTX 1g x1. Was also given
2LNS. Admitted then for UTI and failure to thrive. Prior to
transfer to the floor, the patient had an episode of acute
dyspnea, and moderate respiratory distress. He underwent saline
nebulization and deep suctioning, with resolution of his
symptoms; no change in O2 sats throughout. Episode thought to be
due to mucus plug, which patient has multiple times ___.
Vitals prior to admission were 98.0 BP 124/74, HR 57, RR 16, O2
Sat - 99%RA.
.
On the floor, the patient is feeling comfortable, and denies
dyspnea, lightheadedness, chest pain, fever, cough, or abdominal
pain. He is anxious about his ability to fall asleep. He
endorses a ___ lb weight loss over the past year. He feels
that his episodes of lightheadedness and dizziness are occurring
more frequently (now, ___ and may have coincided with the
initiation of several medications, namely lorazepam, trazodone
and citalopram, all of which were started several weeks ago.
.
Review of sytems:
(+) Per HPI
(-) Denies 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.
Past Medical History:
ONCOLOGY HISTORY:
- Laryngeal cancer
---> Multiple stripings from ___
---> ___: Stage I squamous cell carcinoma of R true cord,
-***--> Radiation therapy: ___ at ___
---> ___: Stridor, SCC stage III, T3, N0 second primary
---> ___: Total laryngectomy & L modified neck dissection
with SCM rotation flap to cover mediastinal vessels
-***--> Tumor invaded through the thyroid & tracheal cartilages;
into surrounding soft tissues & skeletal muscles.
-***--> Pathology report: T4b, stage IV SCC of supraglottic
larynx.
---> ___: Surveillance CT revealed a new L neck mass, FNA
showed SCC now s/p resection
PAST MEDICAL HISTORY:
- HTN
- Atrial fibrillation
- Mitral valve prolapse
- GERD
- Hypothyroidism
- BPH
- SLE
- H/o DVT in bilateral legs ___ with recurrence
Social History:
___
Family History:
- Brother with unspecified cancer
- Father with unspecified cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.9, 131/88, 63, 18, 100% tent mask
General: Chronically ill appearing adult male in NAD, using
___ to suction sputum occasionally
HEENT: Mild conjunctival injection, Sclera anicteric, MMM,
oropharynx clear
Neck: occasional mucus production at trach site, neck supple,
JVP not elevated, no LAD. No carotid bruits on either side.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregularly irregular rhythm, regular rate, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAOx3, unable to vocalize but whispers words, can write
questions down; appropriate, alert. Thought process clear.
Moving all extremities freely except for weakness with
plantar/dorsiflexion of left foot (chronic). Sensation to light
touch grossly intact throughout. Gait assessment deferred
DISCHARGE PHYSICAL EXAM:
Unchanged.
Pertinent Results:
ADMISSION LABS:
___ 11:32PM ___ PTT-36.2 ___
___ 05:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-4* PH-6.0 LEUK-TR
___ 05:20PM URINE RBC-47* WBC-11* BACTERIA-NONE YEAST-NONE
EPI-0
___ 04:35PM LACTATE-1.0
___ 04:25PM GLUCOSE-132* UREA N-20 CREAT-0.8 SODIUM-138
POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-26 ANION GAP-10
___ 04:25PM CALCIUM-8.7 PHOSPHATE-2.4* MAGNESIUM-1.9
___ 04:25PM WBC-6.1 RBC-4.26* HGB-11.7* HCT-36.3* MCV-85
MCH-27.4 MCHC-32.2 RDW-14.2
___:25PM NEUTS-83.6* LYMPHS-10.3* MONOS-4.7 EOS-1.0
BASOS-0.3
___ 04:25PM TSH-1.4
CXR (___): no acute intrathoracic process
DISCHARGE LABS:
___ 07:35AM BLOOD WBC-5.6 RBC-3.86* Hgb-10.3* Hct-33.3*
MCV-86 MCH-26.6* MCHC-30.8* RDW-14.5 Plt ___
___ 07:35AM BLOOD Glucose-87 UreaN-14 Creat-0.7 Na-138
K-4.3 Cl-107 HCO3-25 AnGap-10
___ 07:35AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.8
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
___ M hx/o laryngeal cancer s/p total laryngectomy complicated by
right parastomal infection & fistula formation presents with
weakness & dizziness.
ACUTE DIAGNOSES:
# Weakness & Failure to Thrive: Initially, there was some
concern that the patient was suffering from early satiety that
limited his tolerance to tube feeds. On further discussion with
the patient & his caregivers it was determined that the patient
had not been adequately hydrating himself. He could take his
feed without difficulty but frequently skipped his water
flushes. On the floor there was no concern for difficulty
pushing feeds. Nutrition evaluated the patient and made some
recommendations to his tube feed schedule (Peptamen 1.5 cans
5x/day with 150 cc flushes of free water after each bolus). He
was noted to be ambulating around the floor without difficulty
and reported feeling much better after receiving IVF in the ED.
Given the clear correlation between his weakness and poor
nutritional compliance he was thought to be safe for discharge
after it was made clear that hydration is just as important has
the feeds.
# Depression & Anxiety: The patients has had ongoing
difficulties with depression. He was recently started on
trazodone as a sleep aid and ativan for anxiety. According to
his daughter, these medications have been causing excessive
daytime sleepiness which further limited his adherence to
regular tube feeds. The patient was strongly advised to
discontinue ativan. He had Ambien during admission which he felt
was more helpful for his insomnia. As such trazodone was
discontinued & the patient was provided with a prescription for
Ambien.
CHRONIC DIAGNOSES:
# Larygneal Cancer: The patient is currently in remission. He
is followed by ID for his right parastomal infection and
currently takes ___ augmentin for suppression. He will follow
up with ID & oncology as an outpatient.
# DVTs: Warfarin was continued. INR was 2.5 on admission. The
patient will continue with INR monitoring at ___.
# Hypothyroidism: The patient was continued on his home dose of
levothyroxine.
TRANSITIONAL ISSUES:
# Follow-Up: The patient will follow up with his PCP ___ 1
week of discharge.
# Risk of Readmission: If the patient becomes poorly adherent to
his tube feeds it is possible that he will have recurrent
nutritional problems that could result in readmission.
# Code Status: DNR/DNI
Medications on Admission:
Warfarin 5mg ___
Levoxyl 175 mcg ___
Prazosin 1 mg QHS
Lansoprazole 30 mg ___
Amiodarone 200 mg ___
Duloxetine 30 mg ___
Augmentin 875-125 mg Q12
Metoclopramide 10 mg Q6 Hours
Combivent ___ mcg/Actuation Aerosol Inhalation
Trazodone 50 mg QHS
Ativan 1 mg BID PRN
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet ___
(___).
2. warfarin 5 mg Tablet Sig: One (1) Tablet ___ Once ___ at 4
___.
3. metoclopramide 10 mg Tablet Sig: One (1) Tablet ___ QIDACHS (4
times a day (before meals and at bedtime)).
4. lansoprazole 30 mg Tablet,Rapid Dissolve, ___ Sig: One (1)
Tablet,Rapid Dissolve, ___ ___.
5. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML ___ TID PRN
() as needed for constipation.
6. ipratropium-albuterol ___ mcg/Actuation Aerosol Sig: ___
Puffs Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
7. trazodone 50 mg Tablet Sig: One (1) Tablet ___ QHS PRN as
needed for insomnia.
8. citalopram 20 mg Tablet Sig: One (1) Tablet ___.
9. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet ___ Q12H (every 12 hours).
10. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) ___ BID (2 times a day).
11. Ambien 5 mg Tablet Sig: One (1) Tablet ___ QHS as needed for
insomnia.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Dehydration
- Poor G-tube intake
SECONDARY DIAGNOSIS:
- Laryngeal cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___, it was a pleasure to participate in your care while
you were at ___. You came to the hospital because you have
been experiencing some increased weakness and lightheadness and
your blood pressure was noted to be low when it was taken by
your ___ nurse. While you were here, we confirmed that your
blood pressure was a bit low, but it improved after you were
given some intravenous fluids.
Your symptoms are likely due to the fact that you have not been
including enough free water with your tube feeds. It is also
likely that some of your new medications (ativan and trazodone)
are making you excessively sleepy during the day. We would
recommend that you stop taking ativan because it can cause
excessive daytime sleepiness. You were provided with an
alternate sleep medication called Ambien, which you will take
instead of trazodone.
Please monitor your urine output. If you feel that you are
urinating less frequently than usual, please increase the amount
of water that you take through your tube feeds (or take
additional water between feeds) & consider calling your doctor.
MEDICATION CHANGES:
- Medications ADDED:
---> Ambien as needed for sleep
- Medications STOPPED:
---> Please stop taking ativan as this medication seems to be
causing excessive drowsiness that may be interfering with your
ability to accept nutrition through your G-tube
---> Please stop taking trazodone.
Followup Instructions:
___
|
10294074-DS-22 | 10,294,074 | 22,051,402 | DS | 22 | 2193-08-04 00:00:00 | 2193-08-04 22:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Shortness of breath and running out of hydroxyurea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PCP:
Name: ___.
Address: ___, ___
Phone: ___
Fax: ___
Email: ___
.
Oncologist: Dr. ___
_
________________________________________________________________
HPI: > or equal to 4 ( location, quality, severity, duration,
timing, context, modifying factors, associated signs and sx)
___ with myeloproliferative d/o sent in for elevated K, possible
admission for restarting hydrea and K monitoring. Patient states
he feels fine. Has been off hydrea for 1 week because rx ran out
because he has had 3 changes of doctors at the ___ where he
usually gets his medications. He has been feeling well
otherwise. He did an hour and a half of exercise class today. He
has been having SOB for 1 month with exertion. He is not SOB
during his exercise class but if he is rushing to go somewhere
he becomes sob. He can climb 13 steps without stopping. No
associated chest pressure, nausea or diaphoresis. No associated
edema or pnd. He has sleep apnea and he uses CPAP at night. He
takes a ___ min nap daily for the past 6 months.
.
In ER: (Triage Vitals:98.2 80 160/92 20 96%
Meds Given: nONE,
Fluids given: NONE
.
PAIN SCALE: ___
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [x] All Normal
[ ] Fever [ ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[ ] _____ lbs. weight loss/gain over _____ months
Eyes
[x] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT [x] WNL
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [] All Normal
[X ] Shortness of breath [X ] Dyspnea on exertion [ ] Can't
walk 2 flights [ +] Cough- occasional productive of
brown/yellow phlegm x 1 month [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [x] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ]
Chest Pain [ ] Dyspnea on exertion [ ] Other:
GI: [x] All Normal
[ ] Nausea [] Vomiting [] Abd pain [] Abdominal swelling [
] Diarrhea [ ] Constipation [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [] All Normal
[ ] Dysuria [ ] Incontinence or retention [ x] Frequency -
over the past ___ months for Dr ___ at ___ [ ] Hematuria
[]Discharge []Menorrhagia
SKIN: [] All Normal
[ ] Rash [ ] Pruritus [+] bruise on L hand when he tried
to keep an elevator door from closing
MS: [x] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [x] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [] All Normal
[ ] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy [+] itchy scalp
HEME/LYMPH: [] All Normal
[x ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [x] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
ALLERGY:
[X ]Medication allergies- codeine -> nausea [ ] Seasonal
allergies
[X]all other systems negative except as noted above
Past Medical History:
Hypertension
Chronic Renal Insufficiency (baseline of 1.8 - 2)
CML
Gout
Chronic Low Back Pain
Carpal Tunnel Syndrome
BPH
Social History:
SOCIAL HISTORY/ FUNCTIONAL STATUS: I< 65
Cigarettes: [x ] never [ ] ex-smoker [] current Pack-yrs:
quit: ______
ETOH: [] No [+ ] Yes 3x per week
Drugs: none
Occupation: ___
Marital Status: [x ] Married [] Single
Lives: [ ] Alone [x] w/ family - wife [ ] Other:
Received influenza vaccination in the past 12 months [x ]Y [ ]N
Received pneumococcal vaccinationin the past [x ]Y [ ]N
wife is HCP
>65
ADLS:
Independent of ALL ADLS:
IADLS:
Independent of IADLS: [ ]shopping [ x] accounting [ ]telephone
use [ ]food preparation
Requires assitance with IADLS: [X ]shopping [ ] accounting [x
]telephone use [X ]food preparation
[x ]He has a cleaning person once per week
At baseline walks: [x ]independently [ ] with a cane [
]wutwalker [ ]wheelchair at ___
H/o fall within past year: []Y [x]N
Visual aides [ x]Y [ ]N
Dentures [ ]Y [ x]N
Hearing Aides [ ]Y [ x] N
Family History:
Father died at age ___ with ? Heart disease. Mother with CVA and
died at age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM: I3 - PE >8
PAIN SCORE: ___
1. VS: Tm = 96.5 T P = 89 BP 152/94 RR 29 O2Sat on __RA =
99% __
GENERAL: Elderly well appearing male. As we talk he becomes
noticably short of breath and has to take a breath at times
between sentences.
Nourishment: good
Grooming: good
Mentation
2. Eyes: [X] WNL
PERRL, EOMI without nystagmus, Conjunctiva:
clear/injection/exudates/icteric Ears/Nose/Mouth/Throat: MMM, no
lesions noted in OP
3. ENT [X] WNL
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [] WNL
[X] Regular [] Tachy [X] S1 [X] S2 [] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[] Edema RLE 3+ [] Bruit(s), Location:
[] Edema LLE None 2+ [+] PMI
[] Vascular access [+] Peripheral [] Central site:
5. Respiratory [ ]
[] CTA bilaterally [ x] Rales AT THE bases [ ] Diminshed
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [ X] WNL
[] Soft/firm [] Rebound [] No hepatomegaly [] Non-tender []
Tender [] No splenomegaly
[] Non distended [] distended [] bowel sounds Yes/No []
guiac: positive/negative
7. Musculoskeletal-Extremities [x] WNL
[ ] Tone WNL [ ]Upper extremity strength ___ and symmetrical [
]Other:
[ ] Bulk WNL [] Lower extremity strength ___ and symmetrica [
] Other:
[x] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [X] WNL
[ ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [] WNL
[] Warm [] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[ ] Cool [] Moist [] Mottled [] Ulcer:
None/decubitus/sacral/heel: Right/Left
Multiple ecchymoses
10. Psychiatric [X] WNL
[] Appropriate [] Flat affect [] Anxious [] Manic [] Intoxicated
[] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
11. Hematologic/Lymphatic [ ]WNL
[x] No cervical ___ [] No axillary ___ [] No supraclavicular
___ [] No inguinal ___ [] Thyroid WNL [] Other:
TRACH: []present [x]none
PEG:[]present [x]none [ ]site C/D/I
COLOSTOMY: :[]present [x]none [ ]site C/D/I
.
.
DISCHARGE PHYSICAL EXAM:
VS: T 98.4 BP 153/80 HR 86 RR 20 SaO2 96%RA
Gen: WD/WN, elderly white male, in NAD
HEENT: PERRL, EOMI, clear oropharynx
Neck: no cervical LAD, brisk carotid upstrokes, no carotid
bruits, no JVD
Lungs: CTAB, good excusrion with inspiration, no
wheezes/crackles
Heart: RRR, normal S1/S2, II/VI SEM at RUSB
Abd: Spleen tip palpable with inspiration, normoactive bowel
sounds, no TTP
Extr: 1+ pitting edema, R slightly worse than L
Skin: no rashes or skin breakdown
Neuro: Alert, awake and oriented x3, CNs II-XII intact and
equal, ___ strength in upper and lower extremities, sensation
intact and equal bilaterally, 2+ reflexes in upper and lower
extremities
Psych: mood and affect appropriate
Access: PIV
Pertinent Results:
ADMISSION LABS:
___ 09:20PM URINE HOURS-RANDOM
___ 09:20PM URINE GR HOLD-HOLD
___ 09:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 09:20PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 05:50PM K+-4.6
___ 05:47PM GLUCOSE-100 UREA N-45* CREAT-2.5* SODIUM-143
POTASSIUM-5.2* CHLORIDE-111* TOTAL CO2-18* ANION GAP-19
___ 05:47PM CK(CPK)-77
___ 05:47PM cTropnT-0.11*
___ 05:47PM CK-MB-5
___ 05:47PM CALCIUM-9.0 PHOSPHATE-3.4 MAGNESIUM-1.9 URIC
ACID-6.5
___ 05:47PM WBC-24.7* RBC-3.93* HGB-11.4* HCT-36.0*
MCV-92 MCH-29.0 MCHC-31.7 RDW-17.4*
___ 05:47PM NEUTS-77* BANDS-4 LYMPHS-1* MONOS-3 EOS-5*
BASOS-1 ATYPS-1* METAS-7* MYELOS-1*
___ 05:47PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
___ 05:47PM PLT COUNT-771*
___ 02:18PM UREA N-49* CREAT-2.6* SODIUM-143
POTASSIUM-6.0* CHLORIDE-111* TOTAL CO2-20* ANION GAP-18
___ 02:18PM estGFR-Using this
___ 02:18PM ALT(SGPT)-29 AST(SGOT)-37 LD(LDH)-482* ALK
PHOS-131* TOT BILI-0.5
___ 02:18PM CALCIUM-9.1 PHOSPHATE-3.6 MAGNESIUM-2.0 URIC
ACID-6.5
___ 02:18PM WBC-24.9* RBC-3.93* HGB-11.5* HCT-35.6*
MCV-91 MCH-29.1 MCHC-32.1 RDW-17.5*
___ 02:18PM NEUTS-72* BANDS-0 LYMPHS-8* MONOS-16* EOS-1
BASOS-0 ___ METAS-2* MYELOS-1*
___ 02:18PM PLT SMR-VERY HIGH PLT COUNT-766*
.
DISCHARGE LABS:
___ 03:50AM BLOOD WBC-24.4* RBC-3.70* Hgb-10.8* Hct-33.5*
MCV-91 MCH-29.2 MCHC-32.2 RDW-17.7* Plt ___
___ 03:50AM BLOOD Neuts-70 Bands-0 Lymphs-10* Monos-14*
Eos-2 Baso-1 ___ Metas-1* Myelos-2*
___ 03:50AM BLOOD Glucose-85 UreaN-42* Creat-2.4* Na-142
K-4.9 Cl-111* HCO3-17* AnGap-19
___ 03:50AM BLOOD Glucose-85 UreaN-42* Creat-2.4* Na-142
K-4.9 Cl-111* HCO3-17* AnGap-19
___ 03:50AM BLOOD ALT-21 AST-27 LD(LDH)-397* CK(CPK)-55
AlkPhos-104 TotBili-0.5
___ 03:50AM BLOOD CK-MB-4 cTropnT-0.10*
___ 03:50AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.8 UricAcd-6.6
Iron-36*
___ 03:50AM BLOOD calTIBC-317 VitB12-1641* Folate-GREATER
TH ___ Ferritn-46 TRF-244
___ 03:50AM BLOOD TSH-4.0
.
IMAGING:
___ CXR PA/lat: Frontal and lateral views of the chest were
obtained. There is upper zone pulmonary vascular re-distribution
and perivascular haze. Additionally, there is blunting of the
posterior bilateral costophrenic angles consistent with trace to
small bilateral pleural effusions. More confluent opacity at the
right infrahilar region most likely relates to vascular
structures and is somewhat similar as compared to the prior
radiograph as opposed to underlying consolidation. There is
focal thickening of the white matter fissure which may be due to
thickening or fluid within. The cardiac silhouette remains top
normal. The mediastinal contours are stable.
IMPRESSION: Elevated central venous pressure and trace bilateral
pleural effusions suggest degree of fluid overload/CHF. More
consolidative opacity at the right infrahilar region may be
related to vascular structures although underlying consolidation
not excluded.
.
___ TTE:
Results
Left Atrium - Long Axis Dimension: *4.6 cm
Left Atrium - Four Chamber Length: *5.3 cm
Right Atrium - Four Chamber Length: *5.2 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm
Left Ventricle - Diastolic Dimension: 4.7 cm
Left Ventricle - Ejection Fraction: 45%
Left Ventricle - Stroke Volume: 50 ml/beat
Left Ventricle - Cardiac Output: 4.27 L/min
Left Ventricle - Cardiac Index: 2.39
Left Ventricle - Lateral Peak E': *0.06 m/s
Left Ventricle - Septal Peak E': *0.04 m/s
Left Ventricle - Ratio E/E': *24
Aorta - Sinus Level: 2.9 cm
Aorta - Ascending: 3.0 cm
Aortic Valve - Peak Velocity: *2.4 m/sec
Aortic Valve - Peak Gradient: *23 mm Hg
Aortic Valve - Mean Gradient: 14 mm Hg
Aortic Valve - LVOT pk vel: 1.00 m/sec
Aortic Valve - LVOT VTI: 16
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *1.3 cm2
Mitral Valve - Mean Gradient: 2 mm Hg
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 1.71
Mitral Valve - E Wave deceleration time: 141 ms
TR Gradient (+ RA = PASP): *59 mm Hg
Pulmonic Valve - Peak Velocity: 1.0 m/sec
Findings
LEFT ATRIUM: Mild ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Lipomatous
hypertrophy of the interatrial septum. No ASD by 2D or color
Doppler. Normal IVC diameter (<=2.1cm) with <50% decrease with
sniff (estimated RA pressure ___ mmHg).
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild
regional LV systolic dysfunction. No LV mass/thrombus. TDI E/e'
>15, suggesting PCWP>18mmHg. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free
wall hypokinesis.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Mild AS (area 1.2-1.9cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No
MS. ___ to moderate (___) MR.
___ VALVE: Mildly thickened tricuspid valve leaflets. No
TS. Mild [1+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: Trivial/physiologic pericardial effusion. No
echocardiographic signs of tamponade.
.
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is mild regional left ventricular systolic dysfunction with
inferior and infero-lateral hypokinesis (c/w CAD). No masses or
thrombi are seen in the left ventricle. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The diameters of aorta at the sinus, ascending and
arch levels are normal. There are three aortic valve leaflets.
The aortic valve leaflets are moderately thickened. There is
mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild to
moderate (___) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
.
___ Left lower extremity ultrasound: Grayscale and color
Doppler ultrasounds were performed. There is normal
compressibility, color flow and Doppler signal within the common
femoral, superficial femoral and popliteal veins.
IMPRESSION: No evidence of DVT.
Brief Hospital Course:
Mr. ___ is an ___ gentleman, with myelodysplastic syndrome,
hypothyroidism, prior EF 48% on stress, who presented with
elevated blood counts and falsely-elevated hyperkalemia, as well
as dyspnea on exertion over the past three weeks.
.
.
ACTIVE ISSUES:
# Myeloproliferative disorder: Patient has been symptomatic
since ___. His last bone marrow bx was in ___ which
was consistent with his known myeloproliferative disorder.
Cytogenetics were negative for BCR-ABL. He is positive for Jak 2
mutation. He had been maintained on hydrea 500 mg po qd M-F but
has not taken it for over a week. He was restarted on
hydroxyurea 500 mg PO daily. He will follow up with Dr. ___
___ weeks after discharge, at which point continuation of daily
hydroxyurea vs. 5x/week can be addressed.
.
# Hyperkalemia: Falsely elevated due to elevated cell counts, as
there is increased potassium in clotted serum from release of
intracellular electrolytes. Plasma potassium confirmed that
potassium was actually within the normal range. EKGs did not
show peaked T waves. As described above, hydroxyurea was
restarted.
.
# Dyspnea on exertion: Patient with stress-Echo in ___ with EF
at rest 42% and with stress 48%. Elevated pro-BNP (>4000) on
admission, as well as vascular congestion on CXR and lower
extremity edema raised concern for acute exacerbation of CHF.
Troponin elevated from baseline (0.11 from 0.05), likely
secondary to myocardial strain, on top of worsening renal
function. CK was low and MB flat, decreasing likelihood of acute
MI. No new ischemic changes on EKG (old RBBB, LAFB and inferior
Q's). TTE showed EF 45%, with mild global and regional
hypokinesis, mild AS/MR/AR, and moderate PA systolic
hypertension. Of note, patient is only on statin, and no other
HF medications. No evidence of pneumonia on CXR, no evidence of
DVT on ___ (decreasing concern for PE). Patient was started on
aspirin 81 mg PO daily, and instructed to continue statin. He
will follow up with PCP one week after discharge, at which point
other HF medications (diuretic, beta blocker, ACEi) may be
considered. ___ also consider referral to Cardiology.
.
# Lower extremity edema: Chronic problem, although worsened
subacutely over the past several months. Right leg slightly
larger than left, which is baseline. No calf TTP or erythema.
LLE U/S showed no DVT.
.
.
CHRONIC ISSUES:
# Anemia: Stable and within baseline. Iron studies showed mild
deficiency. Folate and B12 WNL.
.
# Sleep apnea: Continued CPAP
.
# Hyperlipidemia: Continued statin..
.
# Gout: Continued allopurinol.
.
.
TRANSITIONAL ISSUES:
# New onset of symptomatic CHF, may consider diuretic, beta
blocker, ACEi
# Course of daily (vs. 5x/week) hydroxyurea to be determined by
Dr. ___
# Code: full (confirmed with patient)
Medications on Admission:
Meds as listed in OMR but also reviewed with patient upon
arrival to the floor
allopurinol ___ mg Tablet Tablet(s) by mouth once a day
atorvastatin [Lipitor] 20 mg Tablet Tablet(s) by mouth
betamethasone dipropionate 0.05 % Lotion apply to scalp nightly
as needed for
finasteride 5 mg Tablet Tablet(s) by mouth once a day
hydroxyurea [Hydrea] 500 mg Capsule 1 (One) Capsule(s) by mouth
once a day ___ Hold drug on ___ and ___. (Dose
adjustment - no new Rx) levothyroxine 100 mcg Tablet
omeprazole 20 mg Capsule, Delayed Release(E.C.) 1 Capsule(s) by
mouth twice a
zolpidem 10 mg Tablet 1 Tablet(s) by mouth once a day
___
* OTCs *
calcium
Dosage uncertain
(Prescribed by Other Provider) ___
chondroitin sulfate A [Chondroitin Sulfate]
ginseng
multivitamin Tablet 1 (One) Tablet(s) by mouth once a day
(Prescribed by
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*0*
3. allopurinol ___ mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
4. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. betamethasone dipropionate 0.05 % Lotion Sig: One (1)
application Topical at bedtime.
6. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. zolpidem 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. calcium Oral
11. chondroitin sulfate A Oral
12. ginseng Oral
13. multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Myeloproliferative disorder
.
Secondary diagnosis:
Congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to participate in your care here at ___
___! You were admitted because you
had high blood counts, and there was concern for elevated
potassium on your labs. On repeat labs, your potassium level
was noted to be normal. We think that it had been falsely
elevated initially because your blood counts were high. Your
blood counts were high because you ran out of your hydroxyurea.
We restarted this for you in the hospital.
You mentioned that you had been experiencing more shortness of
breath prior to admission. Our labs showed that your heart is
under increased stress, with some evidence of fluid back-up and
congestive heart disease on your chest x-ray. While you were in
the hospital, you had an Echocardiogram (an ultrasound of your
heart), which showed that your heart function was about stable
from where it was in the past. We recommend that you discuss
your symptoms with Dr. ___ may start some new
medications for you, and refer your to a cardiologist for
follow-up. We would like you to start taking a baby aspirin (81
mg, enteric-coated) every day for your heart health. It will be
important for you to continue your atorvastatin as well.
Please note, the following changes have been made to your
medications:
1.) RE-START hydroxyurea 500 mg by mouth daily
2.) START aspirin (enteric-coated) 81 mg by mouth daily
Please continue to take all of your other medications as you had
prior to authorization.
It will be important for you to follow up with your doctors at
the ___ listed below.
Wishing you all the best!
Followup Instructions:
___
|
10294324-DS-16 | 10,294,324 | 23,632,242 | DS | 16 | 2149-10-28 00:00:00 | 2149-10-28 16:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ hx of interstitial cystitis, chronic pain on
nortryptiline presents after a seizure. She had a witnessed GTC~
30s during a spinning class. Postictal for brief period
A&Ox2->A&Ox4.
She had been taking sertraline for depression, but she stopped
sertraline three weeks ago because she ran out of the
medication. She has chronic, severe bladder pain from
biopsy-diagnosed interstitial cystitis. Pain management has
apparently been a significant issue and she has been on TCAs and
Gabapentin in the past. In ___, switched amitryptyline to
nortryptiline. Dose was quite high, ___ pills of 75 mg. She also
apparently takes large doses of keppra for this bladder pain (2g
at night, 1g in AM).
She has been in her USOH though does report intermittent, sharp
retrobulbar pain for two days prior to admission. No history of
similar headaches. Denies fevers/chills/dysuria/diarrhea. She
denies any intentional ingestions and any SI.
In the ED, exam not consistent with any toxidrome. Serum tox +
for TCAs, which is apparently rarely positive in people taking
this medication at normally-prescribed doses. EKG with RBBB,
unclear if new or old. Intervals: PR 150 QRS 120 QTc 418.
Had a VBG with a PC02 of 58. For an infectious workup she had
blood cultures sent, a negative UA. For workup up first seziure,
she had a negative CT head.
Toxicology recommended treatment as TCA overdose given findings
on EKG, serum tox. She was started on gtt of 1 amp bicarb in 1 L
D5W at 250/hr and serial EKGs were trended, which were notable
for a prolonging PR interval, persistent RBBB.
Past Medical History:
Depression
Interstitial Cystitis
Social History:
___
Family History:
Brother w/ ___ ___ sz hx, unclear etiology. No family or personal
history of heart disease
Physical Exam:
ADMISSION PE:
Vitals- Afebrile 55 109/60 100% RA.
GENERAL: Appears well. AOx3. CN2-12 intact. Strength in arms and
legs grossly normal, no pronator drift.
NECK: supple, JVP not elevated, no LAD
LUNGS: clear.
CV: regular, no murmurs.
ABD: soft.
EXT: warm.
DISCHARGE PE:
Unchanged
Pertinent Results:
ADMISSION LABS:
___ 05:20PM BLOOD WBC-6.0 RBC-3.93* Hgb-12.0 Hct-37.0
MCV-94 MCH-30.6 MCHC-32.5 RDW-13.3 Plt ___
___ 05:20PM BLOOD Neuts-71.5* ___ Monos-5.9 Eos-1.7
Baso-0.3
___ 05:20PM BLOOD ___ PTT-35.0 ___
___ 05:20PM BLOOD Glucose-75 UreaN-5* Creat-0.7 Na-140
K-4.1 Cl-102 HCO3-26 AnGap-16
___ 05:20PM BLOOD ALT-27 AST-36 AlkPhos-87 TotBili-0.2
___ 05:20PM BLOOD Lipase-16
___ 03:08AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.2
___ 05:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
___ 05:17PM BLOOD Lactate-0.5
DISCHARGE LABS:
___ 03:08AM BLOOD Glucose-88 UreaN-5* Creat-0.6 Na-142
K-3.4 Cl-99 HCO3-35* AnGap-11
___ 03:08AM BLOOD CK(CPK)-112
___ 03:08AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.2
___ 02:08AM BLOOD ___ pO2-26* pCO2-64* pH-7.39
calTCO2-40* Base XS-9 Intubat-NOT INTUBA
MICRO:
Blood Cx pending
STUDIES/IMAIGING:
CT-head ___: No acute intracranial hemorrhage or mass
effect.
EKG: NSR, RBBB, QRS 120ms
Brief Hospital Course:
___ with history of chronic pain from interstitial cystitis on
keppra and nortryptyline presents with first seizure.
#Seizure: Pt had witnessed seizure-like episode while at ___
class on ___. GTC per report, but lactate was normal on
arrival. No structural lesion seen on CT. Pt is on high doses
of keppra and TCA for chronic pain. Pt seems unsure of her
medication regiment and is not taking keppra as perscribed (she
reports taking 2g QHS whereas her perscription is for 1g QAM and
2g QPM). Thus keppra withdrawal is a possible etiology. TCAs
can also decrease the seizure threshold. Pt's Keppra dosing was
changed to 1g BID and her TCA was discontinued. Pt will need to
f/u with her PCP and see ___ neurologist this week. She was given
the number for ___ to schedule these appointments.
Pt will also need to see her pain doctor to have her pain
medications adjusted.
#TCA Toxicity: Pt was noted to have RBBB (QRS 120ms) on EKG
suggesting TCA toxicity. TCA overdose can also decrease the
seizure threshold. Pt was given fluids with bicarb overnight
per the toxicology team. Her EKG did not change during this
time suggesting that pt did not have TCA toxicity.
Nortriptyline was discontinued on discharge.
TRANSITIONAL ISSUES:
Pt will need to follow up with her PCP and with ___ neurologist
this week. Given that the ___ office was closed,
she was given their number to schedule these appointments
herself. She also needs to follow up with her pain specialist
to adjust her pain medications.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. alfuzosin 10 mg oral qd
2. trospium 20 mg oral daily
3. Nortriptyline 225-300 mg PO QHS
4. LeVETiracetam ___ mg PO QHS
5. LeVETiracetam 1000 mg PO QAM (pt states she is not taking
this dose)
6. Oxybutynin 10 mg PO DAILY
Discharge Medications:
1. LeVETiracetam 1000 mg PO BID
2. alfuzosin 10 mg oral qd
3. Oxybutynin 10 mg PO DAILY
4. trospium 20 mg oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
We believe that you may have had a seizure which may have been
due to withdrawal from Keppra, one of the medications you are
taking for your chronic pain. We have decreased your Keppra
dose to 1000 mg twice a day. We also have stopped your
nortriptyline as it can cause seizures as well. It is very
important that you see your primary care doctor and ___
neurologist this week. Please call ___ to make
these appointments. You should also follow up with your pain
doctor.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10294457-DS-11 | 10,294,457 | 25,052,646 | DS | 11 | 2141-05-12 00:00:00 | 2141-05-13 11:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
codeine / oxycodone / tramadol / Lipitor
Attending: ___.
Chief Complaint:
liver abscess + Klebisella-positive bacteremia
Major Surgical or Invasive Procedure:
___: ___ F R hepatic abscess drain
.
___: Right SL 48cm PICC line has been placed with its tip in
the
proximal SVC per Dr. ___
___ of Present Illness:
___ female w hx of liver cancer sp xrt, s/p embolization on
___
to attempt to downstage the tumor for future surgical
planning. Post procedure, patient continued to have pain
extending throughout the abdomen and into her back. She was
admitted for pain control, and underwent CT A/P which showed
post-embolization changes.
The patient was discharged from transplant service on ___,
She presented to OSH w fatigue, poor po intake and back pain
that
never got better since last discharge as she describes. At OSH
she was found to have elevated WBC 16.6, Na 133, lactate 3.6.
Given pt complicated history she was transferred to ___ for
further evaluation and management. At ___ ED, ___ was 16.5 w
left shift, BP 95/65, HR90, lactate went down to 1.4 without
anion gap.
She does complain of fatigue, she states that she used to walk
with a walker , but she feels that she doest not have the energy
to walk for the past few days, fatigue. She also complain of
left
lower back pain. She stated that she had one episode of chills
yesterday lasted for 15 min. She denies, chest pain, shortness
of
breath, fevers, wt loss, change in bowel habits, N/V or
abdominal
pain.
Past Medical History:
- AV nodal re-entry tachycardia
- NSTEMI (___) s/p ___
- ___
- HLD
- HTN
- Hypothyroidism
- IBS
- Nephrolithiasis
.
Past Surgical History:
- Lumbar fusion
-bilateral ureteral stents
- Bilateral cataract extractions
- Bilateral ureteral stent placement (___)
Social History:
___
Family History:
Father: bladder cancer age ___
Paternal side: cousin with ovarian cancer in her ___
Cancers in the family: paternal uncle colon cancer ___
Physical Exam:
Vitals: T 98.6 BP 115/82 HR 91 RR 18 Sat 95% RA
GEN: A&Ox3, NAD, lying on her left side
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, normal S1/S2
PULM:CTAB
ABD: Soft, nondistended, appropriately tender near the liver, no
rebound or guarding, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Drains: Pigtail into liver abscess left in, 20mL dark blood
Pertinent Results:
Admission: ___
WBC-14.3* RBC-3.76* Hgb-10.2* Hct-31.0* MCV-82 MCH-27.1
MCHC-32.9 RDW-17.0* RDWSD-50.8* Plt ___ PTT-24.8* ___
Glucose-120* UreaN-19 Creat-0.6 Na-137 K-4.5 Cl-101 HCO3-20*
AnGap-16
ALT-111* AST-112* AlkPhos-194* TotBili-0.5
Lactate-1.4
.
Discharge: ___
WBC-10.4* RBC-3.91 Hgb-10.5* Hct-32.1* MCV-82 MCH-26.9 MCHC-32.7
RDW-17.6* RDWSD-51.0* Plt ___
Glucose-132* UreaN-10 Creat-0.6 Na-136 K-5.1 Cl-99 HCO3-24
AnGap-13
ALT-61* AST-43* AlkPhos-184* TotBili-0.6
Calcium-8.9 Phos-2.8 Mg-1.9
.
Blood Culture, Routine (Final ___:
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 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
Brief Hospital Course:
Ms. ___ is a ___ female with a history of biopsy
proven poorly differentiated cholangiocarcinoma which was
initially
discovered in ___ on chest CT. She underwent Y90 arterial
mapping on ___ and underwent Y90 treatment on ___. Her
post-procedural course was complicated by prolonged
hospitalization after the procedure and hospital admission
(___).
Her CTAP demonstrates a 5x3 cm area of mixed
collection and gas in the right lobe of the liver, which is new
in comparison to prior study. Given her symptoms of sepsis, this
collection and gas was determined to be an abscess that was
drained by ___
on ___ and a ___ pigtail drain was placed, draining ~22 ccs
of old blood. Cultures of the drain were negative. After the
procedure, she spiked a fever of 102.9, WBC 14.3 and had rigors;
workup was notable for a BC that was positive for Klebsiella in
___ bottles. Treated with vanc/zosyn before knowing
sensitivities with resolution of her fevers and high WBC. After
speciation showed sensitivities, she was switched from zosyn
(___) to Ceftriaxone/Flagyl (___-) as per ID team. Blood cx
from a short episode of rigors on ___ showed no growth. PICC
was placed on ___ and pt ready for discharge with a planned 4
week course of antibiotics and JP drain in place.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
2. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q ___ HOURS
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Levothyroxine Sodium 25 mcg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Metoprolol Succinate XL 12.5 mg PO QHS
7. Nitroglycerin SL 0.3 mg SL ASDIR chest pain
8. Ondansetron ___ mg PO Q8H:PRN nausea
9. Pantoprazole 40 mg PO Q24H
10. Simvastatin 10 mg PO QPM
11. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
12. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
13. Aspirin 81 mg PO DAILY
Discharge Medications:
1. CefTRIAXone 2 gm IV Q 24H Klebsiella + blood cx
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams IV daily
Disp #*14 Dose Pack Refills:*1
2. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth Three
times a day Disp #*42 Tablet Refills:*1
3. Aspirin 81 mg PO DAILY
4. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
5. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q ___ HOURS
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Levothyroxine Sodium 25 mcg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Metoprolol Succinate XL 12.5 mg PO QHS
10. Nitroglycerin SL 0.3 mg SL ASDIR chest pain
11. Ondansetron ___ mg PO Q8H:PRN nausea
12. Pantoprazole 40 mg PO Q24H
13. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
14. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
15. HELD- Simvastatin 10 mg PO QPM This medication was held. Do
not restart Simvastatin until advised by Dr. ___ it is safe
to restart
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
liver abscess
gram negative bacteremia
s/p Y 90 ___
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:
___ arranged
.
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, worsening yellowing of the
skin or eyes, itching, inability to tolerate food, fluids or
medications, or any other concerning symptoms.
.
No lifting more than 10 pounds
.
No driving if taking narcotic pain medication
.
Drain and record the pigtail abscess drain output twice daily
and as needed so that the drain is never more than ½ full. Call
the office if the drain output increases by more than 50 cc from
the previous day, becomes bloody or develops a foul odor.
.
Change the drain dressing once daily or after your shower. Do
not allow the drain to hang freely at any time. Inspect the site
for redness, drainage or bleeding. Make sure there is a stitch
at the drain site and the stat lock in place.
.
Continue IV antibiotics as directed once a day using the PICC
line. The visiting nurse ___ change the dressing.
PICC line care per protocol
Followup Instructions:
___
|
10294457-DS-12 | 10,294,457 | 21,358,819 | DS | 12 | 2141-06-12 00:00:00 | 2141-06-13 20:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / oxycodone / tramadol / Lipitor
Attending: ___.
Chief Complaint:
Diaphoresis, tachycardia
Major Surgical or Invasive Procedure:
Past Surgical History:
- JP drain placed ___
- Lumbar fusion
- Bilateral cataract extractions
- Bilateral ureteral stent placement (___)
History of Present Illness:
Ms. ___ is a ___ with PMH significant for locally advanced
cholangiocarcinoma s/p Y90 ___ c/b post-embolization
syndrome and liver abscess, AV nodal reentrant tachycardia,
NSTEMI status post DES, insulin-dependent diabetes,
hypertension, hyperlipidemia presented to the ED from liver
clinic with tachycardia, diaphoresis, c/f worsening infection.
Patient was recently hospitalized from ___ - ___ on the
transplant surgery team. During that hospitalization, she was
diagnosed with liver abscess and followed by OPAD. The patient
has a JP drain in place for the liver abscess, and she has been
getting IV ceftriaxone at home for the liver abscess. Over the
last 2 days, the drainage has been darker with less volume. On
evaluation in the outpatient office, the drain site is with
trace yellow drainage, no obvious collection. Mildly TTP (not
worse).
Of note, the patient was complaining of dysuria, so her PCP
gave her ___ Rx a few days ago. Dysuria improved, although
she still reports urinating ___ daily.
On ___, she stopped metoprolol given concern it was making
fatigue and dizziness worse. HR at home has been 110-120. At
home she is effectively in bed almost all day, able to walk to
bathroom but anything else leads to her being sweaty, tired,
SOB. Reports no acute pain.
Past Medical History:
- AV nodal re-entry tachycardia
- NSTEMI (___) s/p ___
- ___
- HLD
- HTN
- Hypothyroidism
- IBS
- Nephrolithiasis
.
Past Surgical History:
- Lumbar fusion
-bilateral ureteral stents
- Bilateral cataract extractions
- Bilateral ureteral stent placement (___)
Social History:
___
Family History:
Father: bladder cancer age ___
Paternal side: cousin with ovarian cancer in her ___
Cancers in the family: paternal uncle colon cancer ___
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VITALS: T98.2 | 163 | 97/69 | 25 | 100% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear with dry mucus
membranes
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, tender to palpation in RUQ, 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 jaundice
NEURO: AOX3, moves all extremities spontaneously
DISCHARGE PHYSICAL EXAM
========================
PHYSICAL EXAM:
Temp: 97.8 PO BP: 136/85 HR: 80 RR: 16 O2 sat: 97% O2 delivery:
Ra FSBG: 150
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: normal rate, irregularly irregular, normal S1 + S2, ___
systolic murmur, no rubs/gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Previous
midline
abdominal drain site non tender to palpation and no bleeding or
leakage.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, PICC c/d/I in R arm
Skin: No jaundice or rashes. Skin dry
Neuro: AxOx3, grossly normal
Pertinent Results:
ADMISSION LABS
===============
___ 12:00PM BLOOD WBC-13.1* RBC-3.97 Hgb-10.4* Hct-32.7*
MCV-82 MCH-26.2 MCHC-31.8* RDW-19.1* RDWSD-53.1* Plt ___
___ 12:00PM BLOOD Neuts-73.2* Lymphs-8.3* Monos-8.4 Eos-5.9
Baso-0.7 NRBC-0.2* Im ___ AbsNeut-9.57* AbsLymp-1.09*
AbsMono-1.10* AbsEos-0.77* AbsBaso-0.09*
___ 12:00PM BLOOD ___ PTT-24.7* ___
___ 12:00PM BLOOD Plt ___
___ 12:00PM BLOOD Glucose-128* UreaN-17 Creat-0.7 Na-135
K-5.5* Cl-91* HCO3-24 AnGap-20*
___ 12:00PM BLOOD ALT-37 AST-39 AlkPhos-208* TotBili-0.5
___ 12:00PM BLOOD proBNP-9828*
___ 12:00PM BLOOD Albumin-3.1* Calcium-9.0 Phos-3.9 Mg-1.2*
___ 12:09PM BLOOD Lactate-4.4*
DISCHARGE LABS
===============
___ 06:13AM BLOOD WBC-8.6 RBC-3.64* Hgb-9.3* Hct-29.4*
MCV-81* MCH-25.5* MCHC-31.6* RDW-19.8* RDWSD-55.8* Plt ___
___ 06:13AM BLOOD ___ PTT-29.3 ___
IMAGING
=======
___ CXR
No acute cardiopulmonary process. Right PICC tip projects over
the mid SVC.
___ CT A/P
1. Since ___, a pigtail catheter is present within the
right hepatic
lobe in the area of a previously suspected abscess. Residual
hypodensity in
this region is present however it is unclear whether this
represents residual
collection or intrahepatic metastatic disease. Multiple
additional hepatic
hypodensities are new/increased since prior concerning for
worsening disease
burden.
2. Gastric wall thickening, unchanged.
3. Colonic diverticulosis.
4. Lymphadenopathy within the porta hepatis and slight
enlargement of
retroperitoneal lymphadenopathy.
___ CT CHEST
1. No interval change in diffuse bilateral pulmonary nodules,
compatible with pulmonary metastases.
2. Apparent filling defect within the distal SVC may reflect
thrombus.
3. Please refer to the separately dictated report of the
abdomen and pelvis for the abdominopelvic findings.
___ UNILAT UP EXT VEINS US RIGHT
1. Small focus of echogenic material in the distal axillary vein
adjacent to the PICC line, compatible with nonocclusive thrombus
which is likely chronic.
2. No evidence of additional deep vein thrombosis in the right
upper
extremity.
___ FLOUROSCOPY - DRAIN REMOVAL
1. Collapse of previously seen abscess cavity in the right
hepatic lobe.
2. Removal of the percutaneous drain which terminated in this
now collapsed
collection.
MICROBIOLOGY
=============
Blood Cultures ___ X2, ___ X1) - negative
Urine Culture (___) - negative
Bile Culture
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Brief Hospital Course:
Ms. ___ is a ___ with PMH significant for locally advanced
cholangiocarcinoma s/p Y90 ___ c/b post-embolization
syndrome and liver abscess, AV nodal reentrant tachycardia,
NSTEMI status post DES, insulin-dependent diabetes,
hypertension, hyperlipidemia presented to the ED from liver
clinic with tachycardia, hypotension and diaphoresis, c/f
worsening infection. However, the patient denied having any
fevers, chills, emesis, or unexplained weight loss. Patient was
recently hospitalized from ___ - ___ on the transplant
surgery team. During that hospitalization, she was diagnosed
with liver abscess and followed by OPAD. The patient had a JP
drain in place for the liver abscess, and she has been getting
IV ceftriaxone (planned 4 week course) at home for the liver
abscess. On ___, she stopped metoprolol given concern it was
making fatigue and dizziness worse. She presented with shock
thought to be from atrial fibrillation with RVR.
=
=
=
================================================================
Active Issues
=
=
=
================================================================
#Hypotension
#Shock
She was admitted to the MICU for hypotension requiring
vasopressors. Ultimately her shock was thought to be secondary
to atrial fibrillation with RVR after stopping her home beta
blocker. It was also thought that she could have septic shock
(leukocytosis with left shift, change in biliary drain output,
though CT Ab/P without obvious new abscess). She was started on
broad spectrum antibiotics with vanc/zosyn for infection with
her known liver abscess being the most likely source. Blood,
urine, and biliary drain cultures were all sent and were
negative. She was also started on metoprolol tartrate Q6H that
was uptitrated slowly. Her blood pressures improved with the
metoprolol. A TTE was ordered to assess her cardiac function, EF
58% and suggestion of elevated pulmonary diastolic pressure but
otherwise normal. She was able to be weaned off of pressors and
was called out to the floor. On the floor, ABx was de-escalated
to ceftriaxone/flagyl, pressures remained stable. She was
discharged with augmentin as below.
#Liver abscess:
Admitted ___ for abscess and klebsiella bacteremia. Abscess
was drained on ___. A PICC was placed on ___ and pt
was started on 4 weeks flagyl and CTX. Flagyl was d/c'ed ___.
Per patient, drain output decreased in the last few days and the
drain output changed from clear to tea colored. Patient admitted
on home
CTX. ABx initially escalated to vanc/zosyn in MICU due to
concern for sepsis shock, as above, and then de-escalated back
to ceftriaxone/flagyl once patient was hemodynamically stable
and well appearing upon transfer to general wards. Inpatient ID
was consulted prior to discharge and recommended discharge on
augmentin PO 875 mg BID X14 days. JP drain was removed by ___ on
___.
#Paroxysmal Atrial Fibrillation with RVR:
Patient has known history of AVNRT, but was noted to be in afib
upon transfer to the MICU. She was monitored on telemetry which
remained unremarkable. CHA2DSVASc- 6 (HTN, Age, DM, vascular
disease, female).
Outpatient oncologist, Dr. ___, was contacted who recommended
apixaban for AC (10mg BID X5 days followed by 5mg BID). She was
effectively rate-controlled with a higher dose of metoprolol and
flipped back into normal sinus rhythm prior to discharge.
#Concern for SVC thrombus
CT chest with suggestion of filling defect, concerning for
distal SVC thrombus, which may be PICC related. Upper extremity
U/S found right axillary vein to likely have nonocclusive
thrombus adjacent to PICC line but no evidence of DVT. She was
started on apixiban as above for AF as well.
#Dysuria
#Urinary frequency
PCP gave her ___ prescription for Augmentin the other day. She
took the abx x 1 day. Ucx negative, though she was treated with
multiple antibiotics for the abscess. She had no urinary
complaints during admission.
#Right ear pain:
Patient endorsed several days of R ear pain andthroat pain. No
evidence of throat erythema on exam. Likely viral. Patient
encouraged to follow-up with PCP.
#Failure to thrive/Deconditioning:
Per chart review, patient hashad several months of decreased
activity and spends most of her days in bed. ___ were consulted
who recommended home discharge with outpatient ___ follow-up.
During admission, she was encouraged to walk as much as she
could tolerate, limited by DOE. Of note, she mentioned having
lightheadedness when sitting upright on a hard chair, though did
not have any similar symptoms when walking or lying down -
etiology unclear.
=
=
=
================================================================
Chronic Issues
=
=
=
================================================================
#Intrahepatic Cholangiocarcinoma
Underwent embolization on ___. She has developed a few lung
nodules that are suspicious for metastatic disease, but per her
hepatologist, the nodules may be too small to biopsy. There is
also a satellite lesion in the right lobe of the liver around
the embolized area. She follows with Drs ___ and
___ (Heme/Onc)
#Lung nodules: CTA ___ showed evidence of bilateral pulmonary
nodules that are new or increased compared to prior study done
in ___. Per hepatology note, these nodules are thought to be
suspicious for metastatic disease, but are too small to biopsy.
#Type 2 diabetes
Home metformin was held and she was placed on ISS, metformin
restarted at discharge.
#Nephrolithiasis
Patient with bilateral stents in place. Patient follows with Dr.
___ at ___. No complaints or indications of active issue
during admission.
#Normocytic anemia.
Most likely reflective of anemia of chronic disease, no
intervention was indicated.
#Glaucoma
Continued home medications (Dorzolamide 2% Ophth. Soln.; Timolol
Maleate 0.25% 1 DROP BOTH EYES BID; Latanoprost 0.005% Ophth.
Soln. 1 DROP BOTH EYES QHS
#NSTEMI s/p DES (___)
#CAD
Continued home aspirin. Held simvastatin- per patient, she was
told by her doctor to stop taking medication but cannot recall
the reason.
#Insomnia: continued zolpidem
=
=
=
================================================================
Transitional Issues
=
=
=
================================================================
[] New diagnosis: paroxysmal AF. Increased her metoprolol and
started on apixiban
[[ Upper extremity PICC associated DVT: started on apixiban
[] Abscess: appears to be improving on CT. JP drain pulled on
___ with ___. Will complete a course of augmentin on ___.
[] Lung nodules found on ___ CT thought to be indicative of
metastatic disease though too small to biopsy. Please follow-up
with oncologist.
[] Follow up with Dr. ___, ___
[] Follow up with Dr. ___ disease, on ___
[] Follow up with liver tumor surgery on ___
NEW MEDICINES: apixiban 10 BID until ___ then apixiban 5 BID.
Augmentin until ___.
STOPPED MEDICINES: flagyl, ceftriaxone
CHANGED MEDICINES: metoprolol succinate 12.5 to 100
# CODE: Full code
# CONTACT: ___ (Husband)
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
2. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
3. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
4. Pantoprazole 40 mg PO Q24H
5. Metoprolol Succinate XL 12.5 mg PO QHS
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q ___ HOURS
9. CefTRIAXone 2 gm IV Q 24H Klebsiella + blood cx
10. MetroNIDAZOLE 500 mg PO TID
11. Aspirin 81 mg PO DAILY
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Nitroglycerin SL 0.3 mg SL ASDIR chest pain
14. Ondansetron ___ mg PO Q8H:PRN nausea
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 14 Days
Take this medication for a total course of 14 days until ___.
Began in hospital on ___.
2. Apixaban 10 mg PO BID Duration: 2 Days
Please take this medication through ___.
3. Apixaban 5 mg PO BID
Please start on ___ after completing your course of 10mg
twice a day.
4. Aspirin 81 mg PO DAILY
5. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
6. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q ___ HOURS
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Levothyroxine Sodium 25 mcg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Metoprolol Succinate XL 12.5 mg PO QHS
11. Nitroglycerin SL 0.3 mg SL ASDIR chest pain
12. Ondansetron ___ mg PO Q8H:PRN nausea
13. Pantoprazole 40 mg PO Q24H
14. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
15. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
#Hypotension
SECONDARY DIAGNOSES
===================
#Intrahepatic Cholangiocarcinoma
#Liver abscess
#Lung nodules
#Atrial Fibrillation with rapid ventricular rate
#SVC thrombus
#Failure to thrive/Deconditioning
#Type 2 diabetes
#Nephrolithiasis
#Normocytic anemia
#Glaucoma
#Coronary Artery Disase status post NSTEMI
#Insomnia
#Right Otalgia
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 part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted because you had low blood pressure and
elevated heart rate requiring medical management
What was done for me while I was in the hospital?
- You were initially admitted to the ICU in order to manage your
low blood pressure
- You were found to have an arrhythmia for which we began you on
anticoagulation with apixaban as suggested by your oncologist,
Dr. ___
___ should I do when I leave the hospital?
- You will take the apixaban 10mg twice a day until ___. Then
beginning on ___ you will take 5mg of apixaban twice a day.
- Please take the antibiotic, Augmentin 875mg twice a day, until
___.
- Please follow up with Dr. ___ disease, in
regards to your antibiotic management
Followup Instructions:
___
|
10295447-DS-28 | 10,295,447 | 26,971,226 | DS | 28 | 2137-10-03 00:00:00 | 2137-10-04 13:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Lomotil / Flagyl
/ Morphine / Loperamide / cefepime / Labetalol / Cephalosporins
/ amlodipine / Milk Containing Products
Attending: ___
Chief Complaint:
Elevated creatinine
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ s/p kidney tx ___ and pancreas tx ___
___omplicated by EBV bacteremia, chronic diarrhea,
chronic allograft nephropathy (baseline ___ over last year)
who presents for further evaluation of increasing cr to 4.7 and
hyponatremia on outpatient labs drawn yesterday. She has overall
feeling well over the last several weeks. She continues to have
baseline loose stool which borders on diarrhea some days. She
does note stool was slightly more loose than normal last week
but had begun to normalize over last 2 days. She has not
experienced any abdominal pain, melena, brbpr, or n/v. She does
continue to feel fatigued but not anymore so compared to prior
presentations earlier this year. She feels cold a lot but doent
experience any fevers or chills. She mostly notices weakness
when she is tasked with doing exercises such as lifting her
arms. However, she is able to continue to exercise several times
per week. Estimates she has lost 6 pounds since start of ___.
Her urine output has been at baseline recently. She has not
experienced any pain over graft, dysuria, or hematuria. She has
been taking all of her immunosuppresive agents as directed.
Moreover, she has not experienced any chest pain, dyspnea,
lightheadedness, or dizziness.
In the ED, vitals were 98.6 58 129/39 18 99%. Labs were notable
for hgb 9.4, Chem 7 with cr 4.8, Na 126, bicarb 15. UA wnl. A
renal graft ultrasound showed no hydronephrosis. Patent main
renal artery and vein.
On arrival to the floor, she is feeling well and is in good
spirits. She has no additional concerns this evening.
Review of Systems:
(+) per HPI
(-) fever, night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
DM (DIABETES MELLITUS), TYPE 1
RENAL FAILURE, CHRONIC ___
HYPOTHYROIDISM
HYPERTENSION, ESSENTIAL, BENIGN
HISTORY OF KIDNEY TRANSPLANT
HISTORY OF PANCREAS TRANSPLANT
ALLERGIC RHINITIS
RENAL OSTEODYSTROPHY
MENOPAUSE
GERD (GASTROESOPHAGEAL REFLUX DISEASE)
DVT (DEEP VENOUS THROMBOSIS) ___
*
Past Surgical History:
TRANSPLANT - KIDNEY
TRANSPLANT ALLOGRAFT PANCREAS
CATARACT EXTRACAPS EXTRACT
Social History:
___
Family History:
No history of kidney or pancreatic failure
Physical Exam:
ON ADMISSION:
Vitals - T:97.5 BP: 170/48 HR:83 RR:20 02 sat:94%
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: transplanted kidney in LLQ, non-tender, reducible
hernia and surgical scar, nondistended, +BS, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
ON DISCHARGE:
Vitals - T:98 BP: 147/60 HR:83 RR:20 02 sat:94% RA
GENERAL: Very pleasant, lying in bed in NAD, conversational
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, no gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Transplanted kidney in LLQ, non-tender, reducible
hernia and surgical scar, nondistended, +BS, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly. Mobile
fibrotic tissue noted in LLQ, which patient states is chronic.
EXTREMITIES: Moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, AxO x3
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ON ADMISSION:
___ 06:40PM BLOOD WBC-4.4 RBC-3.42* Hgb-9.6* Hct-31.7*
MCV-93 MCH-28.1 MCHC-30.3* RDW-13.8 Plt ___
___ 06:40PM BLOOD Neuts-52.4 ___ Monos-12.7*
Eos-6.8* Baso-0.5
___ 07:45AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 06:40PM BLOOD Glucose-110* UreaN-105* Creat-4.8*
Na-126* K-3.7 Cl-95* HCO3-15* AnGap-20
___ 06:40PM BLOOD ALT-17 AST-22 LD(LDH)-192 AlkPhos-152*
TotBili-0.2
PERTINENT INTERVAL:
___ 04:25PM BLOOD ___ 07:45AM BLOOD Ret Aut-1.6
___ 07:45AM BLOOD Hapto-109
___ 07:45AM BLOOD PEP-PND
___ 07:45AM BLOOD tacroFK-2.6* rapmycn-4.6*
___ 04:25PM BLOOD BK VIRUS BY PCR, BLOOD-PND
___ 07:45AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-PND
ON DISCHARGE:
___ 07:45AM BLOOD WBC-4.2 RBC-2.94* Hgb-8.4* Hct-26.5*
MCV-90 MCH-28.7 MCHC-31.8 RDW-13.8 Plt ___
___ 07:45AM BLOOD Glucose-374* UreaN-90* Creat-3.8* Na-141
K-2.8* Cl-99 HCO3-29 AnGap-16
___ 04:25PM BLOOD Glucose-92 UreaN-80* Creat-3.7* Na-131*
K-3.8 Cl-102 HCO3-18* AnGap-15
___ 04:25PM BLOOD Calcium-8.7 Phos-3.0 Mg-1.5*
IMAGING:
RUQ US ___
A transplanted kidney is identified in the left lower quadrant
of the abdomen measuring 10.5 cm in length with normal
corticomedullary architecture. No evidence of a mass lesion or
hydronephrosis.
Doppler assessment of the transplanted kidney reveals patent
main renal artery and vein with appropriate waveforms.
Intraparenchymal arterial resistive indices range from 0.7-0.86,
previously 0.79-0.81.
IMPRESSION:
1. Normal appearance of the transplanted kidney.
2. Resistive indices are not significantly changed compared to
the prior
study.
CXR PA/LA
IMPRESSION:
Linear opacity in left lower lung zone was worse ___ year ago, and
could
represent sequela of prior infection, recrudencense of
infection, or
atelectasis.
Brief Hospital Course:
Ms. ___ is a ___ s/p kidney transplant in ___ and
pancreas transplant in ___ ___omplicated by EBV
viremia, chronic diarrhea, chronic allograft nephropathy
(baseline ___ over last year) who presents for further
evaluation of increasing creatinine to 4.7 and hyponatremia.
# Acute on chronic kidney failure: Patient has baseline chronic
allograft nephropathy but presented with acute rise in creatine.
In the week leading up to her presentation she had increase in
her stool output without increase in her solute intake. Her
creatinine improved with IVF, suggesting a pre-renal etiology.
She has no evidence of acute rejection on imaging. There was no
evidence of medication toxicity with slightly subtherapeutic
tacrolimus and rapamycin levels. She is at higher risk for PTLD
with history of EBV viremia. It can often present indolently
following a transplant with extra nodal disease of GI tract and
pulmonary nodules most common. However, work up including bronch
this past ___ was unrevealing and LDH was WNL. EBV PCR was
initially sent. BK virus was also initially on the differential
initially and BK virus PCR is also pending on discharge. Given
her fatigue and anemia SPEP/UPEP were sent to evaluate for
multiple myeloma and are pending on discharge. There was very
low suspicion for glomerulonephritis given clean UA. Peripheral
smear did not reveal schistocytes to suggest TTP/HUS.
# Hyponatremia: Likely secondary to hypovolemic hyponatremia and
resolved with IVF.
# Anemia: Baseline Hct in the high ___, though in the mid ___
during her admission. Likely a combination of worsening renal
disease and some component of dilutional effect in-house. RDW
was not consistent with iron deficiency and she is on iron
supplementation at home. Hemolysis labs were negative. She was
continued on iron supplementation and is scheduled for
nephrology follow up for further management of CKD
# Hypothyroidism: Continued home Levothyroxine
# Hyperlipidemia: Continued home atorvastatin 40
# LVH: Continue home metoprolol
TRANSITIONAL ISSUES:
- Follow up on EBV PCR
- Follow up on BK virus PCR
- Follow up on SPEP/UPEP
- Repeat labs in 1 week, script provided
- Repeat Tacrolimus and Rapamycin levels in 1 week
- Goal Tacro level = ___
- Goal Rapamycin level = ___
- Lasix held on discharge given ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Creon 12 3 CAP PO TID W/MEALS
3. Atorvastatin 40 mg PO DAILY
4. Sirolimus 1 mg PO DAILY
5. Tacrolimus 1 mg PO QAM
6. Tacrolimus 0.5 mg PO QHS
7. Furosemide 40 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Calcitonin Salmon 200 UNIT NAS DAILY
10. Omeprazole 20 mg PO DAILY
11. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit oral daily
12. Aspirin 81 mg PO DAILY
13. Levothyroxine Sodium 88 mcg PO DAILY
14. Cyanocobalamin 1000 mcg PO DAILY
15. FoLIC Acid 1 mg PO DAILY
16. Calcitriol 0.5 mcg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Calcitonin Salmon 200 UNIT NAS DAILY
4. Calcitriol 0.5 mcg PO DAILY
5. Creon 12 3 CAP PO TID W/MEALS
6. Cyanocobalamin 1000 mcg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Sirolimus 1 mg PO DAILY
13. Tacrolimus 1 mg PO QAM
14. Tacrolimus 0.5 mg PO QHS
15. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit oral daily
16. Outpatient Lab Work
Obtain Chem10, CBC, Tacrolymus, and Rapamycin levels.
PLEASE FAX RESULTS TO ___. ___ ___: ___
___, MD ___: ___
Discharge Disposition:
Home
Discharge Diagnosis:
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 Ms. ___,
You were admitted with an elevated creatinine level. We
performed a workup to determine the cause of this elevation.
Fortunately, your creatinine improved just with fluids, which
suggests to us that you were quite dehydrated. This is most
likely due to your recent increase in loose stools. It will be
very important for you to not only stay well hydrated but also
to make sure you are eating well.
Please follow up on the appointments listed below.
It was a pleasure to be a part of your care!
Your ___ treatment team.
Followup Instructions:
___
|
10295715-DS-17 | 10,295,715 | 25,453,696 | DS | 17 | 2136-05-28 00:00:00 | 2136-05-29 14:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ACE Inhibitors / allopurinol / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / lactose
Attending: ___.
Chief Complaint:
Fever, Malaise
Major Surgical or Invasive Procedure:
-Hemodialysis ___
History of Present Illness:
Mr. ___ is a ___ year old gentleman with SLE, ESRD on HD (MWF),
and Multiple Myeloma (on bortezomib and steroids) presenting
with fever and malaise over the past five days. He states that
on ___, he felt that he was "slowing down". He felt
fatigued, and possibly feverish, but otherwise was experiencing
no symptoms. When he went to dialysis on ___, his nurse noted
that his temperature was mildly elevated. He tried Tylenol to
lower his fever, but otherwise continued to feel poorly, and
remained feverish. He states that his nurse noted his
temperature to be elevated on ___ as well. He laid down to
take a nap that same day and says he felt particularly sweaty
while under the blankets, but otherwise denied shaking chills or
night sweats. He states that on ___, he put on clothes to
go outside, but could not find the energy to leave the house,
and therefore stayed in bed all day. When he was at dialysis
___, his nurse noted his temperature to be elevated
again, and this prompted him to come to the ED in the context of
his progressive malaise. He has had no cough, chest pain, or
dyspnea, and he denies recent travel or known sick contacts. He
has had no flank pain.
Of note, he still makes urine and does report dysuria that
started two weeks ago, but has had no urgency or incontinence.
His dysuria has persisted to today. He has had no abdominal
pain, nausea/vomiting, or change in bowel movements.
He is currently on chemotherapy for his multiple myeloma. He is
followed by oncologist, ___.
Past Medical History:
-Multiple Myeloma (on bortezomib and steroids)
-SLE
-ESRD on HD (MWF)
-CAD s/p CABG in ___
-Type 2 DM
-CVA (___)
-HTN
-Anemia
-Gout
-Hypercholesterolemia
Social History:
___
Family History:
-Mother: Alive (age ___, blind in one eye
-Father: ___
-Daughter: Healthy (age ___
Physical Exam:
PHYSICAL EXAM ON ADMISSION
============================
Vitals- T 99.2, BP 130/77, HR 83, RR 18, 98 RA
GENERAL: AOx3, non-toxic, breathing comfortably and sitting
upright in bed. No acute distress.
HEENT: PERRL. EOMI. Mild scleral injection bilaterally. Moist
mucous membranes, with all teeth removed excluding 1, 16, 17,
32. Oropharynx is clear.
NECK: No cervical lymphadenopathy.
CARDIAC: RRR. S1, S2. ___ apical systolic murmur heard best at
apex, radiating to left axilla. Notable non-radiating systolic
murmur at upper sternal borders. No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
Resonant to percussion.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants. Dullness to percussion in
RLQ, otherwise tympanic. No organomegaly.
EXTREMITIES: Fistula in RUE without erythema or tenderness.
Fistula w/ thrill and bruit on auscultation. No clubbing,
cyanosis, or edema, no sign of atrophy/hypertrophy. Pulses
DP/Radial 2+ bilaterally.
SKIN: Multiple dry, pericuticular blisters, with swelling of ___
and ___ digits bilaterally. No erythema. No CVA tenderness.
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation. No ataxia, dysmetria, disdiadochokinesia.
DISCHARGE PHYSICAL EXAM
===============================
Vitals: Afebrile 100-120s/60-70s 60-70s ___ 97-100%RA
General: A&Ox3, non-toxic, in no acute distress.
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, unchanged apical systolic murmur
radiating to axilla. Unchanged R/L upper sternal border murmur,
non-radiating.
Abdomen: Soft, nontender, nondistended.
Ext: Warm, well-perfused with no ___ edema.
Neuro: CNs ___ intact, full strength throughout.
Pertinent Results:
LABS ON ADMISSION
=====================
___ 04:10PM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 04:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.5*
LEUK-LG
___ 04:10PM URINE RBC-17* WBC->182* BACTERIA-NONE
YEAST-NONE EPI-0
___ 04:10PM URINE WBCCLUMP-MANY
___ 05:24AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 04:41AM LACTATE-1.3
___ 04:30AM estGFR-Using this
___ 04:30AM ALT(SGPT)-24 AST(SGOT)-37 LD(LDH)-304* ALK
PHOS-133* TOT BILI-0.3
___ 04:30AM ALBUMIN-3.5
___ 04:30AM TSH-0.91
___ 04:30AM WBC-12.6* RBC-3.38* HGB-10.2* HCT-30.4*
MCV-90 MCH-30.2 MCHC-33.6 RDW-17.7* RDWSD-58.1*
___ 04:30AM NEUTS-70.9 LYMPHS-9.1* MONOS-15.6* EOS-3.2
BASOS-0.2 NUC RBCS-0.2* IM ___ AbsNeut-8.94* AbsLymp-1.14*
AbsMono-1.96* AbsEos-0.40 AbsBaso-0.02
___ 04:30AM PLT SMR-LOW PLT COUNT-95*
DISCHARGE LABS
======================
___ 06:10AM BLOOD WBC-7.0 RBC-3.16* Hgb-9.4* Hct-28.8*
MCV-91 MCH-29.7 MCHC-32.6 RDW-17.7* RDWSD-59.1* Plt Ct-95*
___ 06:10AM BLOOD Glucose-82 UreaN-26* Creat-5.6*# Na-137
K-4.5 Cl-100 HCO3-27 AnGap-15
___ 06:10AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.8
Urine Culture:
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with SLE, ESRD on HD, and
multiple myeloma presenting with fever over the past five days.
He had symptoms of dysuria and pyuria consistent with UTI. He
was treated initially with vancomycin/cefepime and then narrowed
to ciprofloxacin to complete 14 day course with improvement in
his symptoms. Unfortunately, antibiotics were given prior to
obtaining urine culture and therefore did not have any culture
data. Chest x-ray without evidence of pneumonia, blood cultures
negative growth to date. Of note, bortezimib held while
inpatient due to concurrent infection. This was communicated
with outpatient oncologist.
#UTI
Patient presented with dysuria, malaise, and fever. He received
abx prior to Ucx, and therefore there was no positive culture
data. He was treated initially with vancomycin/cefepime and then
narrowed to ciprofloxacin to complete 14 day course with
improvement in his symptoms.
#Mediastinal vasculature:
Initial CXR read as pneumonia although patient without cough,
dyspnea. Second read of opacity with concern for mediastinal
mass. However on oblique views, this opacity was confirmed to be
mediastinal vasculature
CHRONIC ISSUES:
#Multiple Myeloma. Followed by his oncologist, ___.
Held bortezimib while inpatient due to concurrent infection,
which was communicated with his outpatient oncologist.
#Finger lesions
Per patient, his finger lesions are improved and healing with
topical steroids prescribed by derm as outpatient. Continued
topicals as inpatient
#SLE: continued hydroxychloroquine
#CAD s/p CABG: continued home aspirin, clopidogrel, labetalol,
atorvastatin.
#ESRD on HD: Patient receives HD on ___, which was continued
while inhouse.
#Hypercholesterolemia: Continued atorvastatin.
#HTN: Continued home labetalol.
#Herpes: Continued home acyclovir while on chemotherapy.
TRANSITIONAL ISSUES
============================
[]Patient to take Ciprofloxacin 250mg daily (HD dosed) to
complete 14 day course ___, last day ___
- Blood cultures which were pending on discharge finalized
negative
#Emergency Contact: ___ ___
#Code status: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO ONCE
2. Labetalol 600 mg PO BID
3. Atorvastatin 80 mg PO QPM
4. Aspirin EC 81 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Acyclovir 200 mg PO Q12H
8. Calcitriol 0.25 mcg PO EVERY OTHER DAY
9. Docusate Sodium 100 mg PO BID
10. Hydroxychloroquine Sulfate 200 mg PO DAILY
11. Desonide 0.05% Cream 1 Appl TP BID Systemic Lupus
Erythematosis
12. Clobetasol Propionate 0.05% Cream 1 Appl TP BID Systemic
Lupus Erythematosis
13. B complex-vitamin C-folic acid ___ mg oral ONCE
14. K-Phos-Neutral (sod phos di, mono-K phos mono) ___ mg oral
TID
15. Fluocinonide 0.05% Ointment 1 Appl TP QID Systemic Lupus
Erythematosis
16. Ketoconazole 2% 1 Appl TP BID Dermatomycosis of foot
17. Simethicone 80 mg PO QID:PRN Gas pain
18. Senna 8.6 mg PO BID:PRN Constipation
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q24H
Take AFTER dialysis on dialysis days.
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth daily Disp
#*10 Tablet Refills:*0
2. Acetaminophen 650 mg PO ONCE
3. Acyclovir 200 mg PO Q12H
4. Aspirin EC 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. B complex-vitamin C-folic acid ___ mg oral ONCE
7. Calcitriol 0.25 mcg PO EVERY OTHER DAY
8. Clobetasol Propionate 0.05% Cream 1 Appl TP BID Systemic
Lupus Erythematosis
9. Clopidogrel 75 mg PO DAILY
10. Desonide 0.05% Cream 1 Appl TP BID Systemic Lupus
Erythematosis
11. Docusate Sodium 100 mg PO BID
12. Fluocinonide 0.05% Ointment 1 Appl TP QID Systemic Lupus
Erythematosis
13. Hydroxychloroquine Sulfate 200 mg PO DAILY
14. K-Phos-Neutral (sod phos di, mono-K phos mono) ___ mg oral
TID
15. Ketoconazole 2% 1 Appl TP BID Dermatomycosis of foot
16. Labetalol 600 mg PO BID
17. Omeprazole 20 mg PO DAILY
18. Senna 8.6 mg PO BID:PRN Constipation
19. Simethicone 80 mg PO QID:PRN Gas pain
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Urinary Tract Infection
SECONDARY:
Lupus
Coronary artery disease
ESRD
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Hi Mr. ___,
It was a pleasure taking care of you.
Why you were admitted?
-You were admitted because you were having fevers and low
energy. You were found to have a urinary tract infection.
What we did for you?
-You were given antibiotics with improvement in your symptoms.
-You received dialysis while you were here.
What should you do when you go home?
-You should continue taking ciprofloxacin 250mg daily to
complete a 14 day course (last day ___
-Please take all your medications and attend your follow up
appointments.
-Please talk to your oncologist in regards to when you should
start your chemotherapy again.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10295894-DS-15 | 10,295,894 | 29,928,442 | DS | 15 | 2153-11-02 00:00:00 | 2153-11-02 18:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
cats
Attending: ___.
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
___ CT guided lung biopsy
History of Present Illness:
Mr. ___ is a ___ y/o man who initially presented
with cough and hemoptysis, found to have cavitary left upper
lobe lesion, undergoing outpatient work-up, who is now admitted
for further work-up and management. Briefly, he initially
presented to urgent care at the end of ___ with cough,
left-sided chest pain, and blood streaked sputum, with chills
and mild night sweats. A CXR at that time demonstrated an
opacity adjacent to the left anterior first rib. He then
underwent follow-up CT chest with contrast, which demonstrated a
LUL spiculated cavitary lesion (2.3 x 2.1 x 1.9 cm), thought
most consistent with squamous cell carcinoma without localized
metastases. There was borderline left hilar lymphadenopathy. At
that time, TB was deemed to be relatively less likely given that
he had had a negative PPD test ___ ___. He emigrated
from ___ when he was ___ years old. He received an
empiric 5 day course of levofloxacin ___ case of possible
pneumonia. He was referred to ID, oncology, and thoracic
surgery. ID recommended induced sputum testing, which has been
negative thus far. A PET-CT scan was performed, which
re-demonstrated 2.9 x 2.1 cm spiculated, cavity lesion with
surrounding ground-glass opacity and FDG avidity. The left hilar
lymph node was also FDG avid. He then underwent bronchoscopy
with EBUS, BAL, and FNA at ___, which was negative
He was seen ___ thoracic surgery clinic today, and owing to
concern for possible active TB that would complicate resection,
he was referred to the ED for further management. On arrival to
the ED, his initial vital signs were T 98.4F BP 137/78 mmHg P 80
RR 20 O2 100% RA. During the course of his ED stay, he spiked a
fever to 102.1F. Examination was notable for lungs clear to
auscultation, heart with regular rate and rhythm, and no
abdominal tenderness. Labs were notable for normal lactate,
normal chemistry panel, ALT of 49, AST 29, alk phos 110, lipase
38, Tbili 0.6, albumin 4.1, WBC 8.9k (68%N, 20.4%L), H/H
13.0/38.7, PLT 320,000, INR 1.2, serum iron 31, TIBC 309,
ferritin 271, transferrin 238. CXR was performed, which
demonstrated 3.9 x 3.0 cm dense nodule ___ the LUL better
characterized on chest CT concerning for neoplasia. He received
1000 mg acetaminophen and 800 mg ibuprofen. Case was discussed
with thoracic surgery and interventional pulmonology, and he was
admitted to the medical service.
On arrival to the floor, he endorsed the narrative as above. He
is continuing to have fevers (over the past four nights as high
as ___, chills, and night sweats. He is continuing to have
cough, usually productive of grey sputum, but occasionally
rust-colored. He has also been having occasional
lightheadedness, dizziness, and occasional nausea and vomiting
associated with his coughing. He denies chest pain or shortness
of breath. He has lost approximately two pounds ___ the past
month. He denies swelling ___ his legs or syncope.
Past Medical History:
- cavitary lung lesion s/p induced sputum testing,
bronchoscopy/BAL/FNA
- mitral valve prolapse
- hyperlipidemia
Social History:
___
Family History:
- mother with hypertension
- father with hypertension, CAD/PVD, and stroke
- maternal grandmother died of ovarian cancer
Physical Exam:
ON ADMISSION:
VS: T 100.3F BP 124/85 mmHg P ___ RR 20 O2 97% RA
General: Comfortable, NAD.
HEENT: Anicteric sclerae; EOMs intact.
Neck: Supple.
CV: RRR, no MRGs; normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, non-tender, non-distended, NABS.
Ext: Warm and well-perfused; no edema.
Neuro: A&Ox3.
ON DISCHARGE:
98.1 133/76 79 18 96 Ra
General: Comfortable appearing, NAD
HEENT: Anicteric sclerae, conjunctivae noninjected
CV: RRR, no m/r/g
Resp: CTAB, no w/r/r
ABD: soft, NTND
Ext: Warm and well-perfused; no edema.
Neuro: Alert and interactive, MAEE
Pertinent Results:
ON ADMISSION:
___ 02:46PM BLOOD WBC-8.9 RBC-4.31* Hgb-13.0* Hct-38.7*
MCV-90 MCH-30.2 MCHC-33.6 RDW-11.9 RDWSD-38.7 Plt ___
___ 02:46PM BLOOD Neuts-68.0 ___ Monos-9.2 Eos-1.7
Baso-0.4 Im ___ AbsNeut-6.07 AbsLymp-1.82 AbsMono-0.82*
AbsEos-0.15 AbsBaso-0.04
___ 02:46PM BLOOD ___ PTT-27.0 ___
___ 02:46PM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-139
K-4.5 Cl-101 HCO3-24 AnGap-14
___ 02:46PM BLOOD ALT-49* AST-29 AlkPhos-110 TotBili-0.6
___ 02:46PM BLOOD Lipase-38
___ 02:46PM BLOOD Albumin-4.1 Iron-31*
___ 02:46PM BLOOD calTIBC-309 Ferritn-271 TRF-238
___ 02:54PM BLOOD Lactate-1.2
NOTABLE LABS:
___ 02:46PM BLOOD calTIBC-309 Ferritn-271 TRF-238
___ 05:16AM BLOOD ANCA-NEGATIVE B
___ 05:16AM BLOOD ___ Titer-1:160*
___ 05:16AM BLOOD C3-164 C4-27
DISCHARGE LABS:
___ 04:24AM BLOOD WBC-7.9 RBC-4.11* Hgb-12.2* Hct-36.6*
MCV-89 MCH-29.7 MCHC-33.3 RDW-11.9 RDWSD-38.0 Plt ___
MICROBIOLOGY:
___ 3:46 pm TISSUE
Source: Lung, PLEASE RESERVE FRESH TISSUE FOR UNIVERSAL
PCR.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY; ACID FAST
SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY INPATIENT
___ BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-PENDING; BLOOD/AFB CULTURE-PENDING
___ 9:00 pm SPUTUM Source: Expectorated.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
___ 9:12 pm SPUTUM Source: Induced.
MTD ADDED ON ___ AT 2345.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ CLUSTERS.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
MTB Direct Amplification (Final ___:
M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: A negative NAAT
cannot rule
out TB or other mycobacterial infection.
.
NAAT results will be followed by confirmatory testing with
conventional culture and DST methods. This TB NAAT method
has not
been approved by FDA for clinical diagnostic purposes.
However, this
laboratory has established assay performance by ___
validation
___ accordance with CLIA standards.
___ 10:23 am SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY INPATIENT
___ BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY
INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
IMAGING:
CHEST CT ___:
1. Significant interval increase ___ size of the left upper lobe
mass now
measuring up to 4 cm as described. Findings remain concerning
for a primary
lung malignancy. However, given the rapid interval growth and
surrounding
ground-glass opacities, an invasive fungal infection could also
be considered
___ the context of risk factors such as immunosuppression.
2. Mild interval increase ___ size of the left hilar lymph node
measuring 10 mm
___ short axis, previously 8 mm.
3. 15 mm lesion ___ periphery of segment 2 of the liver is
incompletely
characterized. Further evaluation with MRI is recommended.
RUQ U/S ___:
1. Heterogeneous 2.2 cm subcapsular lesion ___ segment II, and
adjacent 1.0 cm
echogenic lesion posteriorly, which could represent atypical
hemangiomas, but
remain indeterminate. Further evaluation with contrast-enhanced
MRI of the
liver is recommended.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot
be excluded
on the basis of this examination.
Brief Hospital Course:
___ with no significant PMH presenting with a 1 month history of
hemoptysis, intermittent fever and chills found to have a LUL
cavitary mass. Underwent CT-guided biopsy of the mass.
# Cavitary LUL lesion
# Fever, cough, hemoptysis:
Initially presented as an outpatient with blood-streaked sputum
where a CT showed LUL cavitary lesion. Outpatient workup notable
for negative AFBx3, bronchoscopy, BAL, FNA, cytology,
Histoplasma, Aspergillus Ab, and sputum cultures. His PPD was
negative as recently as ___. He was given a 5-day course of
levofloxacin and felt improvement. He presented for evaluation
for tuberculosis at the prompting of thoracic surgery as there
was concern for SCC and wanted to rule out TB prior to planning
for possible resection. A CT scan showed enlargement of the mass
but it was no longer cavitating. He had 3 negative AFB smears on
induced sputa and a negative NAAT. Sputum cultures grew only
commensal flora. A CT-guided biopsy was done ___ with negative
AFB smear and negative gram stain. Of note, he did have a
positive ___ titre at 1:160 with negative ANCA.
Transitional issues:
[] the following studies were pending at the time of discharge:
- Coccidioides aby
- Paracoccidoides aby
- sputum respiratory fungal cultures
- sputum AFB cultures
- blood AFB culture
[] the following biopsy results are pending at the time of
discharge
- pathology
- culture
- AFB culture
- fungal culture
[] Read from MRI liver was pending at the time of discharge. MRI
was done to further evaluate a 2.2 cm heterogenous lesion seen
on RUQ US from ___.
[] Patient found to have positive ___ with titre of 1:160.
Unlikely to be cause of his LUL lesion, but can consider
rheumatology referral/workup if no other etiology found.
**The patient was seen and examined today and is stable for
discharge. Greater than 30 minutes were spent on discharge
planning and coordination.**
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB, wheezing
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H
RX *acetaminophen 500 mg 1 tablet(s) by mouth every six (6)
hours Disp #*28 Tablet Refills:*0
2. Benzonatate 100 mg PO TID cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*21 Capsule Refills:*0
3. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 ml by mouth
four times a day Refills:*0
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB, wheezing
Discharge Disposition:
Home
Discharge Diagnosis:
Hemoptysis
Fever
Left upper lobe lung lesion
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 for coughing up blood and
fevers.
You had a repeat CAT scan of your chest that showed that the
lesion ___ your lungs was larger. The tests of your sputum did
not show tuberculous or infection. You had a biopsy of the
lesion with definite tests pending at the time you left the
hospital.
If any of the infection tests return positive, the infection
disease doctors ___ contact ___ for follow up. The other tests
will be followed up by your PCP.
Until we know for sure that you do not have tuberculosis, you
should wear a mask when you leave the house. You should also
avoid being ___ close contact with infants or people with
weakened immune systems.
It was a pleasure taking care of you and we wish you the best!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10295929-DS-17 | 10,295,929 | 25,926,190 | DS | 17 | 2152-11-08 00:00:00 | 2152-11-08 17:47:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
Epigastric abdominal pain, 2 episodes of BRBPR, and first-time
low-volume hemoptysis x3.
Major Surgical or Invasive Procedure:
NA
History of Present Illness:
Mr. ___ is a ___ with a history of HCV,
intrahepatic cholangiocarcinoma ___, s/p chemo/radiation,
managed at ___, HTN, CAD s/p ___ ___, rheumatic heart
disease s/p mechanical MV with tricuspid valve repair ___ on
coumadin, HFpEF (LVEF 50% ___, sick sinus syndrome s/p ___,
and prior GIB on triple therapy (___) who presented today
with
a 3 days of epigastric abdominal pain, 2 episodes of BRBPR, and
first-time low-volume hemoptysis x3.
The patient states that he was in his usual state of health
until
___ afternoon, when he began experiencing epigastric
abdominal
pain after eating a sausage meal. This pain was intermittent,
worse with meals. He endorsed nausea but had no vomiting. In the
following days, he had 2 episodes of stool with bright red blood
streaks, not on the toilet paper. He denied tarry or black
stools. He also had chest tightness with deep inspiration, but
not affected by change in position, as well as several episodes
of first-time small volume hemoptysis during coughing episodes.
Finally, he endorses generalized fatigue, dizziness, headache,
and itchiness. He has noticed yellowing of his skin and eyes.
In the ED, initial vitals were: Pain ___, Temp: 97.4, HR: 68,
BP: 118/62, RR: 16, O2 sat: 99% RA. Exam was remarkable for
BRBPR
without comment on hemorrhoid.
Past Medical History:
1. Rheumatic heart disease, status post mechanical mitral valve
replacement with tricuspid valve repair in ___.
Original MVR in ___ for MVP/MR ___ CHF ___
2) 4+ Tricuspid Regurgitation s/p TVR ___ SSS s/p Permanent Pacemaker in ___, DDI for bradycardia
during
apneic episodes
4) Hypertension
5) mod Pulmonary hypertension
6) Obstructive Sleep Apnea - on BiPAP
7) BPH
8) h/o urethral meatal stricture s/p dilatation
9) GERD
10) Gout
11) h/o Hep C, s/p interferon, reportedly "cured"
12) Depression/Anxiety
13) H/o Postop Atrial Fibrillation
14) H/o Urosepsis
15) CAD s/p DES to LAD ___
16) Diastolic heart failure.
17) Prior GIB
cirrhosis from HCV
poorly-differentiated intrahepatic cholangiocarcinoma ___ s/p
five cycles of gemcitabine/cisplatin and radiation
no evidence of recurrence per ___ BWH heme/onc note
Social History:
___
Family History:
- Father: died of cerebral hemorrhage ___ aneurysm)in his ___,
h/o stroke
-No history of premature arthrosclerotic CVD or sudden cardiac
death
-Mother: HTN
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 97.6F PO BP: 160 / 91 R Sitting, HR: 76, RR:20 O2Sat: 96
RA
GENERAL: Jaundiced, well appearing man, younger than stated age.
HEENT: Sclera icteric. MMM.
CHEST: Regular rhythm, normal rate. No murmurs auscultated, loud
S2 with click, heard loudest over left lower sternal border.
Midline scar from previous cardiac surgery.
LUNGS: Clear to auscultation bilaterally. Mild
inspiratory/expiratory wheezes, no rhonchi or rales. No
increased
work of breathing.
ABDOMEN: Normal bowels sounds, non distended, tender to deep
palpation in the epigastrium and RUQ without rebound or
guarding,
negative ___. No organomegaly.
EXTREMITIES: No significant peripheral edema.
SKIN: Warm. No rashes.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously.
DISCHARGE PHYSICAL EXAM:
========================
GENERAL: Jaundiced, well appearing man, younger than stated age.
HEENT: Scleral icterus, also under tongue
CHEST: Regular rhythm, normal rate. No murmurs auscultated, loud
S2 with click, heard loudest over left lower sternal border.
Midline scar from previous cardiac surgery.
LUNGS: Clear to auscultation bilaterally. Mild
inspiratory/expiratory wheezes, no rhonchi or rales. No
increased
work of breathing, though shallow breaths.
ABDOMEN: Normal bowels sounds, non distended, tender to deep
palpation in the epigastrium and RUQ without rebound or
guarding.
No organomegaly.
EXTREMITIES: No significant peripheral edema.
SKIN: Warm. No rashes.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously.
Pertinent Results:
ADMISSION LABS:
==============
___ 01:21PM BLOOD WBC-4.8 RBC-5.58 Hgb-11.8* Hct-38.9*
MCV-70* MCH-21.1* MCHC-30.3* RDW-17.6* RDWSD-41.3 Plt ___
___ 01:21PM BLOOD ___ PTT-63.0* ___
___ 01:21PM BLOOD Plt ___
___ 01:21PM BLOOD Glucose-121* UreaN-16 Creat-1.4* Na-139
K-4.1 Cl-103 HCO3-24 AnGap-12
___ 01:21PM BLOOD ALT-289* AST-167* AlkPhos-395*
TotBili-4.3* DirBili-3.3* IndBili-1.0
___ 01:21PM BLOOD Lipase-113*
___ 01:21PM BLOOD cTropnT-<0.01
___ 01:23PM BLOOD Lactate-0.9
DISCHARGE LABS:
===============
___ 06:08AM BLOOD WBC-4.9 RBC-5.52 Hgb-11.8* Hct-38.7*
MCV-70* MCH-21.4* MCHC-30.5* RDW-18.2* RDWSD-42.8 Plt ___
___ 06:08AM BLOOD Plt ___
___ 06:08AM BLOOD Glucose-99 UreaN-12 Creat-1.2 Na-140
K-3.5 Cl-101 HCO3-25 AnGap-14
___ 06:08AM BLOOD ALT-251* AST-163* LD(LDH)-349*
AlkPhos-401* TotBili-7.4*
___ 06:10AM BLOOD ___ PTT-59.5* ___
___ 06:10AM BLOOD Glucose-92 UreaN-11 Creat-1.2 Na-144
K-4.4 Cl-104 HCO3-22 AnGap-18
___ 06:10AM BLOOD ALT-240* AST-157* AlkPhos-411*
TotBili-7.8* DirBili-6.2* IndBili-1.6
___ 01:21PM BLOOD Lipase-113*
___ 06:10AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.6
___ 04:40AM BLOOD calTIBC-312 Ferritn-94 TRF-240
___ 01:23PM BLOOD Lactate-0.9
Brief Hospital Course:
Mr. ___ is a ___ with a history of HCV, intrahepatic
cholangiocarcinoma ___, s/p chemo/radiation, managed at ___,
HTN, CAD s/p ___ ___, rheumatic heart disease s/p
mechanical MV with tricuspid valve repair ___ on coumadin,
HFpEF (LVEF ___, sick sinus syndrome s/p ___, and prior
GIB on triple therapy (___) who presented with a 3 days of
epigastric abdominal pain found to have elevated LFTS and
supratheraputic INR to 9, here for management and work-up for
elevated LFTs.
CT abdomen in ED showed hepatic segment VI is the subtle
hypoattenuating lesion which measures 4.8 x 2.0 cm which is of
indeterminate age and concerning for a primary hepatic mass.
Hepatology consulted for workuo of acute LFT elevation and
jaundice.
MRCP waa performed and showed:
1. Heterogeneously enhancing mass/masses spanning segment for 4a
segment 4b suspicious for residual/recurrent clinical carcinoma.
In addition there is a 6.6 cm lobulated area of enhancement
extending to the left of post-treatment changes within segment 2
of the liver concerning for additional site of malignancy and
potentially could be extracapsular in location. Comparison to
prior images would be useful to assess for interval change.
2. Possible enhancing lesions identified within segments 7 and
8 of the right hepatic lobe suspicious for metastatic disease.
3. 1.4 cm left periaortic lymph node which is nonspecific but
larger when compared to prior CT from ___ also raising
suspicion for metastatic disease.
4. Additional benign Findings as above.
This scan was compared with his previous scans from ___.
Of note, patient has CT abdomen pelvis in ___ which did not
show any evidence of disease in the in left atrophic lobe of
liver.
CT scan from ___ from ___ showed subtle lesion in left
atrophic lobe of liver near the dome.
MRCP showed Now 6.6 X 4.5 cm ring enhancing lesion on left
atrophic lobe of liver. Amendable for biopsy by Body which is
new from prior scans. From discussion with Radiologist, lesion
is in a difficult area to visualize on CT. The radiologist did
not see marked dilatation of bile ducts in right lobe of liver.
Left lobe of liver has some dilation of bile ducts near the 6.6
X 4.5 cm mass.
Given progression of mass over these scans, radiology does think
this is consistent with recurrent cholangiocarcinoma. ___ guided
biopsy would be possible for 6.6 X 4.5 cm mass.
At time of discharge patient was stable, plan for transition to
___ for further evaluation of likely recurrent
cholangiocarcinoma and for decompression of biliary tree either
with ERCP or PCBD.
Patient oncologist at ___ Dr. ___ who was contacted via
E-mail.
___
TRANSITIONAL
- Recheck INR (1.4 at discharge, down from 9 upon admission)
ACUTE/ACTIVE ISSUES:
====================
# Transaminitis:
# Direct hyperbilirubinemia:
# Epigastric pain:
Afebrile, normotensive, and without leukocytosis, reassuring.
RUQ US with no dilated ducts, CT abd/pelv with liver lesion.
MRCP showed new 4x6cm mass on left lobe of liver. Discussed with
radiology and concerning for recurrent chloangiocarcinoma.
#Elevated INR:
#Mechanical Mitral Valve replacement
Patient on thirty mg of warfarin at home. Was taking his typical
dose prior to admission. Was found to have blood streaked stool.
INR was reversed in ED with 10 IV vitamin K. INR now to 1.4.
Continue to trend. His warfarin was held and the patient was
placed on heparin drip while anticipating possible ERCP or
invasive procedure.
Chronic Issues:
#Hypertension:
#CAD:
#Rheumatic Heart Disease s/p mechanical mitral valve:
- continue home amlodipine, lisinopril, carvedilol
- Hold Warfarin in case of need for ERCP
- heparin gtt while subtherapeutic (goal INR 2.5 - 3.5)
- continue home ASA
# Constipation
Continue home docusate. Can consider adding miralax and senna as
this may be contributing to his abdominal pain
#Anxiety:
Anxiety/insomnia worse in hospital, treat with LORazepam 0.5 mg
PO PRN
#COPD:
Continue home tiotropium Bromide 1 CAP IH DAILY, albuterol.
>30 min spent on discharge planning including face to face time
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Ezetimibe 10 mg PO DAILY
7. LORazepam 0.5 mg PO QHS:PRN anxiety
8. Pantoprazole 40 mg PO Q12H
9. Vitamin D 1000 UNIT PO DAILY
10. Lisinopril 20 mg PO DAILY
11. Warfarin 30 mg PO DAILY
12. Cyanocobalamin 100 mcg PO DAILY
13. Tiotropium Bromide 1 CAP IH DAILY
14. pitavastatin calcium 4 mg oral daily
15. Finasteride Dose is Unknown PO DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. Cyanocobalamin 100 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Ezetimibe 10 mg PO DAILY
8. Lisinopril 20 mg PO DAILY
9. LORazepam 0.5 mg PO QHS:PRN anxiety
10. Pantoprazole 40 mg PO Q12H
11. pitavastatin calcium 4 mg oral daily
12. Tiotropium Bromide 1 CAP IH DAILY
13. Vitamin D 1000 UNIT PO DAILY
*Also taking finasteride of unknown dose
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Transaminitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___
___ were hospitalized at ___ for elevated liver tests.
___ were found to have a new mass in your liver.
___ were transferred to ___ for further care from your oncology
team.
We wish ___ the best
Followup Instructions:
___
|
10296292-DS-16 | 10,296,292 | 25,735,847 | DS | 16 | 2152-02-09 00:00:00 | 2152-02-10 12:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Transfer for hand surgery
Major Surgical or Invasive Procedure:
___ Midline peripheral catheter placement
History of Present Illness:
This is a ___ with PMH of IVDU, Hepatitis C, prior endocarditis,
who is transferred from ___ for evaluation by Hand
Surgery after presenting there for left hand abscess and
subsequently found to have a left upper extremity DVT.
One week ago, the patient presented to ___ with fever, left
upper extremity distal erythema, swelling, and pain, consistent
with cellulitis, and found to have an abscess on the dorsum of
his left hand at a drug injection site. The patient was found to
have ___ blood cultures positive for Strep pyogenes (results
which came back post patient discharge). He ultimately had
incision and drainage of the abscess and was sent home on
Cephalexin and Bactrim PO for treatment.
The following ___ the patient went to
___ to detox and was started on
buprenorphine-naloxone. While there it was noted that he had
worsening swelling and erythema of his left arm up to the elbow.
He was sent to ___ where he was again evaluated
for cellulitis and hand abscess. At this time, he reported
having no fevers or chills. He received vancomycin and
clindamycin. Additionally, he was found to have an upper
extremity DVT involving the cephalic, basilic, brachial veins.
He was given Lovenox and transferred to ___ due to the
potential need for hand surgery.
On arrival in the ED:
- Initial vitals were 97.5 77 108/69 16 100% RA.
- Labs nortable for H/H 10.2/29.5 but otherwise normal
chemistry. Lactate was normal. Blood cultures were obtained.
As the patient had already received I + D of the hand wound and
it was healing well, it was determined hand surgery was not
needed. However, given the patient's DVT, recent infection, and
history of endocarditis occuring at the same time as his
previous DVT, it was determined he should be transferred to the
floor for work up of infective endocarditis. Prior to transfer,
vitals were 98.0 85 110/64 18 97% RA.
On the floor, the patient's only complaints were throbbing pain
in the distal half of his left arm, which he says is improved
from when he was diagnosed with cellulitis and abscess 1 week
ago. He denies fever and chills. He also complains of "dope
sickness," which he describes as an overall feeling of malaise.
When asked to describe his previous episode of endocarditis, he
says he was completely wiped out and incapable of even getting
out of bed. He says he does not feel that way currently. His ROS
was negative for headache, sinus tenderness, cough, shortness of
breath, chest pain, palpatations, nausea, vomiting, diarrhea,
constipation, abdominal pain, dysuria, hematuria, arthralgias,
or myalgias.
Past Medical History:
- History of endocarditis (___)
- Left upper extremity DVT (___)
- IV drug use
- Anxiety/Depression
- Bipolar disorder
- Hepatitis C (diagnosed ___, last viral load ~6mo ago >6
million as reported by patient)
Social History:
___
Family History:
Mom: Lung Cancer
Dad: HTN, diabetes
Anxiety and depression on both sides of family. No family
history of clotting disorder.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: T 98.1, BP 110/60, HR 80, RR 20
___: Oriented, likely somnolent, in 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,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses in lower extremities, no
clubbing, cyanosis or edema; erythema at left forearm with
increased warmth and swelling, tender to palpation, entrance at
dorsum of left hand s/p I+D does not appear swollen or purulent.
Cord-like vessels able to be palpated as move proximally along
left arm. Track marks noted on both upper and lower extremities.
No splinter hemorrhages, ___ lesions, ___ nodes noted.
Neuro: CNII-XII intact
DISCHARGE PHYSICAL EXAM:
VS: T 98.2 (98.2) BP 142/80 (101/50-142/80) HR 52 (52-86) RR 18
O2 94%RA
___: Alert and oriented, in no acute distress
HEENT: Mild bilateral mydriasis
Lungs: Clear to auscultation bilateral, without wheezes,
crackles, or rhonchi
CV: Regular rhythm, normal S1 + S2. No murmur noted, no rubs or
gallops
Ext: LUE with mild erythema and minimal swelling to elbow.
Segments of cords tracking along veins; I + D site on dorsum of
left hand now with open wound (scab removed); limited ROM in
left wrist, especially on flexion
Skin: No petechial rash.
Neuro: CN II-XII intact bilaterally.
Pertinent Results:
ADMISSION LABS
==============
___ 12:00PM PLT COUNT-348
___ 12:00PM NEUTS-48.1* ___ MONOS-8.6 EOS-4.2*
BASOS-0.6
___ 12:00PM WBC-7.6 RBC-3.31* HGB-10.2* HCT-29.5* MCV-89
MCH-30.9 MCHC-34.7 RDW-14.1
___ 12:00PM GLUCOSE-82 UREA N-9 CREAT-0.9 SODIUM-141
POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-25 ANION GAP-14
___ 12:09PM LACTATE-1.0
PERTINENT LABS
==============
___ 10:55AM BLOOD HIV Ab-NEGATIVE
___ 11:30AM BLOOD calTIBC-324 Ferritn-166 TRF-249
___ 11:30AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.4 Iron-38*
___ 11:30AM BLOOD ALT-45* AST-35 AlkPhos-85 TotBili-0.3
DISCHARGE LABS
==============
___ 07:45AM BLOOD WBC-6.2 RBC-3.80* Hgb-11.3* Hct-33.6*
MCV-88 MCH-29.7 MCHC-33.6 RDW-13.7 Plt ___
___ 07:45AM BLOOD ___ PTT-37.7* ___
___ 07:45AM BLOOD Glucose-87 UreaN-11 Creat-0.7 Na-138
K-4.6 Cl-100 HCO3-30 AnGap-13
___ 07:45AM BLOOD Calcium-9.6 Phos-5.4* Mg-2.3
RADIOLOGY
=========
___ 6:55 ___ CHEST (PA & LAT)
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are
normal. The pulmonary vasculature is normal. Lungs are clear
EXCEPT FOR A QUESTIONABLE SUBCENTIMETER NODULAR OPACITY IN THE
PERIPHERY OF THE LEFT UPPER LUNG BETWEEN THE SECOND AND THIRD
ANTERIOR RIBS, PARTIALLY OBSCURED BY THE OVERLYING SCAPULAR
MARGIN. No pleural effusion or pneumothorax is seen. There are
no acute osseous abnormalities.
IMPRESSION:
Questionable sub cm left upper lobe nodular opacity, most likely
due to superimposition of normal structures. Repeat radiograph
with repositioning of the scapula would be helpful to better
evaluate this region, particularly considering clinical
suspicion for septic emboli.
___ 2:26 ___ CHEST (PA & LAT)
IMPRESSION:
As compared to the previous radiograph, the nodular structure
projecting over the right lung apex, described on location of
the chest x-ray performed yesterday, is no longer visualized.
On today's image, no abnormalities are noted, in particular
there is no evidence of pneumonia, pulmonary edema or pleural
effusions. Normal size of the cardiac silhouette.
TTE (Complete) Done ___ at 9:12:47 AM
Conclusions
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. Normal left
ventricular wall thickness, cavity size, and regional/global
systolic function (biplane LVEF = 59 %). Doppler parameters are
most consistent with normal left ventricular diastolic function.
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. No
masses or vegetations are seen on the aortic valve. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The estimated pulmonary
artery systolic pressure is normal. No vegetation/mass is seen
on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: Normal biventricular chamber size and systolic
function. No pathologic valvular flow. No 2D echocardiographic
evidence of endocarditis.
___ 4:36 ___ WRIST(3 + VIEWS) LEFT; HAND (PA,LAT & OBLIQUE)
LEFT
IMPRESSION:
No acute fractures or dislocations are seen. There is no bony
destruction to indicate acute osteomyelitis. Joint spaces are
preserved without significant degenerative changes. There is
normal osseous mineralization.The amount of soft tissue swelling
about the wrist has decreased since the prior study. No
erosions are seen.
Brief Hospital Course:
This is a ___ year old male with past medical history of IV
heroine and cocaine abuse complicated by prior endocarditis and
chronic Hepatitis C infection, admitted with Strep Pyogenes
Septicemia, acute left upper extremity DVT, septic
thrombophlebitis, started on IV antibiotics and anticoagulation
with symptomatic improvement, discharged to rehab.
# Left Hand Wound Abscess / Cellulitis / Infection with Strep
Pyogenes - The patient's left hand appeared swollen on
presentation with some erythema. With antibiotics, the pain and
swelling improved. Hand Surgery was consulted and recommended
conservative management with IV antibiotics and elevation. He
had plain films of his left wrist and hand that showed no acute
abnormalities. He was started on ceftriaxone 2gm Q24H on
presentation.
# Streptococcus Pyogenes Septicemia - Previous records obtained
from ___ where he initially presented
showed ___ positive blood cultures for Strep pyogenes on ___.
Given the upper extremity DVT (see below), there was concern for
high grade bacteremia with possibility for endocarditis. He had
a TTE that showed no vegetation. He had chest x-rays with no
signs of septic emboli. He had no peripheral stigmata of emboli
either. Given the likely septic thrombophlebitis, he will need 4
weeks of IV ceftriaxone as above. So far, he has had negative
blood cultures since ___, which will be day 1 of treatment.
# Septic Thrombophlebitis - ID consult team felt that the left
arm DVT is likely a representation of septic thrombophlebitis
given confirmed recent bactermia. Because of this, he will need
4 weeks of IV antibiotics. He was started initially on
enoxaparin subcutaneous injection with a bridge to warfarin for
at least 3 months of therapy. Day 1 is ___.
# Polysubstance Abuse - He was continued on suboxone 8mg-2mg BID
that had been started at his detox prior to admission;
psychiatry evaluated the patient and discovered that the
patient's self reported Xanax is actually not a real
prescription and that he has been getting the medication on the
street. Therefore, he was initiated on a taper off of
alprazolam.
# Hepatitis C
AST was mildy elevated, but ALT, Alk phos and bili were all
within normal limits. The patient has no jaundice or other
systemic signs of liver disease, and has not had any signs of
cirrhosis. The patient reports an elevated viral load at last
outpatient appointment; no records here. Has never been on
treatment. He will need outpatient plans for treatment after
detox.
# Anemia
Per results of iron studies, the patient's microcytic anemia was
determined to be anemia of chronic inflammation, likely due to
the patient's recent bacteremia or Hep C infection. The patient
appears pale, but otherwise has no symptoms of anemia (fatigue,
exertional dyspnea, angina).
# Anxiety/Depression
Symptoms wer stable here and he denied SI/HI. He continued on
paroxetine, aripiprazole, and gabapentin.
TRANSITIONAL ISSUES
- Patient will need antibiotics for 4 weeks. First date of
negative blood cultures so far is ___. Projected end date is
___.
- Patient will need anticoagulation for at least 3 months. Start
date is ___. Projected end date is ___. Plan is to
transition from subcutaneous enoxaparin to warfarin, currently
being bridged.
- Patient will need ongoing Suboxone treatment following
discharge from rehab. The patient is working on establishing
outpatient follow up with a Suboxone provider.
- When patient is ready for discharge, please contact Infectious
Disease Buprenorphine Bridge service at ___ at ___ as
they will provide a prescription for buprenorphine/naloxone to
last until patient establishes with
an outpatient provider.
- When patient is discharged, please order weekly urine tox,
including urine Buprenorphine/Norbup GC/MS screen to be faxed to
___ with OPAT labs.
- For overdose prevention, on discharge please prescribe
Naloxone HCl 1mg/mL 2x intranasal mucosal atomizing device for
suspected opioid overdose, spray 1mL in each nostril, repeat
after 3 minutes if no or minimal response.
- Patient on a xanax taper. He is currently on 1mg TID.
Currently plan for taper is to go down to 0.75mg TID for a day,
0.5mg TID for a day, and then off.
- Consider outpatient treatment plan for hepatitis C
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Paroxetine 30 mg PO DAILY
2. ARIPiprazole 5 mg PO DAILY
3. ALPRAZolam 2 mg PO QID:PRN anxiety
4. Gabapentin 600 mg PO TID
Discharge Medications:
1. ARIPiprazole 5 mg PO DAILY
2. Gabapentin 600 mg PO TID
3. Paroxetine 30 mg PO DAILY
4. Acetaminophen 1000 mg PO TID:PRN Pain, fever
5. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
6. CeftriaXONE 2 gm IV Q24H
7. Docusate Sodium 200 mg PO BID
8. Enoxaparin Sodium 70 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
9. Nicotine Patch 21 mg TD QAM
10. Polyethylene Glycol 17 g PO DAILY
11. Senna 8.6 mg PO BID
12. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
13. Sodium Chloride 0.9% Flush 20 mL IV X1 PRN For PICC
insertion
14. Warfarin 5 mg PO DAILY16
15. ALPRAZolam 1 mg PO TID:PRN anxiety Duration: 1 Day
Then 0.75mg TID x1 day, 0.5mg TID x1 day, and then off.
RX *alprazolam 0.25 mg 4 tablet(s) by mouth three times a day
Disp #*17 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
- Left Hand Abscess
- Left Arm Septic Thrombophlebitis
- Strep Pyogenes Bacteremia
- Injection Drug Abuse
- Polysubstance Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for a left hand infection. As a
complication of the infection, you developed a blood clot in
your left arm, which we suspect is infected due to the positive
blood culture that you had at ___. Because
of the infected cultures, we will be treating you for a total of
4 weeks with antibiotics. For the blood clot, you'll need 3
months of anticoagulation with warfarin as you did before.
We are glad that you are motivated to stay off of IV drugs and
to find a Suboxone provider. Please do not hesistate to contact
us or the infectious disease office (___) if you are
having trouble doing so.
It was a pleasure to take care of you. We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10296451-DS-5 | 10,296,451 | 25,939,858 | DS | 5 | 2143-05-12 00:00:00 | 2143-05-12 22:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Abdominal pain, n/v, fevers, ascites
Major Surgical or Invasive Procedure:
TJ liver biopsy ___
History of Present Illness:
___ yo M with past medical history of sarcoidosis (diagnosed by
lung biopsy in ___ at ___ and hemochromatosis (diagnosed by
liver biopsy in ___ at ___), multiple recent hospital visits
for intractable nausea and vomiting, who presented with
abdominal pain/distention, nausea, vomiting, fatigue, and
jaundice.
He was overall healthy until ___, when he developed severe
generalized pain, weight loss, respiratory symptoms, and was
found to have sarcoidosis (diagnosed by lung biopsy at ___.
He
was started on high dose steroids (prednisone 60 mg) and his
symptoms resolved. He remained on the steroids and then was
tapered off in a year, with complete resolution of his symptoms.
During that hospital stay, his pain was treated with PCA.
Following hospital discharge, he used heroin (snorting) for a
few
months, until his mother found out about it. He went to a ___
rehab in ___ and was started on suboxone then was
transitioned to methadone. He has remained clean since then. He
recently signed a contract to be weaned off the methadone, but
that was not possible due to his illness.
Since ___ and until ___ he felt really well with no symptoms.
In ___, he had symptoms of dizziness, fatigue, bone
pain.
He went to the ED and he was referred to outpatient
rheumatology,
who attributed these symptoms to sarcoidosis. He was started on
prednisone with resolution of his symptoms. He self tapered
himself because he developed moon facies. He was asymptomatic
afterwards. At that time, he was told he has low WBC and low
platelets.
He remained well until ___, when he developed
intractable nausea and vomiting. At that time, he had moved to
___ and moved his care from ___ to ___ (___). He presented to the ED with persistent nausea and
vomiting, and was discharged home twice after IVF. He presented
a
third time and was admitted for further workup. During that
hospitalization, he underwent an EGD (showed gastritis and mild
friability of the lower esophagus) and gastric emptying study
showing delayed emptying. He also had CT abdomen and MRCP, which
showed pan colitis and ?pancreatitis. He was started again on
prednisone 60 mg, which was tapered slowly. His symptoms
improved, and then he tapered the prednisone by himself because
he developed moon facies. During that hospitalization, he was
noted to have abnormal LFT and pancytopenia. His PCP
investigated
this further and a liver biopsy was performed, showing
hemochromatosis. He was started on weekly, then monthly,
phlebotomies. His phlebotomist travelled to ___, and the
patient hadn't had any phlebotomy for several months (probably
since ___ or ___, patient not sure).
In ___, the prednisone was tapered to 10 mg. At that time, he
started experiencing persistent nausea and vomiting again. He
presented to the ED twice and was discharge after IV fluids. The
third time he presented to the ED, he was admitted due to
abnormal lab results. He was told his liver was inflamed. He
received hydrocortisone and the dose of prednisone was increased
to 40 mg. He had subsequent increased lower leg and body edema,
for which he was started on lasix.
Since ___, he has been going downhill. He has increased
swelling, fatigue, jaundice, dark urine, shortness of breath,
body sores, nausea and vomiting.
Of note, themother has asymptomatic hyperbilirubinemia
attributed
to ___ disease. She had a negative hemochromatosis test.
He
is very active and "workaholic" at baseline; he works a ___ where he is on the ___.
Past Medical History:
Sarcoidosis (lung biopsy proven)
Heroin use disorder (last use ___ years ago)
Social History:
___
Family History:
Mother with liver disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: 98.5 PO ___ 18 95% RA
GENERAL: Chronically ill-appearing young male, jaundice, moon
facies
HEENT: NCAT, MMM
NECK: Neck veins flat sitting upright
HEART: RRR, no m/r/g
LUNGS: CTAB
ABDOMEN: Distended, minimal tenderness to palpation, striae
present
EXTREMITIES: warm, several shallow ulcers, significant lower
extremity edema
SKIN: Pale skin throughout, increased facial skin tone
NEUROLOGIC: AAOx3, grossly intact, no asterixis
DISCHARGE PHYISCAL EXAM
=======================
VS: T 98.1 BP 94 / 51 HR 79 RR 18 O2 93% Ra
Weight: (admission:200 lbs) 167.1 lbs
24H I/O: ___
GENERAL: NAD, comfortable in bed, mild general anasarca,
pleasant
HEENT: moist mucosa, Dobhoff in place with bridle
HEART: RRR, no MRG
LUNGS: CTAB
ABDOMEN: soft, improving distension, no tenderness to palpation,
healing purple striae with some leaking of serous fluid
EXTREMITIES: mild residual ankle edema.
SKIN: Pale skin, stria visible on abdomen
NEUROLOGIC: AAOx3, sensation and strength grossly intact, no
asterixis
Pertinent Results:
Admission labs
--------------
___ 04:50PM BLOOD WBC-11.1* RBC-2.91* Hgb-10.0* Hct-32.3*
MCV-111* MCH-34.4* MCHC-31.0* RDW-20.5* RDWSD-83.1* Plt Ct-67*
___ 04:50PM BLOOD ___ PTT-34.6 ___
___ 04:50PM BLOOD Glucose-134* UreaN-8 Creat-0.6 Na-138
K-3.7 Cl-96 HCO3-27 AnGap-15
___ 04:50PM BLOOD ALT-67* AST-110* LD(LDH)-410*
AlkPhos-243* TotBili-10.8* DirBili-7.7* IndBili-3.1
___ 04:50PM BLOOD Albumin-2.7* Calcium-7.9* Phos-1.6*
Mg-2.0
___ 06:02AM BLOOD calTIBC-77* ___ Folate-<2
___ Ferritn-1354* TRF-59*
___ 06:02AM BLOOD %HbA1c-4.3 eAG-77
___ 08:15PM BLOOD Triglyc-120 HDL-<10*
___ 06:02AM BLOOD Ret Aut-4.1* Abs Ret-0.11*
___ 06:02AM BLOOD calTIBC-77* ___ Folate-<2
___ Ferritn-1354* TRF-59*
Interval Labs:
--------------
___ 03:40PM BLOOD TotProt-4.8* Albumin-2.9* Globuln-1.9*
Calcium-8.4 Phos-4.1 Mg-2.1
___ 10:01AM BLOOD ___
___ 05:20AM BLOOD ___
___ 05:08AM BLOOD ___
___ 05:17AM BLOOD ___ 05:20AM BLOOD FSH-2.3 LH-4.0
___ 06:28PM BLOOD TSH-2.2
___ 07:25PM BLOOD PTH-73.4*
___ 07:40AM BLOOD Cortsol-0.7* Testost-80* SHBG-45
calcFT-14*
___ 08:15PM BLOOD 25VitD-13*
___ 01:28PM BLOOD HAV Ab-NEG
___ 08:15PM BLOOD IgM HAV-NEG
___ 06:02AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 08:15PM BLOOD AMA-NEGATIVE
___ 08:15PM BLOOD ___ CEA-5.5* AFP-4.9
___ 04:50PM BLOOD CRP-26.5*
___ 08:15PM BLOOD IgG-655* IgA-215 IgM-150
___ 08:15PM BLOOD HIV Ab-NEG
___ 08:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:28PM BLOOD tTG-IgA-5
___ 06:02AM BLOOD HCV Ab-NEG
___ 01:28PM BLOOD CERULOPLASMIN- 17
___ 05:20AM BLOOD SED RATE- 6
___ 07:40AM BLOOD ALPHA-1-ANTITRYPSIN- 202
___ 07:25PM BLOOD ZINC- 23
___ 07:25PM BLOOD NIACIN- 31
___ 07:25PM BLOOD VITAMIN K- 289
___ 07:25PM BLOOD VITAMIN B6 (PYRIDOXINE)- < 2
___ 07:25PM BLOOD VITAMIN B1-WHOLE BLOOD- 92
___ 07:25PM BLOOD VITAMIN B2 (RIBOFLAVIN)- <5
___ 07:25PM BLOOD VITAMIN E- 4.1
___ 07:25PM BLOOD VITAMIN C- 0.2
___ 07:25PM BLOOD VITAMIN B7 (BIOTIN)- 1066
___ 07:25PM BLOOD VITAMIN A- <5
___ 07:25PM BLOOD ANGIOTENSIN 1 - CONVERTING ___- 35
___ 03:49PM BLOOD HEREDITARY HEMOCHROMATOSIS MUTATION
ANALYSIS-PENDING
___ 08:15PM BLOOD VARICELLA ZOSTER VIRUS DNA, PCR- Not
detected
___ 08:15PM BLOOD IGG SUBCLASSES 1,2,3,4- 353, 229, 55,
52
___ 08:15PM BLOOD CA ___ - 54
Imaging:
--------
EGD ___:
Varices at the lower third of the esophagus
Mosaic pattern in the fundus compatible with portal hypertensive
gastropathy
Normal mucosa in the duodenum
Nasojejunal tube placed
Otherwise normal EGD to third part of the duodenum
Pathology:
----------
___ Transjugular Liver Biopsy:
Liver, transjugular needle core biopsy:
1. Established cirrhosis with prominent sinusoidal fibrosis on
Trichrome stain.
2. Severe predominantly macrovesicular steatosis with associated
frequent balloon degeneration and frequent intracytoplasmic
hyaline. No granulomas.
3. Mild septal mononuclear and moderate lobular mixed
inflammation that is comprised of lymphocytes and neutrophils.
Rare apoptotic hepatocytes are also seen.
4. Focal canalicular cholestasis.
5. Iron stain demonstrates mild iron deposition in hepatocytes
and Kupffer cells.
Note: The findings are consistent with end-stage liver disease
with a component of toxic metabolic injury
Discharge Labs
--------------
___ 05:04AM BLOOD WBC-8.3 RBC-2.47* Hgb-8.8* Hct-27.3*
MCV-111* MCH-35.6* MCHC-32.2 RDW-14.9 RDWSD-60.1* Plt ___
___ 05:04AM BLOOD ___
___ 05:17AM BLOOD ___ 05:04AM BLOOD Glucose-134* Na-134* K-3.8 Cl-92* HCO3-31
AnGap-11
___ 05:04AM BLOOD ALT-52* AST-82* AlkPhos-143* TotBili-3.0*
___ 05:04AM BLOOD Albumin-2.7* Calcium-7.9* Phos-2.6*
Mg-2.2
Brief Hospital Course:
PATIENT SUMMARY:
================
Mr. ___ is a ___ year old man with a PMH of NASH cirrhosis
complicated by ascites, varices, and SBP, as well as sarcoidosis
diagnosed by lung biopsy in ___ and treated with chronic
steroids, also with a history of opioid use disorder and recent
alcohol binge behavior who presented with acute alcoholic
hepatitis, decompensated cirrhosis, and volume overload. He is
s/p treatment for SBP, and s/p aggressive IV diuresis, with
significant clinical improvement.
ACTIVE ISSUES:
==============
#NASH/ETOH Cirrhosis, Childs B, Decompensated
#Volume overload
#Ascites
New diagnosis of NASH/EtOH Cirrhosis, complicated by ascites,
volume overload, varices. His current decompensation is most
likely from alcoholic hepatitis in the setting of recent binge
drinking, and the underlying etiology is likely NASH from
chronic steroids, with superimposed recent nightly alcohol use.
The patient was diuresed with IV Lasix extensively, with gradual
improvement of his anasarca and reduction of his weight. Patient
was found to have Grade II non-bleeding varices on EGD. Nadolol
would be indicated in this patient, however it was not tolerated
due to hypotension. This should be followed up as a transitional
issue.
Mr. ___ has had an extensive workup for alternative
cirrhosis etiologies, which was negative for hemochromatosis,
___ Disease, and Sarcoid of the liver. The patient
underwent a therapeutic/diagnostic paracentesis on ___ for mild
abdominal distension and worsening abdominal pain, which was
negative for SBP. He was empirically covered for SBP with
Ceftriaxone, and was continued on Ciprofloxacin for SBP
prophylaxis indefinitely. The patient was transitioned from IV
Lasix to Torsemide 40mg and Spironolactone 200 mg daily.
#Severe Malnutrition
Patient has multiple nutritional and vitamin deficiencies,
likely from poor PO intake in setting of drinking and abdominal
pain. His mother reports that he is also a picky eater, and
stopped eating red meat when he was told that he had "iron
overload" from a previous physican at ___. Mr.
___ had insufficient calorie intake on his PO trial while in
house, so tube feeds were continued for nutrition
supplementation. He will receive cycled tube feeds at night at
home. Patient will see nutrition in 2 weeks as part of his
continued transplant workup. He will continue taking Zinc BID
for 14 day course (last day ___ and Vitamin A repletion with
50K units for 14 days (last day ___.
#Alcohol hepatitis
#Abdominal Pain
Mr. ___ presented with acute decompensated cirrhosis and
abdominal pain, likely due to recent binge drinking causing
acute Alcoholic hepatitis. His DF on admission was <32, but he
was already on chronic steroids for sarcoidosis (self
administered for bouts of abdominal pain over the past 6
months). Abdominal pain resolved with time. Patient will
continue steroid taper (10 mg daily for 7 days, 5mg on ___
for 7d, then 2.5mg maintenance on ___.
#Coagulopathy
#Thrombocytopenia
#Anemia
Patient presented with thrombocytopenia secondary to
decompensated cirrhosis and malnutrition. His anemia was likely
secondary to chronic illness, malnutrition, and slow oozing from
varices and gastropathy. Patient required no transfusions during
his stay, and his H/H remained stable.
STABLE ISSUES:
==============
#Sarcoidosis
Lung-biopsy-proven in ___ with non-caseating granulomas found
after patient presented with "pulmonary" symptoms (not further
described). From ___ was seen by Dr. ___ at ___, who
did not prescribe him steroids after this time. He then saw Dr.
___ ___ at ___ after presentation with nausea/vomiting/
abdominal pain, and was started on steroids again. He has
intermittently restarted steroids to self-treat his pain. No
signs of active sarcoid at this time and we are trying to wean
steroids. Patient left the hospital on a prednisone taper
(Prednisone 5mg for 7 days, starting on ___, then decrease
to 2.5mg maintenance dose on ___, to be continued indefinitely
until he sees pulmonology).
#EtOH Use Disorder
Patient with alcohol use as outpatient that led to this acute
decompensation. He and his mother have been struggling with
admitting alcohol was a problem, but it was his mother who
showed us evidence of empty bottles in his home. The patient has
expressed that he will not drink again, and has been willing to
meet with social work, and they have provided both support and
resources for alcohol cessation. This work should be continued
outpatient.
#Insomnia
#Anxiety
Patient has anxiety and insomnia, was self-medicating with
alcohol to sleep at night for past several months. He used to
take Ambien and Zoloft, but then lost his insurance and could no
longer afford meds or a psychiatrist. These medications are
dangerous in patients with cirrhosis and can trigger HE. We will
ask his PCP to help with referral to outpatient psychiatry for
follow up with these issues.
#Vitamin D deficiency
Low Vit D with high PTH suggestive of possible underlying bone
mineralization disorder due to steroids. Cushinoid appearance,
low AM cortisol. Patient will need Vitamin D ___ U weekly (day
___ for 8 weeks (last ___ and then 1000U daily from
then on. Patient will need DEXA as outpatient.
#Heroin use disorder:
Patient came with last dose letter from his ___ clinic in
___. He has been stable on a dose of 35 mg daily. He should
continue with the plan to taper as an outpatient. He wants to be
ultimately off methadone entirely and on suboxone. Patient will
need script so he can pick up a week of methadone at a time for
2 weeks.
TRANSITIONAL ISSUES:
====================
[ ] Continue supporting abstinence from alcohol and cigarettes.
[ ] Complete prednisone taper: 5mg daily for 7days (starting
___, then 2.5 daily indefinitely (starting ___.
[ ] Consider discontinuing steroids in future as an outpatient.
[ ] Hep A second vaccine (in ___ months, ~ ___.
[ ] Methadone Taper: Patient goes to clinic in ___.
Letter provided from ___ stating that he can get a week's
supply of Methadone at a time, to prevent travel back and forth.
[ ] Nutrition: tube feeds, will need outpatient nutrition follow
up in 2 weeks to assess progress.
[ ] Psychiatry referral to address insomnia and anxiety (patient
previously on Ambien and Zoloft prior to loss of insurance).
[ ] DEXA scan as outpatient for low vitamin D level.
[ ] Will need outpatient Endocrine follow up for hypogonadism
and chronic steroid use.
[ ] Will need outpatient pulmonary follow up for sarcoid
management.
[ ] Will need outpatient ophthalmology follow up for vision
changes related to sarcoid.
[ ] Consider nadalol for grade II varices (not started in house
due to hypotension).
[ ] Repeat Vit A level: treated with 14d 50,000u daily for 2
weeks.
[ ] Repeat Vit E level: treated with 500mg daily for 2 weeks.
DISCHARGE STATS
-Discharge Weight: 167.1 lbs
-Discharge Creatinine: 0.6
-Discharge MELD: 17
NEW MEDS:
- Ciprofloxacin 500mg daily
- Torsemide 40mg Daily
- Spironolactone 200mg Daily
- Zinc BID for 14 day course (last day ___
- Vitamin A repletion with 50K units for 14 days (last day ___
- Vitamin D ___ U weekly (day ___ for 8 weeks (last
___ and then 1000U daily.
STOPPED MEDS:
- Nystatin
- Lasix
CHANGED MEDS:
- Prednisone: Taper to 5mg daily (___). Taper to 2.5mg
daily (start ___ - indefinitely)
FOLLOW UP:
- Dr. ___: for management of cirrhosis, fluid status,
nutrition.
- PCP: arrange follow up with Pulmonologist, psychiatry,
ophthalmologist, endocrine.
- ___: Plan to continue to taper methadone
(maintenance currently 35mg daily)
# CODE: Full (confirmed)
# CONTACT: ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Methadone (Concentrated Oral Solution) 10 mg/1 mL 35 mg PO
DAILY
2. Pantoprazole 40 mg PO Q24H
3. PredniSONE 30 mg PO DAILY
4. Methocarbamol 500 mg PO QID:PRN Muscle spasm
5. Furosemide 20 mg PO DAILY
6. Nystatin Oral Suspension 5 mL PO Frequency is Unknown
7. Ondansetron ODT 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO DAILY
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth daily Disp
#*28 Tablet Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
3. Lactulose 30 mL PO DAILY PRN constipation
RX *lactulose 20 gram/30 mL 1 packet by mouth daily Disp #*28
Packet Refills:*0
4. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 ___ one patch on arm Once every 24
hours Disp #*28 Patch Refills:*0
5. Spironolactone 200 mg PO DAILY
RX *spironolactone 100 mg 2 tablet(s) by mouth daily Disp #*56
Tablet Refills:*0
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) [Vitamin B-1] 100 mg 1 tablet(s)
by mouth daily Disp #*28 Tablet Refills:*0
7. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*56 Tablet
Refills:*0
8. Vitamin A ___ UNIT PO DAILY Duration: 14 Days
RX *vitamin A 25,000 unit 2 capsule(s) by mouth daily Disp #*10
Capsule Refills:*0
9. Vitamin B Complex w/C 1 TAB PO DAILY
RX *FA-B cmp,C-rice bran-rose hips [B-complex with vitamin C]
400 mcg-500 mg 1 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
10. Vitamin D ___ UNIT PO 1X/WEEK (SA)
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth once per week (___) Disp #*6 Capsule Refills:*0
11. Vitamin E 400 UNIT PO DAILY Duration: 2 Weeks
RX *vitamin E 400 unit 1 capsule by mouth daily Disp #*9 Capsule
Refills:*0
12. PredniSONE 5 mg PO DAILY Duration: 7 Doses
This is dose # 2 of 2 tapered doses
RX *prednisone 2.5 mg 2 tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
RX *prednisone 2.5 mg 2 tablet(s) by mouth Daily Disp #*35
Tablet Refills:*0
13. PredniSONE 2.5 mg PO DAILY
This is the maintenance dose to follow the last tapered dose
RX *prednisone 2.5 mg 1 tablet(s) by mouth daily Disp #*21
Tablet Refills:*0
14. Methadone (Concentrated Oral Solution) 10 mg/1 mL 35 mg PO
DAILY
15. Methocarbamol 500 mg PO QID:PRN Muscle spasm
16. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*42 Tablet Refills:*0
17. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
EtOH Hepatitis
SECONDARY DIAGNOSES
NASH Cirrhosis complicated by Grade II varices, ascites, volume
overload
Sarcoidosis of the lungs
___ Syndrome
Severe Malnutrition
EtOH Use Disorder
Tobacco Use Disorder
Opioid Use Disorder
Anxiety
Insomnia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
-You were admitted for acute decompensated liver failure,
alcoholic hepatitis, and for volume overload.
What was done for me in the hospital?
-You had a liver biopsy, which showed toxic metabolic damage of
your liver, consistent with chronic steroid use and alcohol use.
-You were given diuretic medicines to help remove excess water
from your body.
-A feeding tube was placed in your stomach to give you
additional nutrition.
-Your steroids were reduced, and you will continue tapering
these with the supervision of a physician when you leave the
hospital.
-You were given antibiotics to prevent an infection of your
abdomen.
-You were given your usual methadone dose, with a plan to taper
this as an outpatient.
-You had imaging which showed varices (dilated veins) in your
esophagus. They were stable, and not bleeding, at the time of
the endoscopy.
-You had multiple tests to check for other liver diseases that
could be contributing to your illness. You do not have
Sarcoidosis of the liver, you do not have ___ Disease of
the liver, you do not have Hemochromatosis of the liver.
What should I do when I leave the hospital?
-You should take all of your medicines as prescribed, including
the new ones that were prescribed.
-You should attend all your appointments as listed below. Your
PCP ___ help you make appointments with psychiatry,
ophthalmology, and a pulmonologist to manage your sarcoid.
-You should not drink alcohol ever again.
-You should try to quit smoking.
-You should continue going to your ___ clinic, and work
with your coordinator and PCP to taper down over time.
-You should continue trying to eat as much as you can, along
with the tube feeds. Nutrition is very important to help your
liver recover. You CAN eat red meat.
When should I return to the hospital?
-You should return to the hospital if you experience severe
abdominal pain, vomiting blood, blood in your stool, confusion,
shortness of breath, chest pain, or any other symptoms that
concern you.
We wish you the best of luck in your health!
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
10296451-DS-6 | 10,296,451 | 26,002,528 | DS | 6 | 2143-07-06 00:00:00 | 2143-07-09 14:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Vomiting, weakness
Major Surgical or Invasive Procedure:
EGD w/ NJ tube placement (___)
History of Present Illness:
___ w/ PMH sarcoidosis and hemochromatosis with recent admission
(discharged ___ for acute liver failure and decompensated
cirrhosis c/b portal hypertension presents today with nausea and
vomiting. Patient was discharged on ___ with a NG tube for
feeding. Patient states that he was feeling better at the time
of
discharge. He states that he kept it in for about a month and
pulled it out in the end of ___ due to discomfort. 2 weeks
ago he began having nausea, vomiting, and diarrhea. He states he
has about 4 episodes of nonbloody emesis a day that usually
occurs in the morning. Also describes green-ish stool, that is
also nonbloody. He also describes worsening abdominal distention
and reports RUQ pain that is constant.
To summarize his hospital course, the patient was admitted for
alcoholic hepatitis and found to have alcoholic and EtOH
cirrhosis. He was also worked up for alternatives causes
including hemochromatosis and ___ which were also
negative.
He was treated with steroids and a NG tube was placed as above.
He had grade II non-bleeding varices on EGD.
In the ED, initial VS were:
98.4 92 154/93 20 98% RA
Labs showed:
Mg of 1.1 and K of 2.9. ALT of 62 and AST 279 T. bili of 3.4 and
platelets of 70
Imaging showed:
Liver Or Gallbladder Us (Single Organ) [46] -- Urgent Abn Full
Report
1. Cirrhotic liver with splenomegaly at 16.6 cm. No ascites.
2. No definite flow is visualized within the main portal vein,
suspicious for occlusion versus slow flow. Recommend CT or MR
with contrast for further evaluation.
3. Hepatofugal flow within the left portal vein, as seen
previously.
4. Gallbladder sludge.
Patient received:
___ 18:34 IVF 500 mL NS
___ 19:57 IVF 500 mL NS 500 mL
___ 19:57 IV Ondansetron 4 mg
___ 19:57 TD Nicotine Patch 14 mg
___ 21:01 IV Magnesium Sulfate
___ 22:03 IV Magnesium Sulfate
___ 22:13 PO Potassium Chloride 40 mEq
___ 22:13 IVF 500 mL NS ( 500 mL ordered)
___ 23:13 PO/NG PredniSONE 2.5 mg
___ 23:36 IV Ondansetron 4 mg
Hepatology was consulted and recommended checking a urine and
serum tox
Transfer VS were:
98.2 86 118/71 18 100% RA
On arrival to the floor, patient reports the above story and
continues to feel nausea and RUQ abdominal pain
Past Medical History:
Sarcoidosis (lung biopsy proven)
Heroin use disorder (last use ___ years ago)
Social History:
___
Family History:
Mother with liver disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99.0 PO 116 / 70 75 18 99
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: RUQ tenderness. Hepatosplenomegaly palpated on exam
extending to the umbilicus.
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
==============================
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Mild RUQ tenderness. Nondistended. Normoactive bowel
sounds. HSM.
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, negative
asterixis
SKIN: warm and well perfused, diffuse papular rash on back
Pertinent Results:
ADMISSION LABS:
===================
___ 05:43PM BLOOD WBC-8.5 RBC-4.41* Hgb-14.5 Hct-42.3
MCV-96 MCH-32.9* MCHC-34.3 RDW-13.0 RDWSD-46.5* Plt Ct-70*
___ 05:43PM BLOOD Plt Ct-70*
___ 05:47PM BLOOD ___ PTT-43.3* ___
___ 05:43PM BLOOD Glucose-178* UreaN-3* Creat-0.5 Na-135
K-2.9* Cl-91* HCO3-25 AnGap-19*
___ 05:43PM BLOOD ALT-62* AST-279* AlkPhos-259*
TotBili-3.4*
___ 05:43PM BLOOD Lipase-9
___ 05:43PM BLOOD Albumin-3.2* Calcium-7.5* Phos-3.2
Mg-1.1*
___ 05:43PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:50PM BLOOD Lactate-5.6* K-3.1*
___ 11:05PM BLOOD Lactate-3.1*
PERTINENT LABS:
============================
___ 04:40AM BLOOD CMV VL-NOT DETECT
___ 05:43PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:40AM BLOOD ALT-46* AST-209* AlkPhos-219*
TotBili-4.5* DirBili-2.6* IndBili-1.9
___ 04:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:30PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG
___ 04:30PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 04:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-POS*
MICRO:
=====================
___ 4:30 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ @ ___ ON
___ -
___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay. (Reference
Range-Negative).
___ 6:23 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
___ 7:53 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
___ 4:40 am Blood (CMV AB)
**FINAL REPORT ___
CMV IgG ANTIBODY (Final ___:
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
<4 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results.
___ 9:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
STUDIES:
===========================
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
6:45 ___
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture.
Limited evaluation
of liver demonstrates no evidence of a focal liver mass. No
definitive flow
is seen within the main portal vein is, even with power color
Doppler imaging.
The right portal vein is not seen. The left portal vein is
patent and
demonstrates reversed flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD
measures 5 mm.
GALLBLADDER: Biliary sludge is noted within the gallbladder. No
discrete
stones are seen.
PANCREAS: The pancreas is not well visualized, largely obscured
by overlying
bowel gas.
SPLEEN: Normal echogenicity, enlarged measuring 16.6 cm,
unchanged from ___.
IMPRESSION:
1. Cirrhotic liver with splenomegaly at 16.6 cm. No ascites.
2. No definite flow is visualized within the main portal vein,
suspicious for
occlusion versus slow flow. Recommend CT or MR with contrast
for further
evaluation.
3. Hepatofugal flow within the left portal vein, as seen
previously.
4. Gallbladder sludge.
CHEST (PORTABLE AP) Study Date of ___ 8:10 AM
FINDINGS:
Heart size is normal. Hilar and mediastinal contours are
normal. No focal
consolidations concerning for pneumonia are identified. There
is no pleural
effusion or pneumothorax. Visualized osseous structures are
unremarkable.
IMPRESSION:
No definite focal consolidations concerning for pneumonia
identified.
CTA ABD & PELVIS Study Date of ___ 12:26 ___
FINDINGS:
VASCULAR:
Portal venous system is patent. Esophageal and gastric varices
are noted.
Recanalized umbilical vein is noted.
There is no abdominal aortic aneurysm. There is no calcium
burden in the
abdominal aorta and great abdominal arteries.
LOWER CHEST: Small curvilinear areas of scarring is identified
in the left
lower lobe and 2 foci localized emphysema is noted in the right
lower lobe.
ABDOMEN:
Ascites is small in volume.
HEPATOBILIARY: Liver is diffusely hypodense and enhancement is
diffusely
heterogeneous. Intra and extrahepatic bile ducts are not
dilated. Layering
sludge is noted in the gallbladder.
PANCREAS: Pancreas is atrophic. There is no pancreatic duct
dilation.
SPLEEN: Enlarged spleen measures 19.4 cm.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
There is no evidence of stones, focal renal lesions, or
hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no
perinephric
abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber,
wall thickness
and enhancement throughout. Colonic wall is diffusely thickened
from the
cecum to descending colon, similar to ___. Appendix is
unremarkable.
There is no evidence of mesenteric lymphadenopathy.
RETROPERITONEUM: Retroperitoneal lymph nodes are notable in
number but are not
pathologically enlarged.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
evidence of pelvic or inguinal lymphadenopathy.
REPRODUCTIVE ORGANS: Prostate is unremarkable.
BONES: Sub-centimeter sclerotic lesion in the right iliac bone
is likely a
bone island.
SOFT TISSUES: No suspicious soft tissue lesion is identified.
IMPRESSION:
1. Patent portal venous system.
2. Diffuse hypodensity and heterogeneous enhancement of the
liver is
compatible with severe hepatic steatosis.
3. Evidence of portal hypertension, including splenomegaly,
small volume
ascites, and esophageal and gastric varices.
4. Colonic thickening and edema suggestive of colitis involving
cecum to
descending colon is similar to ___.
5. Fibrotic changes of bilateral lung bases.
DISCHARGE LABS:
====================
___ 07:29AM BLOOD WBC-3.8* RBC-3.61* Hgb-11.6* Hct-35.1*
MCV-97 MCH-32.1* MCHC-33.0 RDW-13.4 RDWSD-47.9* Plt Ct-55*
___ 07:29AM BLOOD ___ PTT-48.5* ___
___ 07:29AM BLOOD Glucose-168* UreaN-<3* Creat-0.5 Na-138
K-3.5 Cl-96 HCO3-31 AnGap-11
___ 07:29AM BLOOD ALT-34 AST-125* LD(LDH)-212 AlkPhos-276*
TotBili-3.7*
___ 07:29AM BLOOD Albumin-2.4* Calcium-7.6* Phos-2.1*
Mg-1.5*
Brief Hospital Course:
___ w/ PMH sarcoidosis and hemochromatosis with recent admission
(discharged ___ for acute liver failure and decompensated
cirrhosis ___ alcoholic hepatitis presented with nausea and
vomiting. Patient found to have EtOH level 202 on admission,
although denied drinking. Also found to have c diff colitis.
These are the likely triggers for his decompensation. He was
started on po vancomycin, dobhoff tube was replaced, and tube
feeds were restarted with rapid improvement.
#Abdominal pain:
#Alcoholic Hepatitis:
#Decompensated NASH/EtOH Cirrhosis:
Patient had progressively worsening nausea and vomiting after he
removed his NG tube a week prior to admission. Patient found to
have elevated EtOH level of 202, although patient denied any
alcohol use. Patient also found to be c diff positive with
diarrhea prior to admission. CT w/ bowel wall thickening that
had been present on prior admission. Decreased flow in PV on
Doppler, however CT showed no e/o clot. Patient was placed on IV
heparin gtt briefly before CT was done and read as no clot. No
signs of ascites or SBP. Patient did not tolerate bedside
dobhoff placement, and underwent EGD on ___ for placement of
post-pyloric dobhoff tube. C diff treated as below and tube
feeds restarted with rapid improvement. Blood and urine cultures
negative. Nausea responded to Compazine well. Of note, patient
and mother denied any EtOH, however abdominal pain and lab
abnormalities suggestive of alcoholic hepatitis.
#C diff Colitis:
C diff positive, having diarrhea for several weeks prior to
admission. Started on po vancomycin for ___ mg q6h
(___). Diarrhea improved significantly at time of
discharge.
#NASH/Alcoholic Cirrhosis:
MELD of 20 on admission. History of 4 cords of grade 2
esophageal varices in lower third of esophagus on last EGD
again, which were again seen this admission during placement of
dobhoff. Diuretics held initially and restarted following
improvement in po intake and dobhoff placement with tube feeds.
Discharge diuretics: spironolactone 100 mg daily, torsemide 20
mg daily.
#EtOH Use Disorder:
The patient noted he quit drinking after he was admitted for
decompensated cirrhosis back in ___ however his EtOH
level was 202 on this admission. Patient put on CIWA protocol,
however did not score and did not receive lorazepam prns.
Patient given thiamine, folate. Did deny EtOH consumption during
different times this admission. Mother very upset at medical
team's assessment of patient's laboratory findings and
presentation.
#Malnutrition:
Patient with poor po intake and had feeding tube placed at prior
admission for alcoholic hepatitis. The patient pulled the tube
but was interested in tube being replaced. Tube replaced via EGD
___ and tube feeds restarted. Switched to cycled feeds from
continuous.
#Coagulopathy:
INR was up to 2.2 during this admission. Likely has a
nutritional component as patient has had poor po intake and
vomiting for the past several weeks.
#Hypomagnesemia:
#Hypokalemia:
Mg 1.0 on admission. Likely ___ vomiting, poor po intake, and
torsemide administration, as well as alcohol use. Patient
received K IV and K po. Patient has significant reaction to IV
Mg and does not tolerate even with dilution and slow rates.
Repleted with standing mag oxide po and monitored closely until
improved.
STABLE ISSUES:
==============
#Sarcoidosis:
Continued home prednisone 2.5 mg.
#History of nacrotic use disorder:
Patient notes he had PO narcotic abuse and had gone to multiple
drug rehabs in the past; has never injected drugs. Patient came
with last dose letter from his ___ clinic in ___. He has
been stable on a dose of 30 mg daily. He should continue with
the plan to taper as an outpatient. He wants to be ultimately
off methadone entirely and on suboxone. Patient will need script
so he can pick up a week of methadone at a time for 2 weeks.
Confirmed methadone dose of 30 mg daily at ___
___.
TRANSITIONAL ISSUES:
==================================
[] Discharge weight: 73.8kg on ___
[] Discharge diuretic regimen: torsemide 20mg daily,
spironolactone 100mg daily.
[] Tube feeds should be continued until liver has recovered.
[] Patient should follow up with outpatient nutrition to discuss
tube feeds.
[] PO Vancomycin should continued 125 mg q6h (___).
[] Please have blood work on ___ and faxed
to PCP and ___ clinic. Follow up on electrolytes (Mg, Phos,
K), LFTs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 30 mL PO DAILY PRN constipation
2. Methadone (Concentrated Oral Solution) 10 mg/1 mL 30 mg PO
DAILY
3. Methocarbamol 500 mg PO QID:PRN Muscle spasm
4. Pantoprazole 40 mg PO Q24H
5. PredniSONE 2.5 mg PO DAILY
This is the maintenance dose to follow the last tapered dose
6. FoLIC Acid 1 mg PO DAILY
7. Torsemide 40 mg PO DAILY
8. Thiamine 100 mg PO DAILY
9. Vitamin E 400 UNIT PO DAILY
10. Vitamin D ___ UNIT PO 1X/WEEK (SA)
11. Vitamin A ___ UNIT PO DAILY
12. Vitamin B Complex w/C 1 TAB PO DAILY
13. Spironolactone 200 mg PO DAILY
14. Nicotine Patch 14 mg TD DAILY
15. Ondansetron ODT 4 mg PO Q8H:PRN nausea
16. Ciprofloxacin HCl 500 mg PO Q24H
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. Magnesium Oxide 800 mg PO BID
RX *magnesium oxide 400 mg 2 capsule(s) by mouth twice a day
Disp #*120 Capsule Refills:*0
3. Nystatin Oral Suspension 5 mL PO QID Duration: 14 Days
RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day Disp
#*480 Milliliter Milliliter Refills:*0
4. Prochlorperazine 10 mg PO BID:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth twice a
day Disp #*10 Tablet Refills:*0
5. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg/2.5 mL 125 mg by mouth every six (6) hours
Disp #*44 Syringe Refills:*0
6. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Ciprofloxacin HCl 500 mg PO Q24H
9. Lactulose 30 mL PO DAILY PRN constipation
10. Methadone (Concentrated Oral Solution) 10 mg/1 mL 30 mg PO
DAILY
11. Methocarbamol 500 mg PO QID:PRN Muscle spasm
12. Nicotine Patch 14 mg TD DAILY
13. Ondansetron ODT 4 mg PO Q8H:PRN nausea
14. Pantoprazole 40 mg PO Q24H
15. PredniSONE 2.5 mg PO DAILY
This is the maintenance dose to follow the last tapered dose
16. Thiamine 100 mg PO DAILY
17. Vitamin A ___ UNIT PO DAILY
18. Vitamin B Complex w/C 1 TAB PO DAILY
19. Vitamin D ___ UNIT PO 1X/WEEK (SA)
20. Vitamin E 400 UNIT PO DAILY
21.Outpatient Lab Work
Draw labs ___.
LFTs, Na, K, Cl, HCO3, BUN, Cr, glucose.
K74.60 cirrhosis.
E43 Malnutrition
Fax: Dr. ___ ___ & Dr. ___ ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
clostridium difficile colitis
abdominal pain
Cirrhosis
SECONDARY DIAGNOSES
Sarcoidosis
history of polysubstance abuse 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 during your stay at ___.
WHY WAS I HERE?
-You were having belly pain and nausea
WHAT WAS DONE WHILE I WAS IN THE HOSPITAL?
-You were given antibiotics
-Your NJ tube was replaced and tube feeds were restarted
WHAT SHOULD I DO WHEN I GO HOME?
-You should take the rest of your vancomycin for c diff.
-You should abstain from drinking
Be well!
Your ___ Care Team
Followup Instructions:
___
|
10296472-DS-10 | 10,296,472 | 23,630,575 | DS | 10 | 2121-06-18 00:00:00 | 2121-06-26 22:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Rectal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a history of poorly controlled HIV (CD4 of 1 and HIV VL
of 71,200 on ___ who presents with rectal pain and
bleeding after EUA, hemorroidectomy, and condyloma excision on
___.
The patient reports he has been feeling weak for some time.
Since his procedure on ___, he has had worsening rectal pain
with some mild bright red blood. The pain is of a 'burning'
nature and worse with moving or defecation. He has been feeling
so unwell that he has not been eating or drinking very much. He
notes that he has also had difficulty urinating over the past
few days and has to 'really force' any urine to come out. He
last took his HIV medications and potassium on supplements on
___ and notes that the only medication he has been taking
since is oxycodone.
Of note, he usually has chronic diarrhea but since his procedure
has intermittently felt more constipated.
On arrival to the ED, initial vitals were pain 10, T 98.3, HR
57, BP 99/57, RR 18, O2 Sat 100%. Labs were notable for K of
2.2, Mg 1.4 HCO3 of 13 BUN/Cr of ___, H/H of 7.1/23.4 (from
8.1/26.7 on ___ AP 228, Alb 2.1 (other LFTs wnl), INR of 1.5.
EKG showed bradycardia with u waves. He received 80meq oral
potassium and 100meq IV with 2g Mg with K increasing to 2.4 and
Mg to 1.9 He received oxycodone and morphine for for pain
control.
Exam reportedly significant for several sutures noted in
perirectal area with TTP along wound sites but no expanding
erythema, fluctuance, or gross pus. He also had suprapubic and
CVA tenderness. Bedised ultrasound showed severely dilated
bladder and foley placed with reportedly a few 100ccs removed.
He was evaluated by ___ surgery and felt exam appopriate
for recent post-op. He then underwent CT A&P which was negative
for pelvic abscess or free air. Given inability to correct
potassium overnight, he was admitted to the FICU. Vitals on
trasfer: 98.8 51 108/65 17 99% RA
Past Medical History:
Anemia
Fatigue
Chronic diarrhea: ? Etiology. In workup with GI
___
-Weight loss
-Hair loss
-History of pancytopenia
HIV (+) from ___: Referred to infectious disease at ___. Hx
HAART ___
pt recalls Td utd ___
Wears eye glasses for vision
Smoker: interested in quitting: counseled: Followup PCP ___.
assistance
RLE Neuropathy s/p mvc ___: pedestrian, was struck: inpt x 1w
Social History:
___
Family History:
Mother: alive: ___
Father: alive
Brother: ___
Brother: HIV positive
Brother: ___: MI
Physical Exam:
Admission Physical Exam:
Vitals- T: BP: P: R: 18 O2:
General: Chronically ill appearing male in no acute distress.
Pleasant and conversant
HEENT: Sclera anicteric,dry mucous membranes
Neck: supple, JVP not elevated, shoddy LAD
Lungs: Bibasilar crackles but otherwise Clear to auscultation
bilaterally, no wheezes, rales, ronchi
CV:Bradycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, mildly-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley draining yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: hyperpigmented macules on back
Rectum:No frank pus or erythema visualized, sutures in place,
extremely tender to palpation, rectal exam not done.
Discharge Physical Exam:
Vitals- Tm 97.9 Tc 98.6 HR 102 (50-102) BP 102/74
(102-135/63-87) RR ___ O2Sat 99%RA (98-100)
General: NAD, ambulating around ward
HEENT: NC/AT, EOMI
Neck: Thin, no LAD, no JVD
CV: RRR, normal S1, S2, no m/g/r
Lungs: CTAB
Abdomen: Soft, NT, ND, +BS, no g/r/r
Ext: Pulses 2+, no edema
Pertinent Results:
ADMISSION LABS:
___ 06:15PM BLOOD WBC-4.6# RBC-2.67* Hgb-7.1* Hct-23.4*
MCV-88 MCH-26.4* MCHC-30.1* RDW-22.7* Plt ___
___ 06:15PM BLOOD Neuts-74.1* Lymphs-11.2* Monos-10.4
Eos-3.8 Baso-0.6
___ 06:15PM BLOOD ___ PTT-44.7* ___
___ 06:15PM BLOOD Glucose-88 UreaN-27* Creat-5.4*# Na-133
K-2.2* Cl-106 HCO3-13* AnGap-16
___ 06:15PM BLOOD ALT-20 AST-26 AlkPhos-228* TotBili-0.3
___ 03:20AM BLOOD Calcium-6.4* Phos-4.0# Mg-1.4*
DISCHARGE LABS:
___ 03:20PM BLOOD WBC-2.7* RBC-3.04* Hgb-8.1* Hct-26.6*
MCV-88 MCH-26.7* MCHC-30.5* RDW-20.5* Plt ___
___ 03:20PM BLOOD ___ PTT-38.4* ___
___ 03:20PM BLOOD Glucose-118* UreaN-13 Creat-2.7* Na-138
K-3.3 Cl-112* HCO3-19* AnGap-10
___ 03:20PM BLOOD Calcium-7.2* Phos-2.1* Mg-1.8
___ 08:27AM BLOOD pH-7.29* Comment-GREEN TOP
___ 08:27AM BLOOD freeCa-1.14
PERTINENT LABS:
___ 06:15PM Hgb-7.1* Hct-23.4*
___ 04:45PM Hgb-9.3* Hct-30.2*
___ 03:20PM Hgb-8.1* Hct-26.6*
___ 08:55AM BLOOD Ret Aut-2.0
___ 06:15PM BLOOD Glucose-88 UreaN-27* Creat-5.4*# Na-133
K-2.2* Cl-106 HCO3-13* AnGap-16
___ 04:30AM BLOOD Glucose-93 UreaN-22* Creat-4.3* Na-137
K-4.4 Cl-116* HCO3-10* AnGap-15
___ 03:20PM BLOOD Glucose-118* UreaN-13 Creat-2.7* Na-138
K-3.3 Cl-112* HCO3-19* AnGap-10
___ 01:58PM BLOOD Type-ART pO2-115* pCO2-23* pH-7.25*
calTCO2-11* Base XS--15
___ 08:27AM BLOOD pH-7.29* Comment-GREEN TOP
___ 10:28AM BLOOD freeCa-1.10*
___ 04:23PM BLOOD freeCa-0.98*
___ 08:27AM BLOOD freeCa-1.14
URINE STUDIES:
___ 09:58PM URINE Color-Straw Appear-Clear Sp ___
___ 09:58PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:58PM URINE RBC-15* WBC-3 Bacteri-FEW Yeast-NONE
Epi-0
___ 03:15PM URINE Eos-NEGATIVE
___ 09:58PM URINE Hours-RANDOM Creat-73 Na-35 K-9 Cl-52
___ 03:15PM URINE Osmolal-252
MICROBIOLOGY:
_____
___ 2:41 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
__________________________________________________________
___ 10:35 am BLOOD CULTURE #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 10:50 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
___ CT abd/pelv
IMPRESSION:
No acute intra-abdominal process.
Again seen are some fluid-filled loops of small bowel which may
represent a nonspecific enteritis.
___ Renal US:
IMPRESSION:
No hydronephrosis bilaterally
___ CXR:
Mild cardiomegaly, increased compared to ___. No
focal
consolidation.
Brief Hospital Course:
___ with poorly-controlled HIV (CD4 ___,200
___, s/p hemorrhoidectomy and condyloma electrodesiccation
___, who presented to the ED with rectal pain and admitted
initially to the MICU for hypokalemia of 2.2, acute on chronic
renal failure and anemia with Hct 23.
ACTIVE ISSUES:
# Hypokalemia: He presented with K of 2.2, with previous history
of admissions for similar electrolyte abnormalities
(hypokalemia, hypomagnesemia, hypophosphatemia) in the setting
of chronic diarrhea and malaborption and medication and
supplement non-adherence. During previous admission ___
his potassium was repleted to a goal of 3. The etiology of his
profound hypokalemia was unclear but thought to be
multifactorial including chronic diarrhea, and renal losses (see
below). He underwent aggressive IV and PO potassium repletions
on admission in the ICU and on the floor while receiving
bicarbonate repletions and his K was stable at 3.3 on PO
supplementations at discharge.
# Acute on chronic kidney injury: The patient presented with
BUN:Cr of ___ from baseline Cr of 1.7-2. FeNA was ~2%. He
was seen by renal consult service, and felt his ___ was a
combination of postobstructive renal injury and pre-renal. He
was noted to have 1500 ml drained by foley insertion in the ED,
supporting postobstructive etiology although no evidence of
hydronephrosis was seen on renal ultrasound. He was given IVF
and UOP monitored closely, meds renally-dosed with improvement
in his Cr to 2.7 at discharge.
# Non-gap metabolic acidosis: He presented with a bicarbonate
level of 13 and as low as 10, with ABG showing pH 7.25 and pCO2
of 23 (appropriate respiratory compensation). His urine anion
gap was negative, suggesting gastrointestinal losses from his
chronic diarrhea as a contributor to his metabolic acidosis.
However, his degree of acidosis and concurrent severe
electrolyte abnormalities suggested renal tubular acidosis as a
cause. Distal RTA was suspected based on his urine pH of 6.0,
as his urine anion gap was confounded by his concurrent diarrhea
leading to volume depleted state. Proximal RTA was less likely
to be a cause given his high urine pH, and lack of glucosuria
(uric acid level not checked), and his neg UAG was felt to be
secondary to his volume depletion from GI losses. Definitive
diagnosis and workup was deferred given his ___ and diarrhea,
with plan for outpatient nephrology f/u. He was given
bicarbonate drip, with close monitoring and repletion of his
electrolytes (K, Mg) and transitioned to oral repletions with
bicarb in range of ___ and pH ~7.3 at discharge.
# Rectal pain: Patient presented s/p recent hemorrhoidectomy
and condyloma electrodessication on ___ and with complaint of
rectal bleed and pain. He was seen by colorectal surgery, and
felt to have no concern for post-operative complications. He
had ___ SIRS criteria, lactate 1.8. CT (w/o contrast) did not
show any pelvic abscess but showed possible enteritis. Given
risk of pelvic sepsis after hemorrhoidectomy, he was started on
cipro/flagyl in ED, and continued through ___ when abx were
discontinued in the setting of his clinical stability without
any s/s for infection and gradual improvement in rectal pain.
# Anemia, multifactorial: H/H of 7.1/___.4 from 8.1/26.7 on ___
(although notably baseline Hgb appears closer to ___ after
recent ___ procedure. He received two units pRBCs with
Hct improved to as high as 30 and stabilized at 25. He did have
post-op blood in his toilet paper but no frank melena or large
amount of blood in his stools. The cause of his chronic anemia
was thought to be likely a combination of anemia of chronic
disease, iron deficiency, and HIV-related impaired bone marrow
production. He was continued on iron supplements and Hct stable
at 25 at discharge.
# HIV/AIDS: Poorly-controlled due to medication non-adherence.
He is followed in ___ clinic by Dr. ___ advised that
patient be continued on prescribed home medications of abacavir,
lamivudine (initially renally-dosed), darunavir, ritonavir and
ppx with bactrim and azithro. Patient was continued on these
medications at discharge w/follow-up in ___ clinic to be arranged
by Dr. ___.
# HIV enteropathy: His chronic diarrhea was previously worked
up with negative infectious studies (including C diff,
Microsporida, Cyclospora, Crypto, CMV-, IGA normal, TTG neg, H
Pylori neg. Strongyloides), upper endoscopy, colonoscopy and
capsule endoscopy with negative biopsies. He was noted to have
chronic diarrhea at slightly decreased frequency while inpatient
(5 versus usual of ___ and given IVF for volume repletion.
## Transitional Issues:
- F/u electrolytes as outpatient on ___.
- Nephrology, ID f/u as outpatient.
- Possible urinary retention as cause of his renal failure but
PVR <50 at discharge, urinating on own. If concern for
retention, refer to urology.
- Concern for med compliance, addressed by medical team, SW and
his outpatient ID doctor during admission. Recommend patient
establish care with a psychiatry as outpatient to offer support
with dealing with his medical illnesses and ongoing social
factors.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Magnesium Oxide 400 mg PO ONCE
2. LOPERamide 4 mg PO DAILY
3. Opium Tincture 10 DROP PO Q6H:PRN diarrhea
4. abacavir-lamivudine 600-300 mg oral daily
5. Darunavir 800 mg PO DAILY
6. RiTONAvir 100 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
9. Azithromycin 1200 mg PO 1X/WEEK (___)
10. Calcium Carbonate 500 mg PO DAILY
11. Potassium Chloride (Powder) 40 mEq PO DAILY
12. albuterol sulfate 90 mcg/actuation inhalation ___ puffs q4hr
cough/sob
13. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
Discharge Medications:
1. Azithromycin 1200 mg PO 1X/WEEK (___)
2. Darunavir 800 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
5. RiTONAvir 100 mg PO DAILY
6. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
7. abacavir-lamivudine 600-300 mg oral daily
8. albuterol sulfate 90 mcg/actuation inhalation ___ puffs q4hr
cough/sob
9. LOPERamide 4 mg PO DAILY
10. Opium Tincture 10 DROP PO Q6H:PRN diarrhea
11. Potassium Chloride (Powder) 40 mEq PO DAILY
12. Calcium Carbonate 500 mg PO TID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth three times a day Disp #*30 Tablet Refills:*1
13. Sodium Bicarbonate 650 mg PO QID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth four times a
day Disp #*30 Tablet Refills:*1
14. Magnesium Oxide 400 mg PO ONCE Duration: 1 Dose
15. Outpatient Lab Work
Check chem-10 on ___ and fax to PCP: ___
___. ICD9: hypokalemia 276.8
Discharge Disposition:
Home
Discharge Diagnosis:
Metabolic Acidosis
Hypokalemia
Acute on chronic kidney Injury
Human immunodeficiency virus/acquired immunodeficiency syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted for low potassium, acidosis, and anemia, as
well as continued pain at your surgical site.
Your low potassium and acidosis are due to both diarrhea and
kidney disease, for which you should follow up in outpatient
___ clinic. Please continue your medications and supplements
as prescribed and follow up in clinic appointments.
For your anemia, it is believed to be secondary to long-standing
infection. You were transfused 2 units of blood while in house
for low blood counts and dizziness.
For your pain, you were evaluated by the colorectal surgery team
who thought your wound looked normal. Pain was controlled with
scheduled tylenol and oxycodone as needed.
We also recommend you establish care with a psychiatrist.
Wishing you well,
Your ___ MEdicine Team
Followup Instructions:
___
|
10296472-DS-12 | 10,296,472 | 28,456,442 | DS | 12 | 2121-09-02 00:00:00 | 2121-09-02 18:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypokalemia, Chronic diarrhea, Weakness
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Seen in outpatient follow-up in ___ clinic yesterday (___) for
routine follow-up. At that time he reported ongoing watery
diarrhea, poor PO intake and dysphagia as well as night sweats.
Labs drawn at that time revealed severe electrolyte disarray
with K of 2.0, phos 1.4 and Mg 0.6. He was contacted by phone
and urged emergently present to the ED, but stated he would come
in the following day.
Most recent hospitalization (___) was for salmonella;
discharged on cefpodoxime PO (reported to have finished course
as outpt). He has been off ART since his most recent hospital
stay. Most recent CD4 count was 1 w/ VL 426K ( )
ROS:
ConstitutionaL: + chills, night sweats without fever
Pulm: no cough/sputum
Neuro: no HA, vision change; weakness with standing
Past Medical History:
HIV dx ___: on HAART ___
pancytopenia
chronic diarrhea: presumed HIV enteropathy, with recurrent
electrolyte derangements
CKD with RTA
RLE Neuropathy s/p mvc ___: pedestrian, was struck
Social History:
___
Family History:
Mother: Alive, hypertension
Father: Alive
Brother: ___
Brother: HIV positive
Brother: ___, MI
Physical Exam:
ADMISSION EXAM
Vitals: R: 18
GENERAL: Alert, oriented, no acute distress. Appears
malnourished.
HEENT: Sclera anicteric, MMM, oropharynx clear without thrush
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: Dry, loss of turgor
NEURO: A&Ox3
DISCHARGE EXAM
Vitals: 97.9 108/67 74 18 100%RA
General: Cachectic man laying in hospital bed in NAD, AOx3
HEENT: NCAT, anicteric, PERRL, EOMI, MMM no evidence of thrush,
O/P clear, temporal wasting
Lymph: no cervical LAD appreciated
CV: RRR, normal S1, S2, no m/r/g appreciated
Lungs: CTAB
Abdomen: + BS, soft, mild distension, nontender to palpation
GU: no Foley
Ext: thin, warm, well perfused
Neuro: CN II-XII grossly intact. A&Ox4.
Skin: warm, dry, mild excoriations noted on his back,
hyperpigmented papules noted across upper and lower back; rash
continues on arms and legs bilateraly. Severe onychomycosis of
the left hand fingernails; onychyomycosis on toenails. Linear
subcutaneous pigmentations on all nails.
Pertinent Results:
ADMISSION
___ 01:00PM BLOOD WBC-6.6# RBC-3.41* Hgb-8.9* Hct-28.0*
MCV-82 MCH-26.2* MCHC-32.0 RDW-21.9* Plt ___
___ 01:00PM BLOOD Neuts-50.5 Lymphs-7.4* Monos-5.6
Eos-36.5* Baso-0.1
___ 01:00PM BLOOD Hypochr-OCCASIONAL Anisocy-3+ Poiklo-2+
Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL
Spheroc-OCCASIONAL Ovalocy-OCCASIONAL Target-OCCASIONAL Tear
Dr-OCCASIONAL
___ 01:00PM BLOOD Plt Smr-NORMAL Plt ___
___ 01:00PM BLOOD UreaN-24* Creat-3.7*# Na-134 K-2.0*
Cl-109* HCO3-12* AnGap-15
___ 01:00PM BLOOD Glucose-91
___ 01:00PM BLOOD ALT-38 AST-55* AlkPhos-266* TotBili-0.3
___ 01:00PM BLOOD TotProt-7.5 Albumin-3.2* Globuln-4.3*
Calcium-3.9* Phos-1.4* Mg-0.6*
___ 07:32AM BLOOD calTIBC-137* Ferritn-439* TRF-105*
___ 06:19PM BLOOD ___ pO2-34* pCO2-29* pH-7.16*
calTCO2-11* Base XS--18 Intubat-NOT INTUBA
___ 10:21PM BLOOD freeCa-0.80*
___ 22:04
LYMPHOCYTE SUBSET PANEL
Test Result Reference
Range/Units
% CD3 (MATURE T CELLS) 59 ___ %
ABSOLUTE CD3+ CELLS 184 L ___
cells/uL
% CD4 (HELPER CELLS) 0 L ___ %
ABSOLUTE CD4+ CELLS <20 L ___
cells/uL
% CD8 (SUPPRESSOR T CELLS) 49 H ___ %
ABSOLUTE CD8+ CELLS 154 L ___
cells/uL
HELPER/SUPPRESSOR RATIO 0.01 L 0.86-5.00
ABSOLUTE LYMPHOCYTES 313 L ___
cells/uL
___ CXR IMPRESSION:
No acute cardiopulmonary abnormality.
___ CT Abdomen + Pelvis IMPRESSION:
1. No acute intra-abdominal finding.
THIS TEST WAS PERFORMED AT:
___
___
Test Result Reference
Range/Units
COMMENT(S) DNR
REPORT COMMENT:
EDTA WHOLE BLOOD
DISCHARGE LABS
___ 03:10PM BLOOD WBC-3.0* RBC-3.20* Hgb-8.7* Hct-27.0*
MCV-84 MCH-27.3 MCHC-32.3 RDW-19.1* Plt ___
___ 04:15AM BLOOD Neuts-60 Bands-0 Lymphs-8* Monos-12*
Eos-20* Baso-0 ___ Myelos-0
___ 04:15AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear Dr-1+
___ 03:10PM BLOOD Plt ___
___ 03:10PM BLOOD Glucose-134* UreaN-9 Creat-2.1* Na-138
K-3.5 Cl-112* HCO3-17* AnGap-13
___ 01:28PM BLOOD LD(LDH)-244
___ 03:10PM BLOOD Calcium-7.3* Phos-2.6* Mg-1.9
___ 01:28PM BLOOD Hapto-86
___ 02:35AM BLOOD 25VitD-8*
___ 03:12PM BLOOD ___ Temp-36.8 pH-7.29* Comment-GREEN
TOP
___ 03:12PM BLOOD freeCa-1.05*
___ 06:03AM BLOOD STRONGYLOIDES ANTIBODY,IGG-Test NEGATIVE
___
ZINC
Test Result Reference
Range/Units
ZINC 52 L 60-130 mcg/dL
THIS TEST WAS PERFORMED AT:
___, ___
___, MD
IMAGING
___ CXR IMPRESSION:
No acute cardiopulmonary abnormality.
___ CT ABDOMEN + PELVIS IMPRESSION:
1. No acute intra-abdominal finding.
Brief Hospital Course:
___ year old male with a history of HIV/AIDS with poor adherence
to ART, very low CD4 count (CD4 1 w/ VL 81,000 in ___
chronic diarrhea resulting in significant electrolyte
abnormalities who was seen in ___ clinic on ___ in routine
follow up after recent hospitalization with Salmonella enteritis
and found to have significant electrolyte abnormalities on
bloodwork in the setting of worsened subacute diarrheal output.
Given the severity of his electrolyte derangements, he was
initially admitted to the MICU for potential CRRT. He was given
aggressive electrolyte repletion, IVF, and monitored closely on
telemetry. Nephrology was consulted given his significant AG
metabolic acidosis caused by his diarrheal illness. Stool
culutures were sent, showing negative C.diff and postive
salmonella species. The patient was started on Lomotil and
Immodium and along with antibiotic therapy (Ceftriaxone), his
output decreased. During this time he was transferred to the
medical floors for further management. He cited his recent
depression as a barrier to adherence of ART therapy. Psychiatry
was consulted, diagnosed major depressive disorder and
prescribed Zoloft. Patient's electrolytes improved during the
course of admission to the floor and his IV repletion was
switched to oral repletion. He will be discharged to a
rehabilitation facility with planned IV ceftriaxone therapy
followed by oral cefpodoxime until scheduled follow-up with his
infectious disease doctors.
# Severe electrolyte abnormalities (Hypokalemia, Hypocalcemia):
Likely combination of GI losses from chronic diarrhea as well as
derangements from chronic renal failure. Patient has required
extensive repletion of K to >4, Mg to >2, Phos and calcium in
the MICU and on the floor. He had no concerning arrhythmias on
telemetry throughout admission. Antidiarrheal agents and fluids
were given to maintain euvolemia.
# Salmonella Enteritis: Likely due to reccurance of Salmonella
as patient may not have completed dose of Cefpodoxime or initial
treatment may have been ineffective. Diarrhea has largely been
attributed to HIV Enteropathy in the past. Infectious disease
team consulted on return of postive stool culture. CT
Abdomen/pelvis noted no acute intrabdominal findings suggestive
of salmonella collection or abscess. Started on IV ceftriaxone
therapy and will transition to PO cefpodoxime as described
above. With negative E.Coli and C.diff, continued Lomotil and
Immodium PRN during admission. Larger goal of immune system
reconsitution via reinitation of ART therapy critical to
preventing future recurrence.
# Normocytic anemia: iron studies with normal iron and elevated
ferritin, most likely in setting of chronic disease. Corrected
retic count inappropriate. However, patient continued to have
slow decreases in blood, requiring a unit of blood on ___ and
___. After this, patient's hemoglobin and hematocrit remained
stable. Patient denied overt blood in BMs. Hemolysis labs to
evaluate for RBC destruction unrevealing. Attributed to frequent
blood draws, dilutional effect in the setting of anemia of
chronic disease. H+H stable for 2 days prior to discharge.
# Non-gap Metabolic Acidosis: Originally anion gap metabolic
acidosis likely from ongoing losses in setting of diarrhea in
the setting of chronic kidney disease. Bicarb and pH improved
throughout admission, closer to chronic baseline. There has been
question of possible RTA in the past in setting of Tenofovir use
and some degree of metabolic acidosis is chronic. Nephrology
followed during admission and recommended aggresive repletion of
lytes during diarrheal illness. Patient discharged on standing
bicarb, potassium, and calcium therapy.
# Acute on Chronic Kidney Injury: Cr on admission of 4.2
improved to 2.1 at discharge. Baseline creatinine is closer to
2 though with frequent elevations on recent admissions, likely
reflecting pre-renal etiology. Has improved with fluid
resuscitation, suggesting again a pre renal etiology with volume
depletion from ongoing diarrhea and poor PO intake. He
described initial dizziness which resolved on admission to the
floor. Patient will continue Vit D2 50,000U daily x 1 week (day
1 = ___.
# HIV/AIDS: Patient's last CD4 count was 1 in ___ of this
year. He notes poor compliance with HAART because of
depression. He has clear failure to thrive at this point and
outpatient ID team is significantly concerned about his social
challenges and adherence to medication. He was seen by SW in
MICU and had extensive conversation about his resources
including SSI and SSDI. Additional conversations were held in
the MICU regarding possible placement of patient in a SNF for
closer monitoring of electrolytes/hydration/medication
administration. Pt refusing to finish course of nystatin swish
and swallow. Patient continued on ppx with Bactrim and
Azithromycin. ART therapy was re-iniated after extensive
conversation with the patient on ___.
# Eosinophilia: Patient with marked eosinophilia this admission,
worsening in past year. Is not entirely new as was noted a year
ago though this is the most profound eosinophilia to date (with
absolute eos of almost 2,000). Unclear etiology but
differential is broad and includes parasitic or fungal
infections, leukemia or lymphoma. Strongyloides IgG negative.
Per discussion with ID, esoinophila has been worked up
extensively including GI work-up and is likely just untreated
HIV infection. Found to be downtrending at time of discharge.
TRANSIITONAL ISSUES:
-Ceftriaxone to complete 2 week course (up to and on ___.
Then start Cepodoxime 200 mg PO q 12hr until follow-up
appointment with Dr. ___ on
___ at 11:30 AM
-Patient needs weekly CBC w/ diff, CHEM10, AST/ALT TBili, Alk
Phos
**PLEASE FAX RESULTS TO ___
**ID SPECIALIST OFFICE PHONE: ___
-Please check Chem10 daily and titrate electrolyte repletion as
indicated
-Patient has newly diagnosed major depression and was recently
started on Zoloft 50 mg PO daily. He should continue this
medicaiton and follow-up with additional non-pharmalogical
measures to help his mood (i.e. therapy, excercise)
-Patient diagnosed with oral thrush at previous discharge,
self-discontinued and unclear how long patient was previously
taking therapy. No evidence of oral thrush during inpatient
stay, however, close monitoring and low threshold for
re-initation if suspected.
-Patient has repeatedly voiced desire for simplified medication
regimen. In setting of recent illness, requires multiple
medications to help treat acute dirrheal illness and subsequent
electrolyte abnormalities. Medication list should be evaluated
and as simplified as possible when re-evaluated in outpatient
setting.
-Patient noted to have vitamin D deficiency requiring 7 days of
high dose therapy (should be continued up to and on ___.
After this time, he can start supplental doses of Vitamin D3
1000 IU daily. His vitamin D level should be re-checked in 8
weeks.
-Patient noted to have low zinc levels during admission, patient
initated on Zinc therapy 220 mg PO for 2 weeks (up to and on
___. His zinc level should be re-checked after completion
of therapy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Azithromycin 1200 mg PO 1X/WEEK (___)
2. LOPERamide 4 mg PO Q6H diarrhea
3. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
2. Calcium Carbonate 1500 mg PO TID
3. CeftriaXONE 1 gm IV Q24H
Please continue to complete 2 week course (up to and on ___
4. Sertraline 50 mg PO DAILY
5. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
6. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
7. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
8. Zinc Sulfate 220 mg PO DAILY
Please continue to complete 2 week course (up to and on
___.
9. Epzicom (abacavir-lamivudine) 600-300 mg oral qdaily
10. Dolutegravir 50 mg PO DAILY
11. LOPERamide 4 mg PO Q6H diarrhea
12. Azithromycin 1200 mg PO 1X/WEEK (MO)
13. Vitamin D 50,000 UNIT PO DAILY Duration: 1 Week
Please continue to complete 7 day course (up to and on ___
14. Psyllium Wafer 1 WAF PO DAILY
15. Potassium Chloride (Powder) 40 mEq PO BID
Hold for K > 5.0
16. Outpatient Lab Work
ICD-9 003.9 Salmonella infection, unspecified
CBC w/ diff, CHEM10, AST/ALT TBili, Alk Phos
**PLEASE FAX RESULTS TO Attn: ___ MD ___
**ID SPECIALIST OFFICE PHONE: ___
17. Sodium Bicarbonate 1300 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
Salmonella Enteritis
Advanced Immunodeficiency Disorder
Major Depressive Disorder, mild to moderate
Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure treating you at ___
___. You were admitted with concern for your abnormally low
electrolyte levels in the setting of your recent diarrhea. You
were initially admitted to the intensive care unit with concern
for these lab findings where they aggresively repleted your
electrolytes and monitored you closely. The kidney doctors also
followed ___ through your admission to help with this. Once your
diarrhea slowed and your eletrolytes repletion slowed down, you
were transferred to the floor you continued to receive
electrolytes. It was found you had a stomach infection similar
to the infection that put you in the hospital last time and you
were prescribed antibiotics to help treat it. Give your recent
depressed mood, our pyschiatric specialists evaluated you and
recommended a new medication to help you feel better. You were
re-started on a new regimen of medication to treat your AIDS. It
is critical you continue take this medication going forward to
help prevent this illness from occuring again. Furthermore, you
were started on a number of medications to help maintain your
electrolyte count in the setting of this chronic diarrheal
illness, which are also essential, along with your prescribed
course of antibiotics. While there are a number of medications
to take, each has been determined to be of critical value by
those evaluating you and taking them will help you get and stay
well. Please follow-up with the outpatient providers as listed
below.
Wishing you the very best of health,
Your ___ team
Followup Instructions:
___
|
10296472-DS-14 | 10,296,472 | 21,047,134 | DS | 14 | 2121-11-21 00:00:00 | 2121-11-25 15:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypokalemia, Hypomagnesemia
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
___ year old male with a history of HIV/AIDS with history of poor
adherence to ART, very low CD4 count (CD4 <20 in ___ with
chronic diarrhea who was advised to come to ED by his PCP after
finding hypokalemia, hypomagnesemia on labs drawn on ___. He
also reports malaise, weakness and ongoing nausea/vomiting x1
week with inability to take in POs. Patient reports not taking
his HIV medications or prescribed potassium/magnesium
supplementation. He denies fevers, increase in stool frequency,
abdominal pain or dysuria.
Of note patient was recently admitted to ___ from
___ for weakness/malaise and flu-like symptoms,
found to have low K and Mg on presentation thought secondary to
chronic diarrhea and poor compliance with prescribed PO
supplementation. During that admission, lytes were aggressively
repleted. In addition was found to have salmonella enteritis,
treated with cefpodoxime, and ___ esophagitis found on small
bowel enteroscopy treated with fluconazole. Patient underwent
colonoscopy as well during that admission focal cryptitis in
colon, CMV negative. Patient had labs drawn after discharge on
___, per records found to have low K (<3) and low bicarb (13).
Pt was called regarding his labs and was advised to take his
potassium supplementation.
In the ED, initial vitals: 99.8 98 86/56 18. Labs notable for:
BUN/Cr 52/12.2, Na 123, K 1.9, ___, Ca 5.5, Mg 1.0,
Phos 5.6, WBC 8.6, ALT/AST/Alk Phos ___, Lip 154,
Lactate 1.6. Patient given 2g MgSO4, 40mEq potassium, and 1g
CTX. CXR with linear left basilar opacity, potentially
atelectasis. ECG with ST dep in lateral leads, worse than
prior, Trop 0.08, CK-MB 4.
On arrival to the MICU, VS were T 98.7 BP 102/58, HR 92, RR 18,
99% on RA. Patient was hemodynamically stable, reported
nausea/vomiting, back pain, no fevers, no abdominal pain, no
chest pain, palpitations.
Review of systems:
(+) Per HPI
(-) Denies fever, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, or wheezing.
Denies chest pain, chest pressure, palpitations. Denies
constipation, abdominal pain. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
-HIV dx ___: on HAART ___
-Pancytopenia
-Chronic diarrhea: presumed HIV enteropathy, with recurrent
electrolyte derangements
-CKD with RTA
-RLE Neuropathy s/p mvc ___: pedestrian, was struck
Social History:
___
Family History:
Mother: Alive, hypertension
Father: Alive
Brother: ___
Brother: HIV positive
Brother: ___, MI
Dad and brother with DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
=============================
Vitals- T:98.7 BP:102/58 P:92 R: 18 O2:99% RA
GENERAL: Cachectic male, alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: Speech fluent, moving all extremities, CN2-12 grossly
intact
DISCHARGE PHYSICAL EXAM:
=============================
PHYSICAL EXAM:
Vitals: 98.3 98.1 87-110/46-68 ___ 16RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, moist mucous membranes, no evidence of
thrush
Neck: supple, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, ___ systolic murmur appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no RUQ tenderness
GU: no foley
Ext: warm, well perfused, edema. Nails crusted, appears possible
fungal infection
Neuro: motor function grossly normal
Pertinent Results:
ADMISSION LABS:
======================
___ 04:22PM BLOOD WBC-8.6 RBC-4.76 Hgb-12.6*# Hct-36.0*
MCV-76*# MCH-26.5* MCHC-35.1*# RDW-18.4* Plt ___
___ 04:22PM BLOOD Neuts-86.6* Bands-0 Lymphs-7.3* Monos-5.5
Eos-0.4 Baso-0.2 ___ Myelos-0
___ 09:15PM BLOOD ___ PTT-38.6* ___
___ 04:22PM BLOOD Glucose-95 UreaN-52* Creat-12.2*# Na-123*
K-1.9* Cl-87* HCO3-12* AnGap-26*
___ 04:22PM BLOOD ALT-235* AST-163* CK(CPK)-97 AlkPhos-263*
TotBili-0.3
___ 04:22PM BLOOD Lipase-154*
___ 04:22PM BLOOD CK-MB-4 cTropnT-0.08*
___ 04:22PM BLOOD Albumin-4.0 Calcium-5.5* Phos-5.6*#
Mg-1.0*
___ 09:48PM BLOOD ___ pO2-107* pCO2-33* pH-7.14*
calTCO2-12* Base XS--16 Comment-GREEN TOP
___ 06:30PM BLOOD Glucose-86 Lactate-1.6 K-1.8*
___ 04:23AM URINE Color-Straw Appear-Clear Sp ___
___ 04:23AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:23AM URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
___ 04:23AM URINE Hours-RANDOM Creat-38 Na-89 K-17 Cl-89
___ 04:23AM URINE Osmolal-270
DISCHARGE LABS:
======================
___ 05:00AM BLOOD WBC-2.4* RBC-2.90* Hgb-7.4* Hct-23.3*
MCV-80* MCH-25.7* MCHC-32.0 RDW-18.1* Plt ___
___ 05:00AM BLOOD Neuts-65.8 ___ Monos-8.4 Eos-4.6*
Baso-0.1
___ 05:00AM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-2+
Macrocy-2+ Microcy-1+ Polychr-NORMAL Tear Dr-1+ Fragmen-1+
___ 05:00AM BLOOD Plt ___
___ 10:40PM BLOOD WBC-2.4* Lymph-18 Abs ___ CD3%-78
Abs CD3-336* CD4%-1 Abs CD4-5* CD8%-69 Abs CD8-299 CD4/CD8-0.02*
___ 12:59PM BLOOD Glucose-130* UreaN-10 Creat-1.8* Na-136
K-3.8 Cl-114* HCO3-14* AnGap-12
___ 05:00AM BLOOD ALT-62* AST-35
___ 12:59PM BLOOD Calcium-7.1* Phos-1.9* Mg-2.4
___ 01:25PM BLOOD ___ pO2-114* pCO2-35 pH-7.19*
calTCO2-14* Base XS--13
___ 01:25PM BLOOD Lactate-1.9
___ 10:11AM BLOOD freeCa-1.05*
MICROBIOLOGY:
=======================
___: HIV-1 viral load
HIV-1 Viral Load/Ultrasensitive (Final ___:
3,660 copies/ml.
Performed using the Cobas Ampliprep / Cobas Taqman HIV-1
Test v2.0.
Detection Range: ___ copies/mL.
___: Stool O+P
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
___: CMV Viral Load
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.
___: Stool C.diff assay and culture
MICROSPORIDIA STAIN (Final ___: NO MICROSPORIDIUM SEEN.
CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___:
Reported to and read back by ___ ___ @9:22 AM.
SALMONELLA SPECIES. CONFIRMED BY STATE LAB ___.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
IMAGING:
=======================
Renal U/S ___:
IMPRESSION:
1. No signs of hydronephrosis. Nonobstructive right and left
renal calculi including a 5 mm right lower pole calculus.
2. 1.9 cm superficial lesion in the right posterior bladder.
Recommend
cystoscopy for further evaluation for a possible urothelial
lesion.
RUQ U/S ___:
IMPRESSION:
1. No sonographic signs of cholecystitis.
2. Gallbladder wall edema is non-specific and may be due to HIV
cholangiopathy or liver disease.
3. 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.
4. 4 mm non-obstructive right lower pole renal calculus.
Brief Hospital Course:
This is a ___ year old male with a past medical history of AIDS,
HIV enteropathy w chronic diarrhea, CKD stage IV, chronic
salmonella enteritis on cefpoxime admitted ___ to the MICU
w ___, metabolic acidosis, severe hypokalemia and magnesemia in
setting of worsening diarrhea, now status post aggressive
electrolyte and fluids repletion, failing trial of PO repletion
and remaining with metabolic acidosis and hypokalemia, opting to
leave against medical advice.
# Metabolic acidosis: Patient admitted with VBG 7.___, an
elevated anion gap (24), HCO3 of 12. This was likely due to ___
and acute on chronic diarrhea. He required ICU admission for
volume resuscitated, IV bicarb to maintain pH>7.25. His diarrhea
was treated as below. He was trialed on cessation of IV fluids
and IV repletion and on day of discharge, his VBG pH was 7.19.
Pt voiced his desire to leave the hospital given family issues.
We informed him of the risks of leaving the hospital given the
degree of acidemia and we recommended that he stay until his pH
stabilized. Despite these risk, he left AMA. Pt was discharged
with the safest possible combination of repletion which included
increasing his PO sodium bicarbonate dose along with increased K
repletion (increased bicarbonate would lead to intracellular
shift of K and cause a drop). Pt was given all of his
prescriptions and a ___ was set up to ensure he had the meds at
home. He will follow-up with his PCP.
# Hypomagnesemia/Hypokalemia/hypophosphatemia: This was likely
related to severe diarrhea. Admission EKG showed U waves. He
was repleted with IV. As above, trial of PO repletion failed,
but patient left against medical advice.
# Acute on Chronic Diarrhea / HIV Enteropathy - patient
presented with acute on chronic watery diarrhea; ruled out for
acute bacterial infection; repleted electrolytes as above;
diarrhea felt to relate to non compliance to ART. Improved with
initiation of home meds and use of intermittent lomotil once
acute infection was ruled out.
# History of Salmonella enteritis: Given history of salmonella
enteritis, patient was maintained on cefpodoxime prophylaxis.
# Acute Kidney Injury / CKD stage 3 - creatinine at 12.2 on
admission from baseline likely between 2.0-3.0, related to
dehydration; resolved to baseline with fluid resuscitation
# Hyponatremia: Na at 123 on admission, likely hypovolemic
hyponatremia in the setting of chronic diarrhea. This resolved
with aggressive IVF resusicitation.
# Transaminitis: On admission ALT 235, AST 163. Thought to be
related to dehydration and hypoperfusion. CMV negative. At
discharge had trended down to ALT 62, AST 35. Can be rechecked
as outpatient for resolution
# HIV: Suspected noncompliance as outpatient. Continued ART
regimen. Continued bactrim, azithromycin, cefpodoxime
prophylaxis at discharge.
# Depression / Social challenges: The patient had a history of
depression and medication non-compliance. We continued him on
sertraline and maintained close communication with his PCP and
outpatient providers. He was extensively counseled on the
importance of taking his medications. Additionally, he met with
social work to discuss some of his home challenges. We
recommended discharge to rehab to ensure med adherance but he
declined. As described above, he left AMA.
TRANSITIONAL ISSUES
[] A 1.9 cm oval lesion was detected in the right posterior
bladder. We recommend cystoscopy for further evaluation for a
possible urothelial lesion.
[] The patient will require followup with the ___ clinic.
[] The patient will require followup with the ___ clinic and
further counseling on medication compliance.
[] The patient is moving to ___ with his daughter, and may
need additional care coordination.
[] The patient will be on cefpodoxime until his immune system is
re-constituted. This will be up to his outpatient providers to
decide.
[] Trend transaminitis as an outpt.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Azithromycin 1200 mg PO 1X/WEEK (MO)
2. Dolutegravir 50 mg PO DAILY
3. Magnesium Oxide 400 mg PO TID
4. Sertraline 50 mg PO DAILY
5. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
6. Nystatin Cream 1 Appl TP BID
7. Ondansetron 4 mg PO Q8H:PRN nausea
8. Phosphorus 250 mg PO DAILY
9. Epzicom (abacavir-lamivudine) 600-300 mg oral qdaily
10. Psyllium Wafer 1 WAF PO DAILY
11. Sodium Bicarbonate 1300 mg PO BID
12. Potassium Chloride (Powder) 40 mEq PO BID
13. LOPERamide 4 mg PO DAILY
Discharge Medications:
1. Azithromycin 1200 mg PO 1X/WEEK (MO)
RX *azithromycin 600 mg 2 tablet(s) by mouth once a week Disp
#*8 Tablet Refills:*0
2. Dolutegravir 50 mg PO DAILY
RX *dolutegravir [Tivicay] 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
3. Potassium Chloride (Powder) 40 mEq PO BID
RX *potassium chloride 40 mEq/15 mL 15 mL by mouth twice a day
Refills:*0
4. Sertraline 50 mg PO DAILY
RX *sertraline 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Calcium Carbonate 1000 mg PO QPM
RX *calcium carbonate 500 mg calcium (1,250 mg) 2 tablet(s) by
mouth with dinner Disp #*60 Tablet Refills:*0
6. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every 12 hours Disp
#*60 Tablet Refills:*0
7. Diphenoxylate-Atropine 1 TAB PO BID
RX *diphenoxylate-atropine 2.5 mg-0.025 mg 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
8. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth once a week Disp #*4 Capsule Refills:*0
9. Magnesium Oxide 400 mg PO TID
RX *magnesium oxide 400 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
10. Nystatin Cream 1 Appl TP BID
RX *nystatin 100,000 unit/gram apply to rash twice a day
Refills:*0
11. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*15 Tablet Refills:*0
12. Psyllium Wafer 1 WAF PO DAILY
RX *psyllium [Metamucil] 1.7 g 1 wafer(s) by mouth daily Disp
#*30 Wafer Refills:*0
13. Epzicom (abacavir-lamivudine) 600-300 mg oral qdaily
RX *abacavir-lamivudine [Epzicom] 600 mg-300 mg 1 tablet(s) by
mouth once a day Disp #*30 Tablet Refills:*0
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
15. Potassium Chloride 20 mEq PO NOON
Hold for K >
RX *potassium chloride 20 mEq/15 mL 15 mL by mouth at noon
Refills:*0
16. Neutra-Phos 2 PKT PO BID
RX *potassium & sodium phosphates [Phos-NaK] 280 mg-160 mg-250
mg 2 powder(s) by mouth twice a day Disp #*120 Packet Refills:*0
17. Sodium Bicarbonate 1300 mg PO TID
RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth three times a
day Disp #*180 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Acute Kidney Injury on Chronic Kidney Disease,
Hypokalemia, Hypomagnesia, Hypocalcemia, Metabolic Acidodisis,
Salmonella Enteritis
Secondary: HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you during your admission to
___. You were initially admitted due to poor oral intake of
fluids and foods as well as severe electrolyte abnormalities
that we thought could cause serious life-threatening
arrhythmias. Additionally, your blood was found to be too
acidic, your renal function was impaired, and you had diarrhea
caused by salmonella enteritis. These issues probably developed
in the context of not taking your HIV anti-retrovirals and
prescribed electrolytes. We hospitalized you to replete your
electrolytes and give enough fluids to return your renal
function to normal. We started you on antibiotics to treat your
salmonella enteritis and re-started you on your HIV medications.
We also aggressively repleted your electrolytes.
We wanted to ensure that your electrolytes were stable and
address your acidosis. However, you chose to leave against
medical advice. We explained that the risks of leaving could
include a potentially fatal arrhythmia or renal failure. You
understood the risks of which included death from an abnormal
heart rhythm. You were instructed on the importance of taking
your medications.
It is absolutely vital that you continue your prescribed
medications, or you will likely require another hospitalization
in the immediate future. Additionally, please make sure to
attend your follow up appointments. Please let us know if you
have any questions.
___ MDs
Followup Instructions:
___
|
10296472-DS-15 | 10,296,472 | 26,427,089 | DS | 15 | 2121-12-22 00:00:00 | 2122-01-09 09:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weakness/malaise
Major Surgical or Invasive Procedure:
___ - Right IJ Central Venous catheter placement
History of Present Illness:
___ yo M with a PMHx of AIDS (last CD4 count was 5 on
___ difficulty adhering to HAART, chronic metabolic
acidosis secondary to diarrhea and possible RTA, and recurrent
salmonella enteritis, who presented with complaints of diffuse
weakness, lethargy and malaise as well as increase in stool
output. Patient has had several admissions for similar
problems, largely in the setting of medication nonadherence in
___ and ___. Though he has not been feeling
well for several weeks since leaving the hospital, but he only
finally presented to the ED today in the setting of weakness.
At home he has not been taking any of his medications because he
was having nausea and vomiting and couldn't keep anything down.
He has had increase in his number of daily BMs from about 4 to
___ daily.
Review of his chart shows multiple attempts on behalf of Mr.
___ ID team at ___ to contact him regarding his
electrolyte management in the past few weeks.
In the ED, initial vitals: Pain 10 99.5 94 113/65 16 100% RA.
His labs were notable for K of 1.7, corrected Calcium of 6.3,
Mag of 0.7, Phos of 1.8 and Na 125. Creatinine was 9.7 (at last
check was 1.9). He was noted to have a leukocytosis to 13. He
was complaining of low back pain. A CXR was concerning for a
left lower lobe infiltrate. He was given empirically
Cipro/Flagyl given his increased stool output. He was repleted
with Magnesium and a liter of NS with 40 mEq was started.
On transfer, vitals were: 98.9 78 107/66 18 100% RA.
On arrival to the MICU, Mr. ___ complained of some
dizziness. He denied cough or fever. He reported no current.
He was endorsing seeing some shadows in the past few days that
he knew weren't really there like his eyes were playing tricks
on him. He notes feeling some confusion regarding why he
continues to have diarrhea.
Review of systems:
(+) Per HPI
(-) Denies fever, chills. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies cough, shortness of breath, or
wheezing. Denies chest pain. Denies abdominal pain. Denies
dysuria, frequency, or urgency. Denies rashes or skin changes.
Past Medical History:
-HIV dx ___: on HAART ___
-Pancytopenia
-Chronic diarrhea: presumed HIV enteropathy, with recurrent
electrolyte derangements
-CKD with RTA
-RLE Neuropathy s/p mvc ___: pedestrian, was struck
Social History:
___
Family History:
Mother: Alive, hypertension
Father: Alive
Brother: ___
Brother: HIV positive
Brother: ___, MI
Dad and brother with DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
Vitals- T: 98.3 BP: 103/56 P: 76 R: 17 O2: 100%RA
GENERAL: Alert, oriented, pleasant
HEENT: Sclera anicteric, mucus membranes dry, O/P clear, no
thrush present
NECK: supple, JVP not elevated
LUNGS: grossly clear to auscultation, no crackles
CV: Regular rate and rhythm, II/VI systolic murmur best heard at
___ without radiation
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: Warm, well perfused, 2+ pulses
SKIN: warm, dry, no rashes, occhynomycosis of fingernails
bilaterally
NEURO: CN II-XII grossly intact, nonfocal
DISCHARGE PHYSICAL EXAM:
===========================
Pertinent Results:
ADMISSION LABS:
======================
___ 03:57PM BLOOD WBC-13.0*# RBC-3.51* Hgb-8.8* Hct-27.2*
MCV-78* MCH-25.2* MCHC-32.5 RDW-20.5* Plt ___
___ 03:57PM BLOOD Neuts-88.6* Lymphs-3.6* Monos-7.3 Eos-0.4
Baso-0.2
___ 07:45PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-2+
Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Ovalocy-1+
Target-OCCASIONAL Schisto-1+ Burr-OCCASIONAL Tear Dr-OCCASIONAL
___ 07:45PM BLOOD ___ PTT-29.9 ___
___ 03:57PM BLOOD Glucose-106* UreaN-46* Creat-9.7*#
Na-125* K-1.7* Cl-100 HCO3-6* AnGap-21*
___ 03:57PM BLOOD Albumin-3.1* Calcium-5.4* Phos-1.8*
Mg-0.7*
___ 05:45PM BLOOD ___ pO2-29* pCO2-27* pH-7.12*
calTCO2-9* Base XS--20
___ 08:16PM BLOOD freeCa-0.89*
OTHER PERTINENT LABS:
=======================
___ 07:45PM BLOOD WBC-13.3* RBC-3.27* Hgb-8.3* Hct-25.8*
MCV-79* MCH-25.3* MCHC-32.1 RDW-20.5* Plt ___
___ 12:42AM BLOOD WBC-10.6 RBC-2.93* Hgb-7.5* Hct-22.7*
MCV-77* MCH-25.6* MCHC-33.1 RDW-20.4* Plt ___
___ 08:58AM BLOOD WBC-10.1 RBC-2.93* Hgb-7.4* Hct-23.2*
MCV-79* MCH-25.2* MCHC-31.9 RDW-20.7* Plt ___
___ 01:55AM BLOOD WBC-9.9 RBC-2.71* Hgb-6.8* Hct-20.9*
MCV-77* MCH-25.2* MCHC-32.6 RDW-20.5* Plt ___
___ 06:15PM BLOOD WBC-5.7 RBC-2.61* Hgb-6.8* Hct-20.4*
MCV-78* MCH-25.9* MCHC-33.2 RDW-20.6* Plt ___
___ 07:45PM BLOOD Glucose-96 UreaN-46* Creat-9.5* Na-126*
K-2.5* Cl-101 HCO3-7* AnGap-21*
___ 08:58AM BLOOD Glucose-101* UreaN-44* Creat-8.1* Na-132*
K-3.1* Cl-111* HCO3-8* AnGap-16
___ 01:55AM BLOOD Glucose-136* UreaN-38* Creat-7.0* Na-138
K-3.4 Cl-115* HCO3-9* AnGap-17
___ 12:41PM BLOOD Glucose-133* UreaN-34* Creat-6.3* Na-135
K-3.1* Cl-110* HCO3-12* AnGap-16
___ 07:45PM BLOOD Calcium-5.4* Phos-3.2 Mg-2.2
___ 08:58AM BLOOD Calcium-7.2* Phos-3.0 Mg-2.4
___ 01:55AM BLOOD Calcium-7.2* Phos-1.6* Mg-1.5*
___ 12:41PM BLOOD Calcium-6.5* Phos-3.1# Mg-1.9
___ 01:55AM BLOOD Cortsol-29.7*
___ 02:11PM BLOOD ___ pO2-44* pCO2-27* pH-7.27*
calTCO2-13* Base XS--12
___ 06:48PM BLOOD Lactate-1.5
___ 06:48PM BLOOD freeCa-1.12
MICROBIOLOGY
=================
___ SKIN SCRAPINGS VIRAL CULTURE: R/O HERPES SIMPLEX
VIRUS-PENDING
___ URINE Legionella Urinary Antigen -FINAL INPATIENT
___ STOOL C. difficile DNA amplification assay-FINAL
INPATIENT
___ STOOL FECAL CULTURE-PRELIMINARY; CAMPYLOBACTER
CULTURE-PRELIMINARY; FECAL CULTURE - R/O VIBRIO-PRELIMINARY;
FECAL CULTURE - R/O YERSINIA-PRELIMINARY; FECAL CULTURE - R/O
E.COLI 0157:H7-PRELIMINARY; MICROSPORIDIA STAIN-FINAL;
Cryptosporidium/Giardia (DFA)-PRELIMINARY; ACID FAST
CULTURE-PRELIMINARY INPATIENT
___ Immunology (CMV) CMV Viral Load-FINAL INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
IMAGING/STUDIES:
==================
___: CXR
In comparison with the earlier placement of a right IJ catheter
that extends
to the mid portion of the SVC. No evidence of pneumothorax. The
left base
appears clear on this study.
___: CXR
rior right IJ central venous catheter is no longer visualized.
There is
patchy opacity at the left lung base. Elsewhere, the lungs are
clear. The
cardiomediastinal silhouette is stable. No acute osseous
abnormalities.
IMPRESSION:
Patchy left basilar opacity, potentially due to a developing
infection.
Consider PA and lateral.
DISCHARGE LABS:
=================
Brief Hospital Course:
___ y/o M hx of AIDS, recurrent salmonella enteritis presenting
with diffuse weakness, increased diarrhea and marked electrolyte
derangements.
# AG and NG metabolic acidosis:
Patient initially presented with a combined anion gap and
non-anion gap acidosis, presumed to be ___ both possible RTA and
severe chronic diarrhea. In patients with severe acidosis,
repletion of the acidosis with bicarbonate can shift potassium
intracellularly, leading to life threatening arrhythmias. Given
this, patient had his potassium repleted first as described
below. This was repleted to >3.5 prior to administering
bicarbonate in the ICU. Ultimately the patient received 6 amps
of bicarbonate in the ICU with an improvement in his acidosis
from a pH of 7.12 to 7.27 on VBGs. He was on a home regimen of
oral bicarbonate for this reason. After transfer from the MICU,
the patient received ongoing repletion of volume with LR. His AG
metabolic acidosis resolved. His NG metabolic acidosis improved,
and was likely due to his ongoing, baseline diarrhea.
# Electrolyte Derangement: HypoK, HypoMg, HypoPhos,
Hypocalcemia.
Patient presented with generalized weakness, without
palpitations, lightheadedenss, or perioral tingling. At
admission, K was 1.7, Mg was 0.7, Phos 1.8. While in the MICU,
patient received hundreds of meq of potassium, in addition to
significant magnesium, phosphate and calcium repletion. On
transfer from the MICU his K was 3.1, Mg was 1.9, Ca of 6.5
(corrected is >7), Phos of 3.1. Patient continued to require
daily repletion. Patient was continued on telemetry and did not
have any wave form abnormalities while on the floor. Once his
diarrhea resolved, he was transitioned to oral repletion. The
patient is discontent with needing to take so many pills each
day, and his concerns were illicited: it was discovered that
primarily he disliked taking the powder/liquid potassium, so he
was switched to pill. Education on which foods have high mineral
content were discussed to try to eat more, especially when his
diarrhea worsens.
# ___ on CKD
Etiology most likely prerenal azotemia given significant
hypovolemia that transitioned to ATN given FeUrea of 57.03% and
elevated urine sodium of 84. The patient was found to be
hypovolemic at admission, and was given significant isotonic
fluid resuscitation both by normal saline initially and then
lactated ringers. His creatinine steadily downtrended, and he
maintained adequate urine output. Nephrotoxins were avoided,
strict I/Os obtained and renal team was consulted and provided
valuable recommendations in the care of this patient. Upon
transfer from the MICU the patient's creatinine was 6.3 down
from 9.7. While on the floor, his Cr continued to downtrend
daily, and his medications were renally dosed. At the time of
discharge from the hospital the patient's creatinine was 2.5.
# HIV/AIDS:
Patient not compliant with his HAART medications. Patient
initially treated for LLL opacity that was not seen on repeat
CXR. ID was consulted and provided recommendations on the
patient's care including checking for legionella (negative),
cessation of empiric HCAP treatment, checking stool AFB for MAC,
and performing rectal DFA to r/o herpes. His HAART regimen was
re-initiated in the hospital. The ID team also provided recs on
the patient's chronic salmonella (see below).
# Anemia Chronic, stool guiac negative on ___. Continue to
guiac stools and transfuse for ___. Transfused 1 U PRBC,
stools remained guiac negative. Iron studies showed normal iron,
low TIBC, and elevated ferritin, consistent with an anemia of
chronic disease. Patient's hemoglobin was 6.9 on day of
discharge, asymptomatic; he was given the choice of blood
transfusion, which he did not want.
# Diarrhea: Norovirus PCR positive. Diarrhea returned to
baseline 3 BM/day once arrived to the floor. Had been
empirically treated with ceftriaxone for presumed recurrent
Salmonella infection. Stool culture was negative for Salmonella
(sensitivity 70%). C diff was negative. At discharge his
suppressive cefpodoxime regimen was restarted for salmonella
prophylaxis per ID recommendations, since this infection is
difficult to clear.
# Lower back pain: Chronic, received tylenol prn.
# Medication Noncompliance:
Social work consulted, and multiple discussions conducted with
patient to help him better understand his disease process and
better understand his noncompliance.
TRANSITIONAL ISSUES
========================
Mr. ___ is a ___ year old male with AIDS (last CD4
count: 5), poor medication compliance, frequent salmonella
enteritis infections, CKD (baseline around Cr 1.8) and a
possible diagnosis of RTA who presented with severe diarrhea and
found to have many severe electrolyte abnormalities, initially
requiring monitoring in the ICU.
He presented afebrile with stable vital signs without chest
pain, palpitations, or muscle cramps. He was admitted to the ICU
for electrolyte repletion and cardiac monitoring, with U waves
on admission ECG. He was started on ceftriaxone for presumed
salmonella infection (should be on cefpodoxime prophylaxis,
however historically non compliant with medications). Once his
electrolytes and EKG normalized, he was called out to the floor.
The stool culture was negative for salmonella (also negative for
shigella, cdiff, campylobacter, Ecoli, yersinia, crypto, vibrio,
giardia, microsporidium), but he was found to have norovirus.
His diarrhea improved over a few days, with return to his
baseline loose stools 3x/day. He was transitioned to oral
electrolyte repletion, and cefpodoxime for salmonella
prophylaxis.
In terms of his HIV/AIDS, he was continued on his HAART regimen,
per ID consult who followed inpatient. He was also restarted on
weekly azithromycin, and started on monthly inhaled pentamidine
this admission for infectious prophylaxis given most recent CD4
count of 5. Although pentamidine is less effective than bactrim
or atovaquone, this was in an attempt to reduce pill burden
given patient noncompliant frequently. He has a scheduled follow
up with ID following discharge.
TRANSITIONAL
====================
# HAART (Epzicom, Dolutegravir) continued at home dose. Patient
states that he wants to take these medications every day no
matter what, and this should be applauded and encouraged.
# Weekly azithromycin (___), monthly inhaled pentamidine,
and daily cefpodoxime for MAC, toxo, PCP, and salmonella
prophylaxis (with the understanding that pentamidine is not as
effective as other medications for PCP ppx, however this was in
an attempt to reduce pill burden given history of noncompliance
with multiple medications).
# Discuss with outpatient ID team (Dr. ___ need for
continued salmonella prophylaxis with cefpodoxime given clear
stool cultures this admission, during next outpatient
appointment.
# Stool AFB pending at time of discharge (for MAC).
# Patient does not like taking liquid electrolyte repletion (K
powder/liquid or Bicitra) so was prescribed pills for
electrolyte repletion, with patient understanding that this
means he will need to take more pills each day.
# ___ recommended home ___ for balance training, patient provided
with a script.
# Nutritious foods with high mineral content were discussed and
should be encouraged.
Foods with high potassium: baked potatoes! tomato sauce, cooked
spinach, yogurt, bananas, winter squash.
# Harm reduction approach taken to encourage patient to take
medications, emphasizing the importance of HAART, potassium, and
antibiotics. He was told that while it's best to take all
medications every day, that if he is having a bad day then it's
best if he at least take what he can.
# Patient is eager to move to ___ with his daughter, who
will support him in taking his medications daily.
# Code: Full
# Emergency Contact: Patient, wife ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Azithromycin 1200 mg PO 1X/WEEK (MO)
2. Dolutegravir 50 mg PO DAILY
3. Potassium Chloride (Powder) 40 mEq PO BID
4. Sertraline 50 mg PO DAILY
5. Calcium Carbonate 1000 mg PO QPM
6. Cefpodoxime Proxetil 200 mg PO Q12H
7. Diphenoxylate-Atropine 1 TAB PO BID
8. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
9. Magnesium Oxide 400 mg PO TID
10. Nystatin Cream 1 Appl TP BID
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. Psyllium Wafer 1 WAF PO DAILY
13. Epzicom (abacavir-lamivudine) 600-300 mg oral qdaily
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
15. Potassium Chloride 20 mEq PO NOON
16. Neutra-Phos 2 PKT PO BID
17. Sodium Bicarbonate 1300 mg PO TID
Discharge Medications:
1. Azithromycin 1200 mg PO 1X/WEEK (MO)
2. Calcium Carbonate 1500 mg PO BID
RX *calcium carbonate 500 mg calcium (1,250 mg) 3 tablet(s) by
mouth twice daily Disp #*180 Tablet Refills:*0
3. Dolutegravir 50 mg PO DAILY
4. Magnesium Oxide 400 mg PO TID
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. Potassium Chloride 60 mEq PO BID
RX *potassium chloride 20 mEq 3 tablet(s) by mouth twice daily
Disp #*180 Tablet Refills:*0
7. Sertraline 50 mg PO DAILY
8. Sodium Bicarbonate ___ mg PO TID
RX *sodium bicarbonate 650 mg 3 tablet(s) by mouth three times
daily Disp #*270 Tablet Refills:*0
9. Diphenoxylate-Atropine 1 TAB PO BID
RX *diphenoxylate-atropine 2.5 mg-0.025 mg 1 tablet(s) by mouth
twice daily as needed Disp #*60 Tablet Refills:*0
10. Epzicom (abacavir-lamivudine) 600-300 mg oral qdaily
11. Neutra-Phos 2 PKT PO BID
12. Nystatin Cream 1 Appl TP BID
13. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
14. Cefpodoxime Proxetil 200 mg PO Q12H
15. Pentamidine-Inhalation 300 mg IH MONTHLY
FOR INHALATION ONLY
To prevent infection because of your HIV.
NOTE: Last administered on ___.
16. Outpatient Physical Therapy
ICD-9-CM Diagnosis Code 042: Human immunodeficiency virus [HIV]
disease
Home physical therapy training for balance training.
17. Outpatient Lab Work
ICD-9-CM Diagnosis Code 042: Human immunodeficiency virus [HIV]
disease
Please check CBC, and chemistries (Na, K, Cl, HCO3, BUN, Cr, Mg,
Ca, Phos) on ___.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
-Norovirus
-Hypokalemia
-Hypomagnesemia
-Hypocalcemia
-Hypophosphatemia
-Metabolic acidosis
-Acute kidney injury
SECONDARY DIAGNOSIS
-Acquired immune deficiency syndrome/human immunodeficiency
virus
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 recent hospital
stay at the ___. You were
admitted because you were having worsening diarrhea with
vomiting, weakness, and lightheadedness. You were found to have
very low levels of potassium and other salts (electrolytes) that
your body needs to keep your heart pumping and your brain cells
working properly. Your body loses these minerals through your
diarrhea, and also from your kidney disease. You had an
infection called norovirus that caused worsening of your chronic
diarrhea, and so worsening of your body's salt balance. Because
the cells that fight infections don't work well with HIV, you
are at higher risk for all kinds of infections, so it is
important that you take antiobiotics that will help prevent
these infections from happening, as well as continue to take
your HAART/HIV medications every day.
It is very important that you take your medications.
Medicines to take EVERY DAY :
-HIV meds/HAART: Epzicom, Dolutegravir
-Potassium
-Sodium bicarbonate
-Chewable Tums
Please try to take your other medications every day, but if you
miss one day, please continue the next day with your normal
dose.
Foods with high potassium if you are having more diarrhea: baked
potatoes! tomato sauce, cooked spinach, yogurt, bananas, winter
squash.
Your future medical appointments are listed below for you. It is
very important that you go to these visits to make sure you
continue to feel well and your body salts (including potassium,
calcium, magnesium) are still at good levels.
It was a pleasure being a part of your care team.
Best of luck with your move to ___ with your family!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10296472-DS-5 | 10,296,472 | 25,712,478 | DS | 5 | 2121-02-07 00:00:00 | 2121-02-07 13:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI:
The patient is ___ year old male with h/o HIV/AIDS first
diagnosed
in ___ with poor compliance with HAART with recent CD4 count of
3 in ___ who presents for the fourth time since ___
with continued diarrhea and electrolyte abnormalities. He has
had
diarrhea since ___ and has had multiple w/u including stool
studies for:C. Diff, yersinia,
vibrio, e. coli, campylobacter, microsporidium, isospora,
cyclospora, cryptosporidium, and ova and parasites which were
negative. His CMV VL was undetectable.
.
He had a negative EGD and colonoscopy in ___. The upper
endoscopy revealed some evidence of gastroesophageal reflux, a
chronic gastritis and duodenitis with some villous blunting, H.
pylori was negative. TTG, IgA and total IgA levels were within
normal limits.
Colonoscopy the same day revealed an acute focal cryptitis in
some of the biopsies. Biopsies demonstrated focal cryptiis
which
is a non-specific finding. He was thought to have HIV
enteropathy. He had a Condyloma acuminata was seen and cared
for
by colorectal surgery in ___. He had a capsule
endoscopy
which demonstrateda jejeunal polyp in ___. He had a
small
bowel enteroscopy on ___ which demonstrated
diffuse esophageal candidiasis in the whole esophagus,
flattening
and possible scalloping in the whole duodenum and proximal
jejunum of which biopsies were performed. The known single
sessile 5 mm non-bleeding polyp in the proximal jejunum was
removed by hot snare polypectomy.
.
He reports difficulties taking his pills because he has to hide
his pills from his mother because he does not want her to know
she has HIV. His mother apparently often searches his room. He
does not have a pill box and admits to having difficulty
remembering to take his pills. He does not recognize the name of
his potassium pill. He does not want his mother to find out that
he has HIV since his other brother who has know HIV would "rub
it
in his mother's face".
.
He also reports back pain which is new for the past two weeks.
It
is worse with laying down. The pain wakes him up in the middle
of
the night. + weakness. No urinary or fecal incontinence. No
trauma or heaving lifting.
.
In terms of his diarrhea he reports that it is improved from ___
bms per day to 3 bms per day since having the small bowel
eneteroscopy. No blood in stool. He has not had nausea or
vomiting. No HA. He thought he had had a 12 lb weight loss but
on
the standing scale on admission he weighs 131 lbs suggesting
that
his weight has been stable.
In ER: (Triage Vitals:100.2, 102/68, 69, 16, 100% on RA )
Meds Given: Potassium chloride 40 meQ po/Mg Sulfate 2 gm IV
along with potassium IVF
.
PAIN SCALE: ___ back pain
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[ ] Fever [+ ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[ ] _____ lbs. weight loss/gain over _____ months
Eyes
[X] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT[X]WNL
[ ] Dry mouth [ -] Oral ulcers [ ] Bleeding gums [ ] Sore
throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [X] All Normal
[ ] Shortness of breath [ ] Dyspnea on exertion [ ] Can't
walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum
[
] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [X] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ]
Chest
Pain [ ] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[ ] Nausea [] Vomiting [-] Abd pain [] Abdominal swelling [
] Diarrhea [ ] Constipation [ ] Hematemesis
[ -] Blood in stool [ ] Melena [ -] Dysphagia: [ ] Solids
[ ] Liquids [ +] Odynophagia [+ ] Anorexia [ ] Reflux
[ ] Other:
GU: [] All Normal
[ +] Dysuria x 1 day [ ] Incontinence or retention [ ]
Frequency [+ ] Hematuria []Discharge []Menorrhagia
SKIN: [X] All Normal
[ ] Rash [ ] Pruritus
MS: [] All Normal
[ ] Joint pain [ ] Jt swelling [ +] Back pain [ ] Bony
pain
NEURO: [X] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
HEME/LYMPH: [X] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [] All Normal
[ +] Mood change [-]Suicidal Ideation [-]HI [ ] Other:
ALLERGY:
[X]NKDA [ ] Seasonal allergies
[X]all other systems negative except as noted above
Past Medical History:
Anemia
Fatigue
Chronic diarrhea: ? Etiology. In workup with GI
___
-Weight loss
-Hair loss
-History of pancytopenia
HIV (+) from ___: Referred to infectious disease at ___. Hx
HAART ___
pt recalls Td utd ___
Wears eye glasses for vision
Smoker: interested in quitting: counseled: Followup PCP ___.
assistance
RLE Neuropathy s/p mvc ___: pedestrian, was struck: inpt x 1w
Family History:
Mother: alive: ___
Father: alive
Brother: ___
Brother: HIV positive
Brother: ___: MI
Physical Exam:
discharge physical exam
afebrile 96/52
thin appears comfortable
clear bs
soft abd non tender
no new rash
onycomycosis wiht dark nails
Pertinent Results:
___ 06:35AM BLOOD WBC-1.5* RBC-3.41* Hgb-8.4* Hct-27.3*
MCV-80* MCH-24.8* MCHC-30.9* RDW-23.0* Plt ___
___ 10:10AM BLOOD Hypochr-3+ Anisocy-3+ Poiklo-2+
Macrocy-OCCASIONAL Microcy-3+ Polychr-OCCASIONAL Ovalocy-2+
Target-OCCASIONAL Tear Dr-1+ Acantho-1+ Ellipto-1+
___ 10:10AM BLOOD WBC-2.0* Lymph-29 Abs ___ CD3%-39
Abs CD3-224* CD4%-1 Abs CD4-5* CD8%-30 Abs CD8-174*
CD4/CD8-0.03*
___ 07:10AM BLOOD Glucose-91 UreaN-10 Creat-1.5* Na-133
K-4.2 Cl-110* HCO3-16* AnGap-11
___ 10:10AM BLOOD ALT-63* AST-59* AlkPhos-160* TotBili-0.3
___ 07:10AM BLOOD Calcium-7.6* Mg-1.8
___ 10:10AM BLOOD TSH-1.9
___ 10:10AM BLOOD Free T4-1.1
___ 07:40AM BLOOD 25VitD-17*
___ 01:32AM BLOOD K-2.8*
___ 08:43PM BLOOD Lactate-1.4 K-2.7*
Brief Hospital Course:
___ with HIV/AIDs with chronic diarrhea, suspected to be HIV
enteropathy. Multiple life stressors, poor medication
compliance. Multiple electrolyte deficits: K, Ca, Mg, Phos.
He received electrolyte repletion and will be given 4 days of
KCL 20meq repletion. Vitamin D level low (17). I gave him Rx
for Calcium -Vitamin D 800, and also Rx for weekly 50,000 units
Vitamin D x 8 weeks for full Vitamin D repletion.
His diarrhea overall improved with supportive care including inc
freq of imodium. Not high volume. Stool micro overall negative
(O+P, crypto, microspora, giardia DFA, isosorpa). Blood
culture for ___ neg to date. Serum crypto ag neg.
He remained on HAART and OI ppx.
He is receiving fluconazole for esophageal candidiasis (2 more
weeks)
Patient met with ___ and has his contact and is encouraged to set
up outpatient
counselling/therapist.
I spoke with his ID provider during admission.
I spoke with path and prelim histo-path from duodenal biopsy
shows only scant macrophages in lamina propria, so PCR for
whipple disease sent. Some infectious stains still pending.
Findings could be consistent with HIV enteropathy.
Discharge Medications:
1. Azithromycin 1200 mg PO 1X/WEEK (MO)
2. Darunavir 800 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Fluconazole 200 mg PO Q24H
5. LOPERamide 2 mg PO QID:PRN loose stool
RX *loperamide 2 mg 1 tab by mouth four times a day Disp #*60
Capsule Refills:*0
6. RiTONAvir 100 mg PO DAILY
7. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
8. abacavir-lamivudine 600-300 mg oral daily
9. magnesium carbonate 54 mg/5 mL oral bid
10. Potassium Chloride 20 mEq PO DAILY Duration: 4 Days
check your potassium level next week
RX *potassium chloride 20 mEq 1 tablet(s) by mouth once a day
Disp #*4 Tablet Refills:*0
11. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral bid
RX *calcium carbonate-vitamin D3 [Calcium 500 + D] 500 mg
calcium (1,250 mg)-400 unit 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
chronic diarrhea
hypokalemia
hypomagnesemia
hypocalcemia
hiv/aids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
you were hospitalized for chronic diarrhea causing low levels of
potassium and other electrolytes
take all medicines as prescribed
you can take more imodium, you can use up to 8mg daily, so take
a 2mg tab after each loose bowel movements, up to 4 times a day
Followup Instructions:
___
|
10296501-DS-10 | 10,296,501 | 26,895,141 | DS | 10 | 2170-08-25 00:00:00 | 2170-08-25 19:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Breakthrough seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo man with a history of complex partial
seizures on trileptal, followed by Dr. ___ presented
after a seizure.
He and his wife were at the ___ theater. He was thirsty and
didn't feel right. He had a visual aura on the right side, like
a
kaleidoscope ___ image. He also had a sense of dread.
This
happened just before the seizure. He has had this before but not
as strong. He usually does not have GTCs. Then his wife saw he
was staring at shoes and seemed unaware of his surroundings. He
took ___ breath in and his arms and legs extended suddenly,
and then started having clonic movements of all extremities in
synchrony. This lasted ___ minutes. He came out of it a little
bit. He seemed confused. He did not resist going in the
ambulance
(which he usually would). He could not state age or year. No
tongue bite, urine or stool incontinence.
He takes Trileptal 600/900. He has been on this dose for several
years. He was sick with a cold 1 week ago but recovered. He
played lots of tennis today (3hours) and didn't hydrate well and
had 2 cappuccinos. He has not been sleeping well recently,
partly
due to sleep apnea. He is also stressed with work and family. He
has not missed the trileptal. No medication changes recently. He
has been exercising this week more strenuously than usual.
Currently he feels tired and 80% back to his usual self.
Regarding his seizure history:
He had his first seizure in ___ described as eyes rolled back,
arms with clonic movements. His seizures are thought due to
multiple prior concussions from sports. Now he usually gets a
visual aura prior to blank stare and loss of awareness. Last
seizure was ___. His seizures have never been captured
on
EEG.
He has had migraines with visual aura with kaleidoscope since
childhood.
Past Medical History:
s/p avr for bicuspid valve
Social History:
___
Family History:
n/a
Physical Exam:
ADMISSION:
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM
Neck: Supple, no carotid bruits appreciated. No nuchal
rigidity.
Pulmonary: CTABL
Cardiac: RRR, mechanical click
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
with help from wife. 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. Attentive, able to name ___ backward
without difficulty. Pt. was able to register 3 objects and
recall ___ at 5 minutes. There was no evidence of apraxia or
neglect. Overall response time is slow during mental status
testing.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch in all distributions
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5
R ___ ___ ___ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: No deficits to light touch, pinprick, proprioception
throughout.
-Coordination: No intention tremor noted. No dysmetria on FNF or
HKS bilaterally.
-Gait: deferred.
DISCHARGE:
No significant deficits noted on discharge exam with MS exam
unremarkable
Pertinent Results:
___
There is no evidence of acute large territorial infarction,
hemorrhage, edema,
or mass effect. The ventricles and sulci are normal in size and
configuration.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality on noncontrast head CT.
Specifically no
intracranial hemorrhage or mass effect.
___ 05:35AM BLOOD WBC-6.7 RBC-4.79 Hgb-13.9 Hct-43.2 MCV-90
MCH-29.0 MCHC-32.2 RDW-13.7 RDWSD-45.4 Plt ___
___ 08:45PM BLOOD WBC-9.9# RBC-4.77 Hgb-14.0 Hct-42.6
MCV-89 MCH-29.4 MCHC-32.9 RDW-13.6 RDWSD-44.5 Plt ___
___ 05:35AM BLOOD ___ PTT-31.0 ___
___ 08:45PM BLOOD ___ PTT-29.7 ___
___ 05:35AM BLOOD Glucose-87 UreaN-14 Creat-0.8 Na-139
K-3.9 Cl-103 HCO3-25 AnGap-15
___ 08:45PM BLOOD Glucose-89 UreaN-19 Creat-0.8 Na-138
K-4.0 Cl-102 HCO3-25 AnGap-15
___ 08:45PM BLOOD ALT-26 AST-36 AlkPhos-59 TotBili-0.4
___ 05:35AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.2
___ 08:45PM BLOOD Albumin-4.4 Calcium-9.1 Phos-2.4* Mg-1.9
___ 08:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:52PM BLOOD Lactate-1.4
Brief Hospital Course:
Mr. ___ was hospitalized due to apparent breakthrough seizure.
Upon admission ___ was negative for acute abnormalities.
Laboratory workup was performed with no significant
toxo-metabolic abnormalities. Due to concern for insufficient
AED therapy, patient's Trileptal was increased from 600-900 to
900-900. Patient's INR was noted to be subtherapeutic at 1.9 and
1.6 and as such patient's Warfarin dose was increased to 6mg and
he was started on Lovenox bridge. Over hospital course,
patient's mental status was seen to significantly improve with
no residual neurologic deficits and no recurrent events. Due to
appearing clinically stable, patient was deemed fit for
discharge from hospital to home with planned follow up tomorrow
with anticoagulation services to reassess INR level.
Transition Issues:
-Pt will need to follow up with anticoagulation services (in
coordination with his cardiologist at ___, Dr. ___, to ensure
his INR is improving to therapeutic range. While awaiting
therapeutic level, patient will need to daily Lovenox injection
to ensure adequate anticoagulated state
-Patient will need to increase Trileptal dosage from 600-900 to
900-900
-Pt will need to follow up with his neurologist in near future
for further management of AED regimen
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 5 mg PO DAILY16
2. OXcarbazepine 600 mg PO QAM
3. OXcarbazepine 900 mg PO QPM
Discharge Medications:
1. Enoxaparin Sodium 120 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
2. LORazepam 1 mg PO Q8H:PRN seizure aura
Please take a dose if you feel a seizure aura as this may
prevent the seizure from occurring
3. OXcarbazepine 900 mg PO QPM
4. OXcarbazepine 900 mg PO QAM
*Please now take oxcarbazepine 900mg twice a day
5. Warfarin 6 mg PO DAILY16
This dose has been increased as your INR was low.
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized at ___ and treated by ___ Neurology
due to a witnessed seizure concerning for uncontrolled seizure
disorder. You were monitored in the ED and in the hospital with
no recurrent events. Your AED regimen was adjusted
appropriately. At this time you are clinically stable to be
discharged from the hospital.
Please change your Trileptal to 900mg in the morning and 900mg
in the evening. Please carry prescribed Ativan with you and take
if suspect that you are having a seizure event. Please take
Warfarin 6mg daily and have your INR checked tomorrow and
regularly in the near future to ensure that it is therapeutic.
Please also take Lovenox ___ daily until your INR is
therapeutic.
Please take your other medications as prescribed.
Please follow up with your primary care provider and ___
as noted below.
Sincerely,
___ Neurology Team
Followup Instructions:
___
|
10296754-DS-2 | 10,296,754 | 25,722,126 | DS | 2 | 2136-07-09 00:00:00 | 2136-07-09 20:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amlodipine / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
Left hip pain, fever
Major Surgical or Invasive Procedure:
CT-guided left hip aspiration ___
History of Present Illness:
Ms. ___ is a ___ with past medical history significant for
renal transplant, currently immunosuppressed on cyclosporine, L
total hip arthroplasty referred by her PCP with left hip pain
and fever (101.3) for osteomyelitis/septic arthritis rule-out.
She states that she previously had been feeling well. She
started to have pain in her left hip 1 to 2 weeks ago,
exacerbated by movement of the hip, so has been unable to
ambulate recently. She denies any preceding trauma. Was seen at
___ ___ and found to be febrile 101.3F there,
referred to ___ ED for eval. She does have a history of total
hip arthroplasty to the left hip > ___ years ago.
In the ED, VSS on RA
Labs showed Hyperkalemia to 5.7 -> 4.4 without intervention. INR
6.2. Blood cultures sent. Was not started on antibiotics.
Renal consulted, kidney function stable, will follow for
immunosuppression.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports story as above. States
that hip pain began gradually two weeks ago, worsening over
time. Never had pain like this before. Pain is "down to the
bone," gnawing, constant, radiates down to knee. Worse with
movement. ___ ___ with movement. Patient received
Tylenol/Codeine but did not seem to help.
Notably, patient denies any antecedent trauma or injury. Denies
systemic signs of illness such as fever, chills, nausea,
vomiting.
Past Medical History:
History of kidney transplant - ___, born with single kidney,
had FSGS leading to renal failure and living donor transplant
from son
History of mitral valve replacement, mechanical, Goal INR=
2.5-3.5; duration of treatment: indefinite. ___
Chronic Impaired fasting glucose
Chronic Hypercholesterolemia
Chronic Hypertension, essential
HISTORY TOTAL HIP REPLACEMENT(aka HIP) - ___ ___ Dr. ___
infection ___
Hypothyroidism, s/p radioiodine ablation
Colonic adenoma
Atrial flutter, paroxysmal a fib
Ventricular fibrillation
Rhabdomyolysis ___ simvastatin
Anemia
Pulmonary nodule
CKD (chronic kidney disease) stage 4, GFR ___ ml/min
Automatic implantable cardioverter-defibrillator in situ
Vitamin D deficiency
Osteoporosis
Social History:
___
Family History:
noncontributory to current presentation
Physical Exam:
ADMISSION PHYSICAL EXAM
=================
VS: 98.3PO 144/78 67 16 98 RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
HEART: Irregularly irregular, ___ systolic murmur heard
throughout precordium
LUNGS: CTAB, no wheezes, or rhonchi; slight rales in right base
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: No cyanosis, clubbing or edema. Left hip is not
swollen or erythematous, nor is it painful to palpation.
Significant pain with left hip flexion. Sensation intact.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=================
VS: T 98.0, BP 130-140s/60-80s, HR 50-70s, RR ___, O2 sat.
98-99% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
HEART: Regular rate and rhythm, ___ systolic murmur heard
throughout precordium
LUNGS: CTAB, no wheezes, rhonchi, or rales
ABDOMEN: Nondistended, +BS, nontender in all quadrants
EXTREMITIES: No cyanosis, clubbing, or edema. Left hip is not
swollen or erythematous, nor is it painful to palpation. No pain
with left hip flexion. Left foot dorsum is mildly tender to
palpation.
BACK: No tenderness to palpation
NEURO: CN II-XII intact
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
==========
___ 11:25AM BLOOD WBC-9.3 RBC-3.30*# Hgb-10.3*# Hct-32.7*#
MCV-99* MCH-31.2 MCHC-31.5* RDW-15.7* RDWSD-56.9* Plt ___
___ 11:25AM BLOOD Neuts-65 Bands-0 ___ Monos-11 Eos-0
Baso-0 ___ Myelos-0 NRBC-1* AbsNeut-6.05
AbsLymp-2.23 AbsMono-1.02* AbsEos-0.00* AbsBaso-0.00*
___ 01:20PM BLOOD ___
___ 11:25AM BLOOD Glucose-107* UreaN-71* Creat-2.3* Na-137
K-5.7* Cl-97 HCO3-23 AnGap-23*
___ 11:25AM BLOOD ALT-10 AST-54* AlkPhos-43 TotBili-1.3
___ 06:53AM BLOOD Calcium-9.3 Phos-3.2 Mg-1.9
___ 11:25AM BLOOD Albumin-4.1
___ 11:25AM BLOOD CRP-63.7*
NOTABLE LABS
=========
___ 08:50PM BLOOD WBC-14.0* RBC-2.54* Hgb-8.1* Hct-25.0*
MCV-98 MCH-31.9 MCHC-32.4 RDW-15.0 RDWSD-54.4* Plt ___
___ 08:00AM BLOOD Glucose-165* UreaN-78* Creat-2.6* Na-141
K-3.5 Cl-103 HCO3-22 AnGap-20
___ 08:00AM BLOOD calTIBC-224* Hapto-<10* Ferritn-1278*
TRF-172*
___ 08:00AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.9 Iron-155
___ 08:00AM BLOOD Ret Aut-1.7 Abs Ret-0.05
___ 01:15PM BLOOD CMV VL-NOT DETECT
___ 08:05AM BLOOD ___ PTT-64.7* ___
___ 07:45AM BLOOD ___ PTT-82.7* ___
___ 09:30AM BLOOD Glucose-198* UreaN-49* Creat-1.8* Na-138
K-4.5 Cl-103 HCO3-19* AnGap-21*
___ 08:10AM BLOOD ALT-14 AST-24 CK(CPK)-59 AlkPhos-60
TotBili-0.5
___ 08:00AM BLOOD calTIBC-224* Hapto-<10* Ferritn-1278*
TRF-172*
___ 11:25AM BLOOD CRP-63.7*
___ 06:53 BLOOD SED RATE 82 H
___ 01:15PM BLOOD PEP-NO SPECIFIC
___ 12:34 MULTIPLE P1NO MONOCLONAL BANDS SEEN
MULTIPLE PROTEIN BANDS SEEN, WITH ALBUMIN PREDOMINATING
BASED ON IFE (SEE SEPARATE REPORT),
NO MONOCLONAL IMMUNOGLOBULIN SEEN
NEGATIVE FOR ___ PROTEIN
INTERPRETED BY ___, MD, PHD
NO MONOCLONAL IMMUNOGLOBULIN SEEN
INTERPRETED BY ___, MD, PHD
___ 08:10AM BLOOD Cyclspr-123
___ 07:25AM BLOOD Cyclspr-91*
___ 08:05AM BLOOD Cyclspr-71*
MICROBIOLOGY
=========
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. >100,000 CFU/mL.
BLOOD CULTURES ___ - NEGATIVE x 3
BLOOD CULTURES ___ - NEGATIVE x 2
URINE CULTURE ___ - NEGATIVE
BK VIRUS DNA, QN REAL TIME <500 <500 copies/mL
PCR, URINE
IMAGING/STUDIES
===========
Pelvis X-RAY ___
Postoperative changes of left hip arthroplasty are noted. There
is no
periprosthetic lucency nor fracture. Heterotopic ossification
seen adjacent
to the left acetabulum and greater trochanter. Pubic symphysis
and SI joints
are preserved. Surgical clips overlie the pelvis on the right.
Phleboliths
noted in pelvis. Atherosclerotic calcifications are seen.
___ Renal transplant ultrasound
1. Abnormal Doppler exam with absent diastolic flow seen
throughout the
arterial waveforms. This is concerning for graft dysfunction
which may be
secondary to ATN, rejection, glomerulosclerosis,
nephrosclerosis.
2. No hydronephrosis and no perinephric fluid collection
identified.
___ Left Foot X-ray
Degenerative arthritis first MTP joint with bunion deformity.
Arterial
calcifications. Degenerative changes midfoot.
DISCHARGE LABS
==========
___ 07:20AM BLOOD WBC-17.9* RBC-2.33* Hgb-7.4* Hct-24.2*
MCV-104* MCH-31.8 MCHC-30.6* RDW-17.5* RDWSD-63.3* Plt ___
___ 07:20AM BLOOD ___ PTT-92.3* ___
___ 07:20AM BLOOD Glucose-104* UreaN-76* Creat-2.2* Na-141
K-4.4 Cl-103 HCO3-24 AnGap-18
___ 07:20AM BLOOD Calcium-9.6 Phos-4.8* Mg-1.9
UricAcd-11.6*
___ 07:20AM BLOOD Cyclspr-76*
Brief Hospital Course:
BRIEF HOSPITAL COURSE
=====================
Ms. ___ is a ___ year old woman with h/o renal transplant on
immunosuppresion, mitral valve repair, a-fib on coumadin, and L
THA ___ admitted with left hip pain and fever, concern for
septic arthritis or prosthetic joint infection. Supratherapeutic
INR to 6.2 on admission, reversed on ___ and hip aspiration
attempted with no resultant fluid. The patient repeatedly
febrile and was empirically started on vancomycin/ceftriaxone on
___. She was evaluated by orthopedics and infectious disease
and thought to be at a low likelihood for a septic joint and
antibiotics were held on ___. Her hip pain improved but her
white count remained elevated. She had no other symptoms and
given her positive urine culture on admission, she was started
on ceftriaxone and completed a 7 day course (___). She
developed ___ with creatinine rising to 2.6 from a baseline of
1.9-2.2. Torsemide was held and she was given 1L NS. Transplant
renal ultrasound showed abnormal diastolic flow, a nonspecific
finding. BK virus and CMV viral load were checked and were not
detected. Her creatinine improved to her baseline while
Torsemide was held. It was restarted on ___ and the dose was
decreased on discharge. Her course was further complicated by
left foot pain that made it difficult to walk. X-ray was
negative. She was trialed on a burst of 40mg prednisone for 3
days with days with improvement in her symptoms. She was then
continued on a prednisone taper. Rheumatology was consulted and
there was no joint amenable to arthrocentesis. Given concern for
gout, her immunosuppression regimen was changed. Azathioprine
was discontinued and replaced with MMF. During her course, she
was kept on a heparin gtt while she was bridged to coumadin. She
was therapeutic with INR 2.6 at the time of discharge and
bridging with heparin was stopped. She was discharged on 10mg
warfarin daily with plan to follow up on ___ with the ___
Anticoagulation Program. This plan was confirmed with the staff
at ___.
ACTIVE ISSUES
=============
# Leukocytosis, Possible UTI: Patient presents with intermittent
fevers to 102.6 in setting of post-transplant immunosuppression.
Only documented fever ___. WBC remained elevated despite no
clear symptoms/signs of infection. She given treatment for UTI
with ceftriaxone for 7 days (___), though urine cultures
returned negative. She had no diarrhea to suggest C. difficile
colitis. She had left foot pain that may have been due to gout
that could have contributed to her leukocytosis. (now at 17.9).
She remained afebrile.
#Left foot pain, presumed gout: Pain near base of ___
metatarsal for two days during her course. There was mild warm
but minimal swelling. Given the joint size it was unable to be
tapped. Rheumatology was consulted and also could not tap the
joint. She was given a trial of a burst of 40mg prednisone with
improvement in her symptoms and prednisone taper was initiated
with a plan to slowly taper and return to her home dose on 5mg
daily on ___. X-ray was negative for fracture. She had no
trauma.
# L hip pain: There was concern for septic hip on admission with
fever prior to the admission and one fever while in house. ___
was consulted and performed aspiration that was dry. She was
treated empirically with vancomycin and ceftriaxone on ___
that was stopped on ___ as her hip pain was localized to the
greater trochanter and was not likely due to a septic joint as
assessed by orthopedics. Her hip pain improved off the
antibiotics.
# ___: Creatinine improved to her baseline (baseline creatinine
1.9-2.2)
# Stage IV CKD-T
# Renal transplant: Cr stable, CKD stage 4. Baseline creatinine
~2. She was continued on immunosuppression with prednisone,
azathioprine, and cyclosporin. She was initially given 3 days of
prednisone 15 in setting of infection then returned to home dose
of 5mg daily. She was continued on torsemide until her
creatinine continued to rise to max 2.6. Torsemide was held, she
was given 1L NS, BK virus and CMV were checked that were
negative, as was SPEP and UPEP. renal transplant ultrasound was
performed that showed diastolic flow abnormality that was
described as nonspecific on discussion with the renal consult
team. White blood cell casts were seen on sediment analysis by
the renal team. Creatinine improved with torsemide held. It was
restarted on ___. GIven that her creatinine up-trended to 2.2
on the day of discharge without signs of volume overload, she
was discharged on 20mg torsemide daily. Given that the patient
had symptoms and exam findings concerning for gout, her
immunosuppression was adjusted. Azathioprine was stopped on ___
and replaced with MMF at 250mg BID. She was continued on
cyclosporine.
# Mechanical mitral valve
# Atrial fibrillation
# Coagulopathy: INR on admission 6.2. warfarin for mechanical
MVR. also h/o a-fib and aflutter. Goal INR 2.5-3.5. Patient
states that in last month underwent colonoscopy and was bridged
from Lovenox to warfarin; likely this elevated INR is in the
setting of medication error. She was reversed with 2 units of
FFP and 2.5mg vitamin K prior to the hip aspiration. She was
then restarted on heparin gtt for anticoagulation while she was
restarted on coumadin. Coumadin dose at discharge was 10mg
daily with INR 2.6.
#Anemia: Hb 10.7 on admission that fluctuated down to 8.1. She
had no signs of active bleeding. Hemolysis labs were concerning
for hemolysis with haptoglobin <10 and elevated LDH with
elevated ferritin and normal iron suggestive of anemia of
inflammation. Peripheral smear showed minimal schistocytes. Hb
stabilized and she was monitored without intervention.
CHRONIC ISSUES
==============
# Hypothyroid: continued home levothyroxine 88 mcg daily
# CV disease: continued home statin and metoprolol
# GERD: continued home ranitidine 150 daily
# Vit D def: contineued home repletion
# Fe deficiency: Initially held iron supplementation but
restarted home dose during the course of her admission.
TRANSITIONAL ISSUES
===================
-NEW MEDICATIONS:
--> Mycophenolate Mofetil 250mg BID
--> Prednisone taper to complete ___ (40mgx1 day, 30mgx3 days,
20mgx3 days, 10mg x 3 days then return to home dosing of 5mg
daily)
-STOPPED MEDICATIONS:
--> Azathioprine
-MEDICATION DOSING CHANGES
--> Cyclosporin changed to 75mg BID
--> Torsemide changed to 20mg daily
- Anticoagulation: Discharged on 10mg Coumadin daily. INR on
___ was 2.6. Plan for follow up on ___ to check INR
arranged with ___ Anticoagulation Program.
- Presumed gout, not crystal proved: If any further episodes,
she should attempt arthrocentesis to obtain crystal diagnosis.
- Check uric acid level when this acute flare of inflammatory
arthritis resolved. Consider renal dosing of allopurinol if
elevated uric acid.
- Consider changing immunosuppression away from cyclosporin if
concern for gout or for anemia as cyclosporine may be
contributing to microangiopathic hemolytic anemia
# Code status: Full
# Contact: Daughter, ___, ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. PredniSONE 5 mg PO DAILY
2. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN Pain - Moderate
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Ranitidine 150 mg PO QHS
5. Metoprolol Tartrate 50 mg PO BID
6. Calcitriol 0.25 mcg PO DAILY
7. Pravastatin 60 mg PO QPM
8. Torsemide 40 mg PO DAILY
9. AzaTHIOprine 100 mg PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. Warfarin 10 mg PO DAILY16
12. Ferrous Sulfate 325 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. CycloSPORINE (Neoral) MODIFIED 100 mg PO Q12H
Discharge Medications:
1. Mycophenolate Mofetil 250 mg PO BID
RX *mycophenolate mofetil 250 mg 1 capsule(s) by mouth Twice
daily Disp #*60 Capsule Refills:*3
2. PredniSONE 5 mg PO DAILY
Start after completing predisone taper
RX *prednisone 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*3
3. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
RX *cyclosporine modified 25 mg 3 capsule(s) by mouth Twice
daily Disp #*90 Capsule Refills:*3
4. PredniSONE 40 mg PO DAILY Duration: 2 Doses
This is dose # 1 of 4 tapered doses
RX *prednisone 10 mg 1 tablet(s) by mouth Daily Disp #*26 Tablet
Refills:*0
5. PredniSONE 30 mg PO DAILY Duration: 3 Doses
This is dose # 2 of 4 tapered doses
Tapered dose - DOWN
6. PredniSONE 20 mg PO DAILY Duration: 3 Doses
This is dose # 3 of 4 tapered doses
Tapered dose - DOWN
7. PredniSONE 10 mg PO DAILY Duration: 3 Doses
This is dose # 4 of 4 tapered doses
Tapered dose - DOWN
8. Torsemide 20 mg PO DAILY
9. Calcitriol 0.25 mcg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Fluticasone Propionate NASAL 1 SPRY NU DAILY
12. Levothyroxine Sodium 88 mcg PO DAILY
13. Metoprolol Tartrate 50 mg PO BID
14. Pravastatin 60 mg PO QPM
15. Ranitidine 150 mg PO QHS
16. Vitamin D ___ UNIT PO DAILY
17. Warfarin 10 mg PO DAILY16
18.Outpatient Lab Work
Anticoagulant Long Term Use V58.61 . Please draw ___ on
___. Please fax results to ___ Anticoagulation Program.
FAX ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis
- Trochanteric bursitis
Secondary diagnoses
- Acute kidney injury on Stage IV CKD-T
- Mechanical mitral valve
- Atrial fibrillation
- Urinary tract infection
- Anemia
- Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were having
worsening left hip pain and and had developed a fever. We were
concerned that you may have developed an infection in or around
your hip. A hip aspiration with a needle was attempted and
removed no fluids. We think you have some inflammation in the
outside of the hip called bursitis. You should contact your
primary care doctor for referral to orthopedics if this pain
returns.
Because we had to stop your warfarin to do the study on your
hip, we started you a heparin drip and then slowly increased
your warfarin until you were in the therapeutic range. On the
day of discharge your INR was 2.6 and heparin was stopped.
You were found to have an infection in the urine. You were
treated with antibiotics and the infection cleared.
You developed pain in the left foot during your admission. The
rheumatologists evaluated you and diagnosed you with gout. Your
steroids were increased to treat gout and you will slowly go
back down to your normal dose.
Because you were diagnosed with gout, the kidney transplant team
changed some of your medications. Your azathioprine was stopped.
You will now take Cellcept (Mycophenolate Mofetil) twice daily
in its place. You will continue to take cyclosporine but at a
lower dose. Please follow up with your nephrologist to discuss
your immunosuppression medications.
You had some slowing of your kidneys during your admission. Your
torsemide dose was decreased to 20mg daily. Please take 20mg of
this medication.
If you develop worsening hip pain, worsening foot pain, swelling
of any of your joints, fevers, chills, shortness of breath, or
leg swelling, please call your doctor or return to the emergency
department.
It was a privilege to care for you in the hospital, and we wish
you all the best.
Sincerely,
Your ___ Health Team
Followup Instructions:
___
|
10296754-DS-3 | 10,296,754 | 27,623,612 | DS | 3 | 2136-09-14 00:00:00 | 2136-09-14 18:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amlodipine / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with h/o renal transplant on
immunosuppresion, mitral valve repair, a-fib on coumadin, and L
THA ___ presenting for nausea and vomiting x1 day.
She states she was in her normal state of health until 2 nights
ago. AT that time she ate dinner of BBQ chicken and coleslaw.
She went to sleep and woke with severe nausea and began to
vomit. The vomit was NBNB. She continued to vomit prompting her
to come to the ED.
She denies any sick contacts, denies fevers, chills. She denies
any other symptoms. States her daughter ate same meal and did
not become sick. She denies any diarrhea.
In the ED her vitals initially T 98.2, HR 64, BP 214/72, RR18,
O2SAt 100% RA
She was given 10 IV hydral and BP on repeat is 112/51. She was
given 2L NS and Zofran with resolution of her symptoms. Her labs
were notable for a WBC of 12 and INR 9.5. She was seen by renal
transplant who felt her renal function was at baseline. She was
given 2.5mg of vit K and admitted to medicine.
On arrival to the floor she states she feel back to baseline and
would like to be started on a normal diet.
ROS: 14 point ROS reviewed and negative except per HPI.
Past Medical History:
History of kidney transplant - ___, born with single kidney,
had FSGS leading to renal failure and living donor transplant
from son
History of mitral valve replacement, mechanical, Goal INR=
2.5-3.5; duration of treatment: indefinite. ___
Chronic Impaired fasting glucose
Chronic Hypercholesterolemia
Chronic Hypertension, essential
HISTORY TOTAL HIP REPLACEMENT(aka HIP) - ___ ___ Dr. ___
infection ___
Hypothyroidism, s/p radioiodine ablation
Colonic adenoma
Atrial flutter, paroxysmal a fib
Ventricular fibrillation
Rhabdomyolysis ___ simvastatin
Anemia
Pulmonary nodule
CKD (chronic kidney disease) stage 4, GFR ___ ml/min
Automatic implantable cardioverter-defibrillator in situ
Vitamin D deficiency
Osteoporosis
Social History:
___
Family History:
Mother: Severe HTN
Father: Stomach cancer
Physical Exam:
ADMISSION EXAM:
.
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
HEART: Regular rate and rhythm, ___ systolic murmur heard
throughout precordium
LUNGS: CTAB, no wheezes, rhonchi, or rales
ABDOMEN: Nondistended, +BS, nontender in all quadrants, no
rebound or guarding
EXTREMITIES: No cyanosis, clubbing, or edema.
BACK: No tenderness to palpation
NEURO: CN II-XII intact
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
.
.
DISCHARGE EXAM:
GEN: Well appearing in NAD
HEENT/Neck: anicteric sclera, MMM, OP clear, neck supple
HEART: RR ___ systolic mumur heard throughout, +mechanical
sounds
LUNGS: + mild bibasilar rales; otherwise CTAB no wheezes, rales,
or crackles; normal WOB; no accessory muscle use
ABD: soft NT/ND +BS no rebound or guarding
EXT: warm well perfused, b/l compression stockings on to knees
NEURO: alert and oriented. clear, fluent speech, moving ext w/
purpose and grossly normal strength
Pertinent Results:
Admission Labs:
___ 05:35AM BLOOD WBC-12.0* RBC-3.16* Hgb-9.6* Hct-31.5*
MCV-100* MCH-30.4 MCHC-30.5* RDW-14.7 RDWSD-54.0* Plt ___
___ 07:32PM BLOOD Neuts-78.6* Lymphs-12.2* Monos-7.9
Eos-0.0* Baso-0.5 Im ___ AbsNeut-9.69* AbsLymp-1.50
AbsMono-0.98* AbsEos-0.00* AbsBaso-0.06
___ 05:36AM BLOOD ___
___ 05:35AM BLOOD Glucose-173* UreaN-36* Creat-1.5* Na-145
K-3.9 Cl-106 HCO3-23 AnGap-20
___ 07:32PM BLOOD ALT-11 AST-57* AlkPhos-33* TotBili-1.2
___ 07:45AM BLOOD Cyclspr-53*
Imaging:
___ RENAL TRANSPLANT ULTRASOUND:
EXAMINATION: RENAL TRANSPLANT U.S. RIGHT
TECHNIQUE: Grey scale as well as color and spectral Doppler
ultrasound images of the renal transplant were obtained.
COMPARISON: ___
FINDINGS:
The right iliac fossa transplant kidney demonstrates a diffuse
increase in
renal cortical parechymal echogenicity. The pyramids are
normal, there is no urothelial thickening, and renal sinus fat
is normal. There is no
hydronephrosis and no perinephric fluid collection.
The resistive indices of the intrarenal arteries are elevated
and range from 0.86 to 0.93 . The main renal artery shows an
abnormal waveform with prompt systolic upstroke, but little to
no diastolic flow. Peak systolic velocity measures 138
centimeters/second decreased from prior when it measured 151
centimeters/second. There is significantly elevated velocity at
the anastomosis measuring about 254 cm/ second without diastolic
flow. The doppler waveform demonstrates aliazing just distal to
the anastomosis.
IMPRESSION:
1. Diffusely echogenic cortex of the transplant kidney
concerning for medical renal disease or rejection.
2. Abnormal Doppler exam with minimal diastolic flow and
decreased peak
systolic velocity from prior exam concerning for graft
dysfunction.
3. Significantly increased velocity at the anastomosis without
diastolic flow concerning for anastomotic stricture.
Micro: none during admission
Pathology: none during admission
Notable labs during hospitalization:
.
___ 05:36AM BLOOD ___
___ 07:00AM BLOOD ___
___ 07:20AM BLOOD ___ PTT-38.7* ___
___ 07:20AM BLOOD ___ PTT-42.1* ___
.
___ 07:00AM BLOOD Glucose-125* UreaN-47* Creat-3.0*# Na-144
K-3.9 Cl-103 HCO3-26 AnGap-19
___ 07:20AM BLOOD Glucose-85 UreaN-55* Creat-2.6* Na-142
K-3.6 Cl-106 HCO3-22 AnGap-18
___ 07:20AM BLOOD Glucose-84 UreaN-46* Creat-2.1* Na-143
K-4.2 Cl-108 HCO3-20* AnGap-19
.
___ 07:32PM BLOOD ALT-11 AST-57* AlkPhos-33* TotBili-1.2
___ 07:00AM BLOOD ALT-10 AST-24 LD(LDH)-771* AlkPhos-42
TotBili-1.0
.
___ 07:32PM BLOOD Lipase-65*
.
___ 07:32PM BLOOD cTropnT-<0.01
.
___ 07:00AM BLOOD Hapto-<10*
.
___ 07:45AM BLOOD Cyclspr-53*
___ 09:15AM BLOOD Cyclspr-125
___ 07:20AM BLOOD Cyclspr-147
Discharge labs:
.
___ 07:20AM BLOOD WBC-9.2 RBC-2.81* Hgb-8.6* Hct-28.2*
MCV-100* MCH-30.6 MCHC-30.5* RDW-14.6 RDWSD-53.2* Plt ___
___ 07:20AM BLOOD ___ PTT-42.1* ___
___ 07:20AM BLOOD Glucose-84 UreaN-46* Creat-2.1* Na-143
K-4.2 Cl-108 HCO3-20* AnGap-19
___ 07:20AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.7
___ 07:20AM BLOOD Cyclspr-93*
Brief Hospital Course:
___ yo F with renal transplant from solitary kidney and FSGS,
CKD, HTN, mechanical MVR with paroxysmal AF and h/o cardiac
arrest and ICD, who presents with acute
nausea/vomiting/diarrhea.
Acute gastroenteritis:
acute nausea/vomiting consistent with acute gastroenteritis,
resolved. Medication effect also be considered though there
have not been any recent changes so felt unlikely. No signs for
obstruction or pancreatitis/gastritis. Given IVF until
tolerating good PO for full 24 hours. Tolerating regular diet
with no GI symptoms on the day of discharge.
Afib:
Mechanical MVR:
Coagulopathy:
A paced rhythm. ICD in place. She has mechanical MVR with INR
goal 2.5-3.5. Her INR on presentation was >9 without signs of
bleeding, likely related to her acute illness. Her confirmed
most recent dosing was 7.5mg daily with prior INR 3.5. Since
hospitalization she had been given vitamin K 5mg making her at
very high risk for INR correction. Her INR dropped to 4.2 after
24 hrs, then 3.2, before settling at 3.6 after warfarin 7.5mg.
She was given a dose of warfarin 6mg on ___
Given her ARF/CKD and GFR, she is was not a candidate for
Lovenox bridging.
- discharge warfarin dose: 6 mg daily
- follow up INR scheduled for ___ (2 days after
discharge)
ARF on CKD with renal transplant:
Suspected to be pre-renal from acute n/v and poor PO intake.
Renal ultrasound performed and given IVF. Renal ultrasound
showed interval progression of possible chronic rejection. The
prospect of anastamotic stricture was raised as well.
Transplant surgery deferred to the nephrology team regarding its
significance. The Nephrology team recommended no additional
imaging (i.e. no additional contrast) while inpatient, and
advised follow-up as planned with her primary nephrologist, Dr.
___, in ___ weeks, with consideration of further imaging at
that time.
- final Renal team recs:
- continue cyclosporine and cellcept at current dosing
- repeat BMP within 3 days (scheduled for ___
- resume Torsemide on ___
- f/u w/ her primary Nephrologist, Dr. ___, as
scheduled in late ___
HTN: Stable, continued metoprolol
Anemia, NOS: No signs of bleeding. Haptoglobin low and similar
to prior from ___, consistent with hemolysis from
mechanical valve potentially. no signs for acute bleeding or
other reason for hemolysis. Hgb 9.8 on admission. Hgb nadir of
7.9. Hgb up to 8.6 on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
3. Warfarin 7.5 mg PO DAILY16
4. Ranitidine 150 mg PO QHS
5. Pravastatin 60 mg PO QPM
6. Mycophenolate Mofetil 250 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. Torsemide 20 mg PO DAILY
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Calcitriol 0.25 mcg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
Discharge Medications:
1. Warfarin 6 mg PO DAILY16
Target INR 2.5-3.5
Indication: mechanical MVR, AFib
Adjust as needed to achieve target INR
2. Calcitriol 0.25 mcg PO DAILY
3. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
4. Ferrous Sulfate 325 mg PO DAILY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Metoprolol Tartrate 50 mg PO BID
7. Mycophenolate Mofetil 250 mg PO BID
8. Pravastatin 60 mg PO QPM
9. PredniSONE 5 mg PO DAILY
10. Ranitidine 150 mg PO QHS
11. Vitamin D 1000 UNIT PO DAILY
12. HELD- Torsemide 20 mg PO DAILY This medication was held. Do
not restart Torsemide until ___
13.Outpatient Lab Work
___
To be drawn on ___
ICD-9 code: ___.3 (Mechanical mitral valve)
Please send results to Dr. ___
Fax ___
14.Outpatient Lab Work
Basic metabolic profile
To be drawn on ___
ICD-9 code: ___ (___)
Please send results to Dr. ___ at ___
___
Discharge Disposition:
Home
Discharge Diagnosis:
Acute gastroenteritis
Acute on chronic kidney disease
Coagulopathy with supratherapeutic INR
Renal transplant
Mechanical mitral valve
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation of nausea and vomiting likely
due to a gastroenteritis. As a result, you were dehydrated and
your INR was very high which was corrected. There have been
some changes to your medications and you will need laboratory
testing shortly after discharge:
- Please resume torsemide on ___
- Please take 6 mg of Coumadin (warfarin) tonight and tomorrow
night.
- Please have your INR checked on ___, and have the
results sent to your ___ clinic, they will help you make
adjustments to your Coumadin dose
- Please have your BMP checked on ___ (you have been
given a prescription for this); these results should be faxed to
Dr. ___.
Please plan to follow-up with your kidney doctor, ___, as
scheduled. When you see Dr. ___ discuss with him/her
about what additional testing might be needed based upon the
results of your recent kidney ultrasound (the results of which
will be included in the discharge summary).
Followup Instructions:
___
|
10296832-DS-3 | 10,296,832 | 22,727,060 | DS | 3 | 2114-03-02 00:00:00 | 2114-03-07 11:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Darvocet-N / latex
Attending: ___.
Chief Complaint:
abdominal pain, chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo G2P1 with hx factor V Leiden mutation and 7.5 weeks GA
presents as transfer from ___. She
presented there with abdominal pain radiating to her chest,
dyspnea on exertion and fever x2 this week at home.
At present she reports mild SOB that comes and goes, mild chest
pain but seems to originate in epigastrium. Had GI cocktail
without effect. Mild N/V for several week. No bowel or bladder
complaints, no vaginal bleeding.
Found out she was pregnant 2 weeks ago at which time she
switched from coumadin -> lovenox.
Past Medical History:
OB Hx: G2P1
- SVD after IOL of labor at 6 months of gestation, induction
recommended after found to have "70 blood clots" in body. Had
IVC filter placed at that time. Infant demised after birth, had
intracranial hemorrhage.
Gyn hx: history of sexual assault age ___ and contracted herpes.
denies hx abnl Pap, fibroids, endometriosis.
PMHx: factor V Leiden carrier (unsure homozygote or
heterozygote) with VTEs from age ___. ___ IVC filter
placed ___ and has been on therapeutic anticoagulation. also
has panic disorder, bipolar, asthma, hyperglycemia (? unclear if
diagnosis of diabetes)
Surghx: IVC filter placement, "brainstem surgery" for ___
___ malformation, open heart surgery for removal of "lipoma",
tonsilectomy
Social History:
___
Family History:
no family hx of VTE/strokes. mother with mitral valve prolapse
Physical Exam:
(on admission)
VITALS: T 98.7, HR 90, BP 109/73, RR 20, 94% RA
___: NAD, sleeping on my arrival
HEART: RRR
LUNGS: CTAB no increased WOB or adventitious sounds
ABDOMEN: soft, mildly TTP epigastrium, no R/G, morbidly obese
legs symmetric, no edema or erythema, no TTP
TVUS: live SIUP s=d, CRL corresponds to 8w0d
On discharge:
Gen - NAD
CV - RRR
Lungs - CTAB
Abd soft, obeset, nontender
Ext- no calf tenderness, no edema
Pertinent Results:
___ WBC-7.5 RBC-4.26 Hgb-12.1 Hct-34.6 MCV-81 Plt-160
___ Neuts-75.4 ___ Monos-6.3 Eos-1.5 Baso-0.5
___ ___ PTT-36.1 ___
___ Glu-89 BUN-12 Creat-0.7 Na-137 K-4.3 Cl-106 HCO3-23
AnGap-12
___ ALT-10 AST-13 AlkPhos-55 TotBili-0.2
___ Lipase-20
___ Albumin-3.7
___ 12:03PM BLOOD Heparin-0.70
___ PELVIC U/S
FINDINGS:
An intrauterine gestational sac is seen and a single living
embryo is
identified with a crown rump length of 15.5 mm representing a
gestational age of 8 weeks 0 days. This corresponds
satisfactorily with the reported date of the 7.5 weeks
documented on the ED dashboard. The uterus is normal. The
ovaries are normal.
IMPRESSION: Single live intrauterine pregnancy with size =
dates.
___ CHEST CTA
IMPRESSION:
Assessment of the subsegmental level is limited due to body
habitus and bolus timing.No evidence of central or segmental
level pulmonary embolism, however subsegmental pulmonary
embolism is not excluded.
Brief Hospital Course:
___ yo G2P0 with bipolar d/o, hx factor V Leiden mutation and
diffuse VTE, filter in place, transfered from OSH at 7w5d with
chest symptoms and concern for pulmonary embolism. On admission,
she was hemodynamically stable. Chest CTA revealed no evidence
of a large PE, although it was a suboptimal study due to body
habitus. Hematology was consulted and recommended increasing her
Lovenox to therapeutic dosing (120mg bid), and she had a
therapeutic anti-Xa level during this admission. She had a
reassuring Ob ultrasound measuring size equal to dates. Given
her complex medical history and plan to continue her prenatal
care at ___, her medical records from various facilities were
obtained. She was discharged to home in stable condition on HD#2
and will return for her scheduled prenatal visit on ___. She
will also followup with hematology as an outpatient.
Medications on Admission:
lovenox ___ daily, written by PCP. PNV. previously was taking
abilify and clonipin (stopped with pregnancy)
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing, shortness of
breath
2. Enoxaparin Sodium 120 mg SC Q12H
3. Nicotine Patch 14 mg TD DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Chest muscle pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were discharged to the hospital for work-up of blood clots.
None were found. You were started on lovenox ___ mg twice daily.
Please take as prescribed. Please call the office for any
questions or concers.
Followup Instructions:
___
|
10296929-DS-7 | 10,296,929 | 22,391,343 | DS | 7 | 2164-07-19 00:00:00 | 2164-07-19 17:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending: ___.
Major Surgical or Invasive Procedure:
Airway intubation x2
EGD with food disimpaction
CVL
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 10:30AM BLOOD WBC-8.7 RBC-3.88* Hgb-13.1* Hct-39.3*
MCV-101* MCH-33.8* MCHC-33.3 RDW-13.4 RDWSD-50.2* Plt ___
___ 10:30AM BLOOD Neuts-71.6* Lymphs-10.4* Monos-14.4*
Eos-2.0 Baso-0.2 Im ___ AbsNeut-6.22* AbsLymp-0.90*
AbsMono-1.25* AbsEos-0.17 AbsBaso-0.02
___ 10:30AM BLOOD ___ PTT-38.1* ___
___ 10:30AM BLOOD Glucose-123* UreaN-21* Creat-0.7 Na-141
K-3.0* Cl-97 HCO3-30 AnGap-14
___ 04:30PM BLOOD CK(CPK)-45*
___ 02:29PM BLOOD ALT-7 AST-16 LD(LDH)-142 AlkPhos-57
TotBili-0.8
___ 04:30PM BLOOD Calcium-8.4 Phos-3.4 Mg-1.5*
___ 03:07PM BLOOD Type-ART pO2-76* pCO2-48* pH-7.40
calTCO2-31* Base XS-3
___ 03:07PM BLOOD O2 Sat-92
ADDITIONAL PERTINENT LABS:
==========================
___ 02:29PM BLOOD ___
___ 10:30AM BLOOD proBNP-820
___ 04:30PM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-1294*
___ 07:32AM BLOOD proBNP-984*
___ 02:29PM BLOOD Hapto-126
___ 12:05AM BLOOD Type-ART pO2-89 pCO2-49* pH-7.44
calTCO2-34* Base XS-7
___ 03:07PM BLOOD Glucose-160* Lactate-1.5
___ 04:32PM BLOOD Lactate-1.8
___ 11:22AM BLOOD Lactate-2.2*
___ 05:00PM BLOOD Lactate-2.1*
___ 12:19AM BLOOD Lactate-1.5
___ 03:02AM BLOOD Lactate-1.3
___ 12:05AM BLOOD Lactate-1.2
___ 03:02AM BLOOD freeCa-1.15
___ 12:05AM BLOOD freeCa-1.11*
___ 02:29PM BLOOD ALT-7 AST-16 LD(LDH)-142 AlkPhos-57
TotBili-0.8
___ 04:30PM BLOOD CK(CPK)-45*
DISCHARGE LABS:
===============
___ 07:32AM BLOOD WBC-9.9 RBC-3.64* Hgb-12.1* Hct-37.2*
MCV-102* MCH-33.2* MCHC-32.5 RDW-13.5 RDWSD-51.1* Plt ___
___ 07:32AM BLOOD ___ PTT-36.2 ___
___ 07:32AM BLOOD Glucose-108* UreaN-20 Creat-0.6 Na-141
K-3.4* Cl-99 HCO3-25 AnGap-17
___ 07:32AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.7
MICRO:
======
Blood Cultures x2 ___ - no growth
Gram stain sputum ___ - H. Flu positive
Urine legionella ___ - negative
MRSA Screen ___ - negative
Blood cultures x2 ___ - no growth to date
Blood culture ___ - no growth to date
URINALYSIS:
===========
___ 07:40PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 07:40PM URINE Blood-MOD* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 07:40PM URINE RBC-98* WBC-0 Bacteri-FEW* Yeast-NONE
Epi-0
IMAGES:
=======
___ Chest Xray:
Endotracheal tube tip projects 3.5 cm above the level of carina.
Mild
cardiomegaly, unchanged from prior. Atherosclerotic
calcifications of the
aorta. Multifocal airspace opacities, with relative sparing of
the bilateral upper lobes concerning for multifocal pneumonia.
Airspace opacities also noted within the retrocardiac region.
There are no pneumothoraces.
___ Chest Xray:
In comparison with the study of ___, the monitoring
support devices are unchanged. Cardiomediastinal silhouette is
stable, as are the diffuse
bilateral pulmonary opacifications. This pattern would be
consistent with
substantial pulmonary edema, widespread pneumonia, or even ARDS.
___ Chest Xray:
There has removal of the right IJ central line. Heart size is
upper limits of normal but stable. There is moderate pulmonary
edema with prominence of the pulmonary interstitial markings,
stable. There is mild blunting of the left CP angle suggestive
of small pleural effusion. There are no pneumothoraces.
___ Transthoracic Echo Report
The left atrial volume index is moderately increased. The right
atrium is moderately enlarged. 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 70%. There is no resting left
ventricular outflow tract gradient. Moderately dilated right
ventricular cavity with
moderate global free wall hypokinesis. Tricuspid annular plane
systolic excursion (TAPSE) is depressed. Intrinsic right
ventricular systolic function is likely lower due to the
severity of tricuspid regurgitation.
There is abnormal interventricular septal motion c/w right
ventricular pressure and volume overload. The aortic sinus is
mildly dilated with a normal ascending aorta diameter for
gender. The aortic arch
diameter is normal with a normal descending aorta diameter. The
aortic valve leaflets (3) are moderately thickened. There is
mild aortic valve stenosis (valve area 1.5-1.9 cm2). There is
mild [1+] aortic
regurgitation. The mitral valve leaflets are mildly thickened
with no mitral valve prolapse. There is severe mitral annular
calcification. There is mild functional mitral stenosis from the
prominent mitral
annular calcification. There is trivial mitral regurgitation.
Due to acoustic shadowing, the severity of mitral regurgitation
could be UNDERestimated. The pulmonic valve leaflets are normal.
There is
significant pulmonic regurgitation. The tricuspid valve leaflets
appear structurally normal. There is moderate to severe [3+]
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is
borderline elevated. In the setting of at least moderate to
severe tricuspid regurgitation, the pulmonary
artery systolic pressure may be UNDERestimated. There is no
pericardial effusion.
IMPRESSION: dilated, hypokinetic right ventricle with
moderate-to-severe tricuspid regurgitation Compared with the
prior TTE (images reviewed) of ___ , right ventricle is
more dilated and hypokinetic. Tricuspid regurgitation is
significantly worse.
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[ ] After rehab, would recommend f/u with PCP for volume status
and adjust diuretic dose as needed.
[ ] Patient needs to follow up with the outpatient GI endoscopy
suite for a dilation procedure of the Schatzki's ring.
[ ] Patient will need an appointment made for ___ procedure w/
Dr. ___, dermatology.
[ ] Metprolol dose was increased to 200mg, will need to be
decreased as an outpatient to his home dose of 100mg daily.
[ ] Patient needs daily weights. Weight on Discharge was 184.52
lb. Please call his cardiologist for titration of his home
bumetanide if his weight goes up or down by more than 3lb in
24-hours.
HOSPITAL SUMMARY:
=================
Mr. ___ is an ___ male patient with a history of Afib on
apixaban, HFpEF, and Schatzki's ring that has been stable for
___ years who presented w/ a 4 day history of cough and a 1 day
history of progressive feeling of choking who was admitted for
intubation and emergent EGD for retrieval of an esophageal
obstruction at his existing Schatzki's ring. After the
procedure, the patient subsequently developed flash pulmonary
edema that required re-intubation and an IV diuretic gtt to
improve his fluid status and was then extubated and successfully
transitioned back to his home diuretic with plan to discharge to
rehab and to follow up with outpatient endoscopy for Schatzki's
ring dilation.
ACUTE/ACTIVE ISSUES:
====================
#Hypoxemic Respiratory Failure
#Acute on Chronic HFpEF Exacerbation:
After the procedure to retrieve the impacted food from the
patient's esophagus, he was extubated, at which time he began to
develop significant shortness of breath and his O2 saturation
had dropped significantly requiring re-intubation. A chext Xray
showed flash pulmonary edema. Diuresis was increased with a
bumetanide 0.5 mg/hr IV gtt and after a 4 day ICU stay, the
patient was successfully extubated and transferred to the floor
where his respiratory and volume status continued to improve and
was transitioned back to his home bumetanide dose of 4mg PO
daily and spironolactone 25mg daily. Weight on Discharge was
184.52 lb, felt to be euvolemic at that time.
#Food Impaction s/p EGD Disimpaction
#Schatzki's Ring:
Has had a stable Schatzki's ring for decades; however, the week
leading up to hospitalization he began having coughing fits with
food that escalated to not being able to swallow anything and
the feeling of choking. Emergent EGD successfully disimpacted
the esophagus and the patient's diet was advanced to pureed
foods by discharge. Plan to follow up outpatient for dilation
with GI on ___.
___ ___ Cardiorenal Physiology:
Patient had a mild increase in his serum Cr that was likely
caused by significant vascular congestion ISO CHF exacerbation,
as the Cr improved with diuresis and de-congestion.
#H.Flu CAP PNA:
The chest Xray also showed evidence of a consolidation w/
cultures growing H. Flu, for which the patient completed CAP
therapy in hospital, with ceftriaxone finishing on ___.
#pAF with RVR (150s):
Patient's metoprolol dose was fractionated and increased to from
100mg daily to 200mg daily due to AF w/ RVR to the 150s during
his ICU course. He was discharged on metoprolol succinate XL
200mg daily and his home apixiban 5mg BID. His metoprolol should
be decreased to home dose as an outpatient if heart rates are
well controlled.
#Thrombocytopenia
#Chronic Macrocytic Anemia:
Patient has a chronic macrocytic anemia dating back years; B12
and folate haven't been checked. Nutritional status could be the
potential cause here and he may benefit from a multivitamin.
Thrombocytopenia was new this admission and may have been
secondary to infectious process, and the platelet count had
begun up-trending at discharge.
CHRONIC/STABLE ISSUES:
======================
#GERD
Continued Omeprazole 20mg BID during hospitalization.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Bumetanide 4 mg PO DAILY
3. Modafinil 200 mg PO DAILY
4. Omeprazole 20 mg PO BID
5. Spironolactone 25 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 200 mg PO DAILY
2. Apixaban 5 mg PO BID
3. Bumetanide 4 mg PO DAILY
4. Modafinil 200 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Esophageal Obstruction - Food Impaction
Schatzki's Ring
CHF Exacerbation
SECONDARY DIAGNOSIS:
====================
Community Acquired Pneumonia
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 Mr. ___,
It was a privilege caring for you at ___.
Please see below for more information on your hospitalization.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were in the hospital for food that was stuck in your
throat.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You had a breathing tube placed in your mouth and a device was
used to retrieve the food that was stuck.
- You developed a significant amount of fluid in your lungs that
required the breathing tube being left in place.
- Your breathing improved by increasing the amount of water pill
you take and the breathing tube was removed.
- You continued to get better and you were cleared to go to
rehab to regain your strength.
WHAT ___ YOU NEED TO ___ WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs. Weight on Discharge was 184.52
lb
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10297650-DS-6 | 10,297,650 | 28,384,907 | DS | 6 | 2117-02-17 00:00:00 | 2117-02-17 15:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
bee strings / Dilaudid / Codeine / Nambutone / metformin /
metformin / morphine
Attending: ___.
Chief Complaint:
Chest pain, dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of hypertension, hyperlipidemia, diabetes,
anxiety, PTSD presenting with lightheadedness, dizziness.
Patient states that he recently finished a course of antibiotics
for pneumonia. He takes Propanolol for panic attacks which was
recently increased from 10mg to 20mg up to TID PRN. He has been
having exertional chest pain recently with 5 episodes today
lasting 1"-10" and is described as a pressure on his left chest.
He has also been lightheaded and dizzy when he stands up. He
presented to primary care provider's office today and was found
to be bradycardic in the ___ and normotensive. He was
referred to emergency department for further evaluation. He
currently denies any symptoms at rest. He is scheduled to have
an echocardiogram to evaluate for heart murmur in ___. He
has been under a significant amount of emotional stress and is
currently living in a homeless shelter.
Past Medical History:
Diabetes (diet controlled)
HTN
Decreased Hearing, Bilateral
Presbyopia - ___
Myopia - ___
Migraines
___ Cyst, Right Knee
Alcohol Abuse
Anxiety
Depression, Major
PTSD, panic attacks
Bariatric Surgery weight loss of > 100 lbs.
Bilateral Hearing loss
Social History:
___
Family History:
- Mother: diabetes
- Father: CAD with MI in his mid ___, quadruple bypass in his
___, Alzheimer's, diabetes, ?blood clot
Physical Exam:
Admission:
VS: T 98.1 BP 134/79 HR 41-55 RR 18 O2 SAT 95% RA
GENERAL: Well developed, well nourished in NAD.
NEURO: Oriented x3. Pleasant and cooperative. Speech clear,
appropriate and comprehensible. MAE equal and strong. Ambulating
in room independently without assistive device.
NECK: Supple. No JVO appreciated
CARDIAC: Regular rate and rhythm.
LUNGS: Non-labored and without accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused with trace peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable ___
Discharge:
VS: T 97.7 BP 101-134/57-79 HR 41 RR 16 O2 SAT 97% RA
GENERAL: pleasant man in NAD ambulating in his room.
NEURO: Alert and oriented. Speech clear, appropriate and
comprehensible. MAE equal and strong. no focal deficits
NECK: Supple. No JVD
CARDIAC: Regular rate and rhythm no M/R/G
LUNGS: Non-labored and without accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused with trace peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable ___
Pertinent Results:
___ 11:50AM BLOOD WBC-8.2 RBC-4.05* Hgb-12.7* Hct-37.0*
MCV-91 MCH-31.4 MCHC-34.3 RDW-13.1 RDWSD-42.9 Plt ___
___ 11:50AM BLOOD Neuts-68.5 ___ Monos-5.2 Eos-1.5
Baso-0.7 Im ___ AbsNeut-5.65 AbsLymp-1.95 AbsMono-0.43
AbsEos-0.12 AbsBaso-0.06
___ 11:50AM BLOOD ___ PTT-28.5 ___
___ 11:50AM BLOOD Glucose-156* UreaN-10 Creat-0.7 Na-136
K-4.6 Cl-98 HCO3-28 AnGap-15
___ 11:50AM BLOOD cTropnT-<0.01
___:10AM BLOOD cTropnT-<0.01
___ 08:10AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.0
___ 08:10AM BLOOD Glucose-122* UreaN-10 Creat-0.7 Na-142
K-4.5 Cl-102 HCO3-26 AnGap-19
___ 08:10AM BLOOD WBC-5.8 RBC-4.31* Hgb-13.1* Hct-39.8*
MCV-92 MCH-30.4 MCHC-32.9 RDW-13.0 RDWSD-43.5 Plt ___
Brief Hospital Course:
Mr. ___ presented to the ED with c/o CP and dizziness. He was
found to bradycardic in SR with rates ___. He reports that
the Propanolol he takes prn for anxiety was recently increased
from 10mg PRN TID to 20mg PRN TID. He ruled out for MI by enzyme
and EKG.
His propranolol was discontinued. His rate continued to be
bradycardic during his hospital stay but rates improved to
mainly ___'s and ___'s with occasional dips to the 30's. He was
discharged back to ___ Shelter with follow up with
his PCP in one week.
# Sinus bradycardia - Baseline HR appears to be ___. Likely
cause of current bradycardia is recent increased propranolol
dose. No signs of ACS and troponin negative x2. There are no
concerning changes on his EKG to suggest high grade heart block
or other unstable rhythm.
- discontinue propranolol
-Follow up with PCP in one week
Chronic problems:
# Anxiety:
- Continue hydroxyzine prn
- Hold propranolol
# PTSD:
- Continue prazosin
#Diabetes: diet controlled
- Continue carbohydrate controlled diet
#Dispo: Discharge to ___ shelter with follow up at
PCP within ___ week
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
2. Prazosin 1 mg PO QHS
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
4. Benzonatate 100 mg PO TID:PRN cough
5. HydrOXYzine 25 mg PO BID:PRN anxiety
6. Propranolol 20 mg PO TID:PRN panic
7. CloNIDine 0.2 mg PO PRN insomnia
8. Ferrous Sulfate 325 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
11. Calcium Carbonate Dose is Unknown PO DAILY
12. Magnesium Oxide 250 mg PO DAILY
13. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Calcium Carbonate unknown PO DAILY
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. Benzonatate 100 mg PO TID:PRN cough
4. CloNIDine 0.2 mg PO PRN insomnia
5. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
6. Ferrous Sulfate 325 mg PO DAILY
7. HydrOXYzine 25 mg PO BID:PRN anxiety
8. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
9. Magnesium Oxide 250 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Prazosin 1 mg PO QHS
12. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
bradycardia
anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent
Discharge Instructions:
You presented to ___ for complaints of chest
pain and dizziness. It was felt the cause of your low heart rate
was an increase in your Propranolol medication. Your EKG and lab
work were negative for a heart attack.
Please stop taking your Propranolol.
We made no further changes to your medications.
Please follow up with your primary care doctor within ___ week.
Followup Instructions:
___
|
10297774-DS-10 | 10,297,774 | 20,364,526 | DS | 10 | 2194-05-16 00:00:00 | 2194-05-18 10:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
___ M with hx of CAD s/p CABG, severe mitral
regurgitation, atrial fibrillation, ischemic cardiomyopathy
(LVEF 35%) and history of VF arrest s/p ICD who presened with
general malaise, nausea, fatigue.
He had a prior ___ CCU admission in early ___ for cardiogenic
shock on IABP and dopamine and deemed not a surgical candidate
for MVR. His course was complicated by ___, UTI, and RP bleed on
the
contralateral side (left) of the IABP, with appropriate response
to transfusion. He also had NSVT and monomorphic VT requiring
ICD shock. After discharge, he was found to be in 2:1 atrial
flutter.
and after discussion with EP, EPS deferred due to inability to
safely anticoagulate. He has since tolerated addition of low
dose carvedilol and has remained in sinus rhythm.
Morning of presentation, after getting up to go to the shower,
he began feeling unsteady. This lasted for approximately an hour
and a half, when his wife had to assist him with walking as he
did not feel strong enough to walk unassisted. During this time,
he endorsed fatigue and feeling cold. He denied any other
symptoms.
Upon arrival to the ED, he reported improvement in his symptoms.
He no longer felt any nausea and was dizzy only upon standing.
His breathing was unlabored, and he was resting comfortably in
his bed upon interview. He was found to be hyperkalemic at 5.9.
10 units insulin, 1g calcium gluconate, and 1L IV bolus of NS
were given. Repeat chemistry was hemolyzed. Later he became
tachypneic and was satting in the ___ with crackles on lung
exam, and CXR consistent with pulmonary edema. He became
agitated and unable to tolerate NIV. He was then sedated and
intubated. His BP dropped to SBPs ___ and was started on
Levophed.
Also of note, EKG revealed a paced rhythm of 57, QRS 143, QTc
543, STE in lead III, V3, TWI in V6, aVL, RSR' in V6. TWI new
from prior. Troponins x2 came back 0.04 and 0.05, respectively.
Cardiology was consulted to weigh in on the new STE and said EKG
changes consistent with hyperkalemia. Dr. ___
admission to the CCU for further management.
On arrival to the CCU, the patient was intubated and sedated.
Vital signs were stable.
Per wife, present at bedside, the patient has had ongoing
diarrhea for past 3 weeks, with progressive generalized fatigue
and feeling tired despite patient not typically wanting to
complain about any symptoms. On the night prior to admission,
his wife endorses he had had some episodes of coughing but
denies orthopnea or PND. She states he was also reporting
subjective chills and rigors on the day of admission. She denies
patient complaining of CP or SOB, hematuria or hematochezia, or
dysuria.
Past Medical History:
Cardiomyopathy - thought viral ___, diagnosed at ___, with
multiple readmissions for CHF exacerbations with signficant DOE
and ___ edema in ___. ECHO then showed global dyskinesis with
EF 20%. Did show e/o asymptomatic VT in ___ DC summary.
Tobacco abuse
Ethanol abuse
Allergies - treated with clarinex
Bronchitis
Social History:
___
Family History:
Father died heart dz ___, mother at ___ of "natural causes."
Sister died from ovarian cancer. Son and daughter both reportdly
well.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
Vitals: BP 115/56 HR 55 Sat 99% on vent
GENERAL: well-nourished male, intubated and sedated on
ventilator
HEENT: NC/AT, no conjunctival erythema or scleral icterus noted
LUNGS: CTA in anterior lung fields bilaterally, no crackles
rales or rhonchi
CV: RRR, holosystolic murmur noted at ___
ABD: soft, nondistended; normoactive bowel sounds
EXT: warm and well perfused. PIVs in place. no lower extremity
edema noted
SKIN: clean, dry and intact; no ecchymoses, rash, or wounds
noted
NEURO: patient intubated and sedated, patient intermittently
moving upper extremities to painful stimuli. Pupils equal and
reactive, 2mm
ACCESS: PIVs
DISCHARGE PHYSICAL EXAM:
==========================
VSS
GENERAL: Thin male in NAD
HEENT: NC/AT, no conjunctival erythema or scleral icterus noted
LUNGS: CTA in anterior lung fields bilaterally, no crackles
rales or rhonchi
CV: RRR, holosystolic murmur noted at ___. JVP ~8 cm
ABD: soft, nondistended; normoactive bowel sounds
EXT: warm and well perfused. PIVs in place. no lower extremity
edema noted
SKIN: clean, dry and intact; no ecchymoses, rash, or wounds
noted
NEURO: CN II - XII grossly intact.
ACCESS: PIVs
Pertinent Results:
ADMISSION LABS
========================
___ 11:15AM BLOOD WBC-22.2*# RBC-4.07* Hgb-11.5* Hct-35.8*
MCV-88 MCH-28.3 MCHC-32.1 RDW-16.0* RDWSD-51.3* Plt ___
___ 11:15AM BLOOD ___ PTT-24.8* ___
___ 11:15AM BLOOD Glucose-319* UreaN-36* Creat-1.6* Na-128*
K-5.4* Cl-91* HCO3-24 AnGap-18
___ 11:15AM BLOOD CK(CPK)-63
___ 11:14PM BLOOD ALT-31 AST-26 LD(LDH)-408* AlkPhos-246*
TotBili-2.4* DirBili-1.2* IndBili-1.2
___ 11:15AM BLOOD CK-MB-3
___ 11:15AM BLOOD cTropnT-0.04*
___ 11:23AM BLOOD Lactate-1.9 K-5.4*
___ 07:00PM BLOOD Type-ART Rates-18/ Tidal V-450 PEEP-10
FiO2-50 pO2-70* pCO2-50* pH-7.29* calTCO2-25 Base XS--2
Vent-CONTROLLED
RELEVANT IMAGING
=========================
___ CT A/P:
IMPRESSION:
1. No acute intra-abdominal process on this noncontrast
examination.
2. Consolidative lung base opacities, right greater than left,
likely
representing a combination of atelectasis and pneumonia,
possibly secondary to
aspiration.
3. Mild pulmonary edema and small right pleural effusion.
4. Heterogeneous fat containing lesion in the left
retroperitoneum, unchanged
and better characterized on the prior MRI as likely reflecting a
chronic
hematoma with associated fat necrosis.
5. Stable right adrenal adenoma and left adrenal hypertrophy.
CXR (___):
Interval resolution of pulmonary edema. Pulmonary vascular
congestion.
DISCHARGE LABS
=========================
___ 07:05AM BLOOD WBC-8.6 RBC-4.08* Hgb-11.4* Hct-36.1*
MCV-89 MCH-27.9 MCHC-31.6* RDW-16.5* RDWSD-53.3* Plt ___
___ 07:05AM BLOOD Glucose-147* UreaN-35* Creat-1.4* Na-132*
K-4.2 Cl-90* HCO3-28 AnGap-18
___ 07:05AM BLOOD Calcium-9.9 Phos-3.8 Mg-1.9
MICROBIOLOGY
=========================
-BCx (___) x 2: NO GROWTH
-URINE CULTURE (Final ___: NO GROWTH.
-Legionella Urinary Antigen (Final ___: NEGATIVE FOR
LEGIONELLA SEROGROUP 1 ANTIGEN.
-RESPIRATORY CULTURE (Final ___: SPARSE GROWTH Commensal
Respiratory Flora.
Brief Hospital Course:
PRESENTATION
___ M with PMHx significant for HTN, diabetes, ischemic
cardiomyopathy (EF 25%), severe mitral regurgitation, and CAD
s/p CABG presented with pneumosepsis.
ACUTE ISSUES
=====================
#CAP: Initially required intubation and levophed, had WBC to 23.
Sputum gram stain with GNRs, GN diplococci, GPCs, GPR; culture
growing respiratory flora. Dramatic clinical improvement with
vanc/cefepime/flagyl with WBC down to 8. Extubated and levophed
stopped on hospital day 1. Narrowed to vanc/cefepime, then
discharged on clindamycin to complete 7 day course (last day
___ for CAP.
#Acute on chronic systolic heart failure (LVEF 35%): Initially
with flash pulmonary edema in setting of volume overload. Pt was
diuresed with multiple doses of 40 mg IV Lasix, and then
restarted on his home torsemide 10 mg BID.
Discharge weight: 61.9 kg
Discharge Cr: 1.4
#Paroxysmal AF/Aflutter: On amiodarone and digoxin as
outpatient. Some concern for digoxin toxicity given progressive,
non-specific symptoms including nausea and malaise. Digoxin
level was 1.7 ~24 hours after pt's last reported dose. Repeat
level 48 hours later was .9. Decision was made to continue
patient on his outpatient dose (0.125 mg every other day), as
well as his amiodarone.
#Hoarseness: s/p extubation. No choking/trouble eating, and with
daily improvement. If persistent, consider ENT consultation for
possible vocal cord paralysis.
CHRONIC ISSUES
=====================
#DM2 with hyperglycemia: Poorly controlled on Glipizide/Januvia
and Lantus 10 as outpatient, with persistently high blood sugars
as inpatient. Lantus 15 U + HISS in house.
#CKD: Had ___ on CKD with Cr. to 1.9 on admission (from baseline
~1.5). Discharge Cr was 1.4.
TRANSITIONAL ISSUES
=====================
TRANSITIONAL ISSUES:
- Discharge weight: 61.9 kg.
- Discharge creatinine: 1.4
- last day of clindamycin: ___
- Medication changes:
-- Patient had frequent ectopy and was discharged on magnesium
oxide supplement.
- Please check Chem-10 at next appointment.
- Blood sugars poorly controlled during this admission in
setting of acute illness. Please adjust diabetic regimen as
appropriate.
- Patient with hoarseness following extubation. No evidence of
aspiration. Improving by day of discharge. Please ensure
resolution of hoarseness.
- Communication: Wife ___, phone ___
- Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
2. Lisinopril 10 mg PO DAILY
3. Carvedilol 6.25 mg PO BID
4. Digoxin 0.125 mg PO EVERY OTHER DAY
5. Amiodarone 200 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Torsemide 10 mg PO BID
8. TraMADol 50 mg PO BID:PRN as needed for back pain
9. Pantoprazole 40 mg PO Q24H
10. Aspirin 81 mg PO DAILY
11. GlipiZIDE 5 mg PO BID
12. sitaGLIPtin 50 mg oral DAILY
13. menthol-camphor-benzyl alcohol ___ % topical BID:PRN
pruritus
14. BuPROPion (Sustained Release) 150 mg PO DAILY
15. Glargine 10 Units Breakfast
Discharge Medications:
1. Clindamycin 300 mg PO Q8H Duration: 4 Days
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every eight (8)
hours Disp #*4 Capsule Refills:*0
2. Magnesium Oxide 400 mg PO DAILY
RX *magnesium oxide 400 mg 1 capsule(s) by mouth Daily Disp #*14
Capsule Refills:*0
3. Glargine 10 Units Breakfast
4. Torsemide 10 mg PO BID
5. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
6. Amiodarone 200 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. BuPROPion (Sustained Release) 150 mg PO DAILY
10. Carvedilol 6.25 mg PO BID
11. Digoxin 0.125 mg PO EVERY OTHER DAY
12. GlipiZIDE 5 mg PO BID
13. Lisinopril 10 mg PO DAILY
14. menthol-camphor-benzyl alcohol ___ % topical
BID:PRN pruritus
15. Pantoprazole 40 mg PO Q24H
16. sitaGLIPtin 50 mg oral DAILY
17. TraMADol 50 mg PO BID:PRN as needed for back pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
================
Primary Diagnosis
===================
Community Acquired Pneumonia
Sepsis
===================
Secondary Diagnosis
===================
Acute on chronic systolic heart failure
Acute kidney injury
Diabetes mellitus
Atrial fibrillation
Thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with difficulty breathing, which was
likely caused by a lung infection that worsened your heart
failure. Initially, a breathing tube was placed in your windpipe
to help you breathe, and you were given medications to keep your
blood pressure in a normal range. You were given antibiotics to
treat your lung infection. You quickly improved and the
breathing tube was taken out and you were taken off of the blood
pressure medications. You were put on a water pill to take extra
fluid off of your lungs. Over the next few days, you further
improved and were discharged home.
When you return home, you will need to continue taking the
antibiotic with the last day being ___. You should hold your
torsemide this evening and resume taking your usual dose
tomorrow. You will follow up with your cardiologist and PCP.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
10297774-DS-12 | 10,297,774 | 24,045,881 | DS | 12 | 2195-03-08 00:00:00 | 2195-03-08 17:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ ___ gentleman with a cardiac
history pertinent for CAD/inferior MI s/p CABG x6 (___), VF
arrest s/p ___ ICD (___), recurrent VT, pAF/AFL, atrial
tachycardia, severe mitral regurgitation, as well as multiple
medical comorbidities including T2DM, CKD 3, and prior history
of severe GI (___) and RP bleeding (___) while on
anticoagulation who presents for subacute onset shortness of
breath.
Of note, in terms of recent history, patient was admitted to
___ for cardiogenic shock ___ thought due to
dietary indiscretion as well as severe mitral regurgitation. He
required inotropic support with dopamine while being diuresed
and briefly required an IABP. He was deemed not to be a surgical
candidate for MVR.
He was later hospitalized in ___ in
___ after presenting with fever, back pain, and
nausea/vomiting. A CT abdomen/pelvis at ___
revealed a L-sided retroperitoneal mass. Images were reviewed
with radiology and follow up MRI abdomen/pelvis was consistent
with an evolving chronic hematoma with associated fat necrosis.
His back pain since resolved.
Most recently he had an elective VT ablation ___ during
this admission he was found to be c diff positive and put on
flagyl. He was seen in ___ clinic ___ and started on
spironolactone if his labs remained ok (per insurance hx on OMR
this was not yet filled)
In the ED, initial vitals were: 98.4 72 110/70 18 96% RA
- Exam notable for:
JVP to chin
Minimal crackles
2+ ___ R>L
- Labs notable for:
Cr 1.8 from 1.3, Na 127 from 131, BNP 7289
Crit 10.5 from ___
Micro: urine cx pending
- Imaging was notable for: negative CXR for acute process,
negative RLE U/S
- Patient was given: 80 iv Lasix, 40 atorvastatin, 6.25 mg
carvedilol
Upon arrival to the floor, patient reports that he feels short
of breath "just like when his heart acts up n past:. He denies
any recent cough or sick contacts of fevers or chills. He self
reports he feels as though his legs were more swollen, but
cannot definitely say if he felt more short of breath while
lying down. He denies chest pain.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
CAD s/p CABG (___) CABG x 6 (___)
Infarct Cardiomyopathy w/EF 35%, NYHA Class II symptoms
VF arrest s/p ___ ICD (___)
PAF (not currently on anticoagulation given history of GI Bleed
and retroperitoneal bleed ___ and ___ while on
anticoagulation)
Severe MR
DM Type II - Insulin Dependent
CKD Stage III (eGFR 55)
Cardiogenic Shock ___ requiring inotropic support w/dopamine,
IABP s/p chronic left hematoma
UTI
Spontaneous Retroperitoneal hematoma
Atrial Flutter (___)
PNA ___
Severe MR
___ right lateral foot ulcer w/recent abdominal and RLE
angiogram
Phacoemulsification w/posterior chamber lens implant
Esophageal bleed in setting of Pradaxa ___
Social History:
___
Family History:
Father died heart dz ___, mother at ___ of "natural causes."
Sister died from ovarian cancer. Son and daughter both reportdly
well.
Physical Exam:
ADMISSION PHYSICAL EXAM:
PHYSICAL EXAM:
Vital Signs: afeb BP 108/70 HR 68 RR 20
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, dry mucous membranes
Neck: Supple.
CV: Regular rate and rhythm. JVP at 10 cm, holosystolci LLSB ___
murmur radiating to axilla
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
Vital Signs: 97.7 ___ RA
Weight: 62.7 -> 61.1 kg
General: Alert, oriented, no acute distress
HEENT: NC/AT, Sclerae anicteric, dry mucous membranes
Neck: Supple.
CV: Regular rate and rhythm. JVP at 8 cm, holosystolic ___
murmur radiating to axilla
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, wrapped ___ ulcer dressing c/d/i
Neuro: CN II-XII grossly intact, sensation and strength grossly
intact
Pertinent Results:
ADMISSION LABS:
----------------
___ 05:09PM BLOOD WBC-9.9 RBC-3.66* Hgb-10.5* Hct-32.4*
MCV-89 MCH-28.7 MCHC-32.4 RDW-16.1* RDWSD-50.7* Plt ___
___ 05:09PM BLOOD Neuts-75.8* Lymphs-12.8* Monos-9.7
Eos-0.6* Baso-0.2 Im ___ AbsNeut-7.48* AbsLymp-1.26
AbsMono-0.96* AbsEos-0.06 AbsBaso-0.02
___ 05:09PM BLOOD ___ PTT-29.5 ___
___ 05:09PM BLOOD Glucose-115* UreaN-47* Creat-1.8* Na-127*
K-4.8 Cl-92* HCO3-21* AnGap-19
___ 05:09PM BLOOD CK(CPK)-79
___ 05:09PM BLOOD cTropnT-0.04*
___ 05:09PM BLOOD Calcium-8.9 Phos-3.6 Mg-2.1 Iron-59
___ 05:09PM BLOOD calTIBC-218* Ferritn-898* TRF-168*
___ 05:09PM BLOOD TSH-1.1
OTHER LABS:
---------------
___ 05:05AM BLOOD Digoxin-1.2
___ 09:00AM BLOOD Digoxin-3.7*
___ 09:00AM BLOOD cTropnT-0.05*
___ 05:09PM BLOOD cTropnT-0.04*
___ 05:09PM BLOOD CK-MB-4 proBNP-7289*
DISCHARGE LABS:
----------------
___ 05:05AM BLOOD WBC-7.7 RBC-3.54* Hgb-10.1* Hct-32.1*
MCV-91 MCH-28.5 MCHC-31.5* RDW-16.4* RDWSD-52.7* Plt ___
___ 05:05AM BLOOD Glucose-76 UreaN-46* Creat-1.6* Na-136
K-4.0 Cl-98 HCO3-26 AnGap-16
___ 05:05AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.1
MICROBIOLOGY:
----------------
___ 4:54 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
----------
___ CXR
Stable moderate cardiomegaly with congestion and probable mild
interstitial
pulmonary edema.
___ TTE
The left atrium is moderately dilated. The estimated right
atrial pressure is at least 15 mmHg. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is severe regional left ventricular
systolic dysfunction with inferior and inferolateral akinesis.
There is hypokinesis of the remaining segments (LVEF = ___.
No masses or thrombi are seen in the left ventricle. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The effective regurgitant orifice is >=0.40cm2
Severe (4+) mitral regurgitation is seen. Moderate to severe
[3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension.
IMPRESSION: Dilated left ventricle with severe LV systolic
dysfunction, c/w CAD. Severe mitral regurgitation. Moderate to
severe tricuspid regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
Brief Hospital Course:
___ gentleman with a cardiac history pertinent for
CAD/inferior MI s/p CABG x6 (___), VF arrest s/p ___
ICD (___), recurrent VT, pAF/AFL not on anticoagulation ___
prior bleeds, paroxysmal atrial fibrillation, severe mitral
regurgitation, T2DM, CKD 3, who presented with severe SOB,
improved after diuresis. He was found to have an elevated
digoxin level as well.
# Acute on Chronic Systolic CHF: Patient presented with elevated
BNP, evidence of volume overload on initial exam, and symptoms
consistent with CHF exacerbation. He was given 80 of IV
Furosemide with prompt symptomatic improvement. He was diuresed
to below his reported dry weight. He then restarted his home
Torsemide 10 mg BID, and his home heart failure medications were
continued. He will follow up with Dr. ___ as
an outpatient.
# Elevated Digoxin level: Patient is on digoxin for atrial
fibrillation. Level was 3.7 on ___, although this was drawn
shortly after receiving the medication. On the discharge day the
level was 1.2. Given he has complained of chronic diarrhea for
several weeks, the elevated digoxin level was thought to be a
potential contributor to these symptoms. He remains on digoxin
per outpatient cardiologist because it is the only effective
rate-control agent he can tolerate (side effects from beta
blockers). His dose was therefore decreased from 125 mcg every
other day to 62.5 mcg every other day.
# Hx CAD: Patient with remote history of 6 vessel CABG. No chest
pain this admission, and mildly elevated troponin was likely
simply demand ischemia in setting of CHF exacerbation. Home ASA
and statin were continued.
# ___ on CKD: Improved from 1.8 on admission to 1.6 with
diuresis, from a baseline of 1.3-1.6. Likely cardiorenal given
improvement with diuresis.
# pAF: Not on anticoagulation given prior history bleed.
Continued digoxin (see above).
# Anemia: Appears at baseline. Continued home iron
supplementation.
# IDDM: Continued home insulin.
# Chronic R foot wound: Continued home wound care. Wound care
nurse provided education to patient and wife prior to discharge.
TRANSITIONAL ISSUES
=====================
- Given elevated Digoxin level, his Digoxin dosage was decreased
to 62.5 mcg every other day, from previous dosage of 125mcg
every other day.
- Discharge weight: 61.1kg
- Discharge Cr: 1.6
- Discharge diuretic: Torsemide 10mg BID
# CONTACT: wife ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. BuPROPion XL (Once Daily) 150 mg PO DAILY
4. Carvedilol 6.25 mg PO BID
5. Digoxin 0.125 mg PO EVERY OTHER DAY
6. Pantoprazole 40 mg PO Q24H
7. Torsemide 10 mg PO BID
8. collagenase clostridium histo. 250 unit/gram topical DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Lisinopril 10 mg PO DAILY
11. SITagliptin 50 mg oral DAILY
12. Toujeo SoloStar (insulin glargine) 300 unit/mL (1.5 mL)
subcutaneous DAILY
Discharge Medications:
1. Digoxin 0.0625 mg PO EVERY OTHER DAY
RX *digoxin 125 mcg 0.5 (One half) tablet(s) by mouth every
other day Disp #*15 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. BuPROPion XL (Once Daily) 150 mg PO DAILY
5. Carvedilol 6.25 mg PO BID
6. collagenase clostridium histo. 250 unit/gram topical DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Lisinopril 10 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. SITagliptin 50 mg oral DAILY
11. Torsemide 10 mg PO BID
12. Toujeo SoloStar (insulin glargine) 300 unit/mL (1.5 mL)
subcutaneous DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute on chronic systolic heart failure
Coronary artery disease
Acute kidney injury on chronic kidney disease
Paroxysmal atrial fibrillation
Chronic anemia
IDDM
Chronic right foot wound
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:
Mr. ___,
It was a pleasure caring for you at ___. You were admitted
because of trouble breathing. You were given an IV water pill
called Lasix to remove fluid from your lungs, and this made your
breathing feel better.
On our bloodwork, we found that your level of Digoxin was quite
high. This high level could be what was causing some of your
symptoms, including the diarrhea. We have decreased the dosage
of the Digoxin to keep the levels lower. You will now take
0.0625 mg every other day, which is half of one tablet.
Otherwise, we did not change any of your medications.
Weigh yourself every morning, call Dr. ___ if weight
goes up more than 3 lbs in one day, or 5 pounds in one week.
Please see your follow-up appointments below.
We wish you the best!
Your ___ Team
Followup Instructions:
___
|
10298374-DS-22 | 10,298,374 | 27,654,530 | DS | 22 | 2137-10-21 00:00:00 | 2137-10-21 21:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Trileptal / Zonegran / Sulfa (Sulfonamide Antibiotics) /
hayfever / House Dust
Attending: ___.
Chief Complaint:
increasing seizure frequency
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ LH F with h/o refractory
epilepsy s/p VNS, anxiety and depression who presents with
increased seizure frequency over the past 6 months. She is
accompanied by her husband ___ who helps provide history.
See below for detailed epilepsy history. In brief, she has had
focal-onset seizures since age ___. She has simple partial
seizures
that
typically occur at night out of sleep with preserved
consciousness characterized by left foot and arm dystonic
posturing. She has also had complex partial seizures captured
during an inpatient evaluation in the ___,
characterized
by bitemporal rhythmic activity. Her brain MRI initially in
___
did not show any focal abnormalities, but the ictal SPECT showed
an area of increased uptake in the right frontal region. Pt also
has known non-epileptic events which are fairly similar in
semiology to the epileptic spells but can also involve trunk
flexion, non-rhythmic jerking and spread to both sides of the
body.
She was admitted to Neurology from ___ - ___ for
increased
seizure frequency -- more nocturnal events and also occurring
while awake in the morning. She was monitored on cvEEG which
captured 3 nocturnal events (with EEG correlate) but no daytime
episodes occurred. The daytime events were felt more likely to
be
non-epileptic in nature. She was discharged without any med
changes. She last saw her outpatient epileptologist (___)
in ___ but missed an appt this ___. At last appt,
seizure frequency was down to ___ nocturnal events per week.
Today, she presents complaining of increased frequency of
seizure
"clusters" over the past 6 months. She describes the "clusters"
as recurrent seizures that occur ~q10 minutes for 24 hours a
day.
In the past the clusters would last for ~3 days at a time, but
for past 6 months they have been lasting ~4 days in a row, which
is significantly worsening her quality of life. She has
approximately one cluster per week. They are triggered by sleep
deprivation and stress. She spoke to Dr. ___ on phone earlier
this week who increased Ativan to 2mg q4-6hrs (from 1mg TID) and
advised presenting to ED if clusters continued. She is taking
the
highest dose (Ativan 2mg q4hrs) but it has not helped.
Last night, pt slept for only 4 hours, thus triggering a new
seizure cluster this morning. Currently she is having events
q5-10 minutes. I witnessed multiple events while in ED -- please
see Physical Exam for details about semiology. Pt reports that
there are some NEW features to these seizures which never
occurred in the past: she now experiences the events as "colors"
(they now appear "brownish"). Regarding seizure triggers, she
endorses sleep deprivation per above, but denies increased
stress/anxiety. She has been more weepy and emotional lately per
husband. ___ fever, chills, cough, nausea, diarrhea, dysuria
or other infectious symptoms. She has been compliant with her
home AEDs.
Of note, pt states that she lost her VNS magnet an unclear
amount
of time ago (most likely a few weeks ago) so has not been able
to
swipe it at all during the events. She does not think that
losing
the magnet triggered the worsening clusters though, as they
became more severe before she stopped using it.
Neuro and General ROS: positive per above, otherwise negative.
Past Medical History:
- Epilepsy: followed by ___ MD. with complex partial
seizures, focal motor seizures as well as nonepileptic events.
Started in childhood. Other than family history of epilepsy, no
specific risk factors for epilepsy. Normal MRI, but previous
ictal SPECT that showed right frontal tracer uptake. She had a
VNS placed in ___ which she has been able to tolerate
well. Has been admitted for LTM three times at ___. The
results
have shown the following:
INTERICTALLY: large amplitude delta frequency slowing in the
left
temporal region as well as a couple of high amplitude sharp and
slow wave complexes in the left temporal region phase reversing
at T3 in sleep. Also, broadly based sharp waves seen in the left
temporal region were observed.
ICTALLY:
1) during sleep, she develops beta activity in frontopolar
region, followed by left arm elevation and elbow flexion, with
left side held in tonic extension. Left leg also extends and
tremors, with flexion at the knee and hip. Electrographically,
these were characterized by fast beta activity in the ___ Hz
range seen in the frontal polar region bilaterally which then
persists and eventually slows down after a variable period of
time.
2) The second event is stiffening and jerking of the R>L legs,
correlated with onset of left temporal sharp and spike and slow
wave discharges.
NONEPILEPTIC EVENTS:
Typically involve significant flexion of the trunk, spread to
the
right arm and leg with nonrhythmic jerking of both arms and
legs.
Also, in ___, we captured episodes of arousal, staring, and
extremity trembling which did not have an apparent EEG
correlate.
- Depression/anxiety: Currently sees a therapist and
psychiatrist. No prior hospitalizations, per patient.
Social History:
___
Family History:
GF on father's side had petit mal szs per doctors and was on
dilantin. ___ on father's side had a stroke. Sister has
migraines.
Physical Exam:
GENERAL EXAM:
- Vitals: 99.2 89 113/68 14
- General: middle-aged woman in NAD, appears fatigued but
talking
comfortably with examiner.
- HEENT: NC/AT
- Neck: Supple, no carotid bruits appreciated. No nuchal
rigidity
- Pulmonary: CTABL
- Cardiac: RRR, no murmurs
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
NEURO EXAM:
- General observations: I witnessed multiple events while
examining pt. Would stop talking for a few seconds, stare
straight ahead and then have ___ seconds of low-amplitude
non-rhythmic shaking of her left arm and leg. Once the left arm
stiffened before beginning to shake. The shaking always stopped
when I attempted to suppress it with my hand. She was able to
speak, answer questions and look around in all directions during
the episodes. Could remember word ("pink elephant") that I told
her during the event. Afterward, no Tod's paralysis or
post-ictal
lethargy.
- Mental Status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Mildly inattentive, skipped ___ on
___ backward. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Able to register 3 objects and recall ___ at 5
minutes.
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 with marked endgaze nystagmus bilaterally
(probably ___ AEDs). Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
- Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
- Sensory: No deficits to light touch throughout. No extinction
to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was flexor bilaterally.
- Coordination: No intention tremor, no dysdiadochokinesia
noted.
No dysmetria on FNF or HKS bilaterally.
- Gait: Not tested
Examination on discharge: not considerably different from that
above.
Pertinent Results:
ADMISSION LABS:
___ 12:12PM BLOOD WBC-4.6 RBC-4.20 Hgb-12.9 Hct-37.8 MCV-90
MCH-30.7 MCHC-34.1 RDW-11.8 Plt ___
___ 12:12PM BLOOD Neuts-59.8 ___ Monos-6.7 Eos-1.2
Baso-1.8
___ 12:12PM BLOOD Glucose-98 UreaN-17 Creat-0.8 Na-140
K-4.0 Cl-101 HCO3-30 AnGap-13
___ 04:35AM BLOOD ALT-13 AST-17 AlkPhos-98 TotBili-0.3
___ 12:12PM BLOOD Calcium-8.9 Phos-3.6 Mg-2.1
___ 12:12PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:35 LAMOTRIGINE 12.1 ( 4.0-18.0 mcg/mL )
___ 06:05AM BLOOD LEVETIRACETAM (KEPPRA)-PND
___ 01:30PM URINE Color-Straw Appear-Clear Sp ___
___ 01:30PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:30PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-2
====================================================
EEG ___:
This is an abnormal video EEG due to the presence of very
frequent bursts of rhythmic sharp activity in the frontal
regions predominantly over the right frontal region him a
lasting up to 17 seconds in duration. Review of the video of
these bursts often revealed no clear clinical change. These do
raise high concern for ictal activity; however, they do not
clearly evolve to suggest definite electrographic seizures.
There are several pushbutton activations for clinical events
typically consisting of left arm flexion and posturing along
with left leg slight flexion and posturing. During these events,
rhythmic sharp wave activity in the theta
frequency range is seen in the frontal regions bilaterally,
predominantly over the right; however, without clear evolution.
In addition, occasionally, superimposed muscle and movement
artifact is seen in the left temporal region. Clinically, these
events appear to represent simple motor seizures. Occasionally,
partial seizures, evolving small areas of the subdural cortex
did not have clear surface EEG correlate. Interictally, spike
and wave discharges are also seen independently in the left and
right temporal region indicative of independent areas of
potentially epileptogenic cortex. The waking background reaches
normal alpha frequency. Superimposed generalized beta activity
is also seen, likely due to medication effects.
EEG ___:
This is an abnormal continuous EMU monitoring study because of
the presence of bitemporal independent epileptic appearing
activity. The left tended to predominate particularly when the
patient became drowsy and went to sleep. There did not appear to
be an associated focal slowing. No sustained events were
recorded.
EEG ___:
This is an abnormal continuous EMU monitoring study because of
intermittent paroxysmal appearing potential epileptic activity
from both
temporal regions with a definite leftsided predominance. No
asymmetric
slowing of cortical rhythms is noted. No sustained events were
seen.
EEG ___:
This is an abnormal continuous EMU monitoring study because of
multiple clinical events occurring after 23:00 hours. These
events all
appeared stereotypic as described above and most were associated
with rhythmic 6 Hz central theta activity. This is not
conclusive evidence for seizure activity but is suspicious for a
midline origin that perhaps supplementary motor. There were also
left temporal interictal discharges identified and occasional
periods of left temporal slowing.
EEG ___:
This was an abnormal continuous ICU monitoring study because of
numerous pushbutton activations, many of which were for rhythmic
movements of either the arm or the leg and occasionally for left
arm elevation. The EEG, during the majority of these episodes,
showed some rhythmic slowing over the central leads and
occasionally over the right frontal region. Outside of these
episodes, there were periods of right frontal slowing that was
not associated with movement on the video. It was difficult to
determine whether the rhythmic activity over the vertex leads
was related to motion artifact; however, there were several
distinct episodes in which there was rhythmic slowing not
associated with motion. There were multifocal spikes seen both
from the left temporal and right central temporal regions
indicative of multiple regions of cortical irritability.
Otherwise, the background was in a normal alpha rhythm.
EEG ___: his was an abnormal continuous ICU monitoring study
because of
three pushbutton activations, many of which were for rhythmic
movements of
either the arm or the leg, with EEGs during these episodes
showing rhythmic
slowing over the central leads, and occasionally over the right
frontal
region. Outside of these episodes, there were periods of right
frontal
slowing that was not associated with movement on the video. It
was difficult to determine whether the rhythmic activity over
the vertex leads was related to motion artifact; however, there
were several distinct episodes in which there was rhythmic
slowing not associated with motion. There were multifocal spikes
seen both from the left temporal and right central temporal
regions indicative of multiple regions of cortical irritability.
Otherwise, the background was in a normal alpha rhythm. In
comparison to the prior day's record, there was an improvement
in the frequency of pushbutton activations and periods of
rhythmic right frontal slowing.
EEG ___: report pending on discharge
====================================================
SPECT SCAN ___: Severely limited study secondary to motion and
seizure activity during imaging. Motion corrected data was not
able to completely correct for the motion artifact.
====================================================
EKG: Sinus rhythm. There is an RSR' pattern in lead V1 that is
probably normal.
====================================================
Brief Hospital Course:
Mrs. ___ is a ___ year-old left-handed woman with a
history of refractory focal seizures from the right frontal
region (given the left sided semiology and ictal SPECT findings)
s/p VNS as well as non-epileptic seizures who presented with
increased duration of seizure clusters. As she described she had
___ hour clusters each week wherein she would have seizures
every ___ minutes. These were quite distressful and even
painful if they lead to left leg spasms.
During her admission, we witnessed an existing cluster
terminate, a seizure free period for 2 days, and then another 50
hour cluster which terminated prior to discharge. During her
seizure cluster, she had multiple seizures (over 100 per 24hour
period). Her seizures were extremely stereotyped and were
preceeded by feeling. She had tonic posturing of her left arm
and flexion of the left lower extremity and forward flexion at
the torso which lasted ___ seconds. During the events she
appeared frightened and short of breath. She then let out a
deep breath afterwards. At those times, her EEG showed 6Hz
central rhythmic activity that was consistent with seizures from
the supplementary motor area especially since they are not
associated with loss of consciousness. When the seizures were
close together she would develop persistent spasm of the left
leg that would appear quite painful, ultimately relieved with a
muscle relaxant and analgesia. Her seizures were only partially
responsive to large doses of ativan.
She underwent an ictal SPECT scan, but unfortunately the large
amounts of Ativan after the isotope injection did not completely
suppress her seizures and the images showed considerable
artifact. She did not have an interictal scan. Additionally
toxic-metabolic workup was unrevealing. She was started on
clobazam (replacing her home standing Ativan) and this was
uptitrated slowly to 15mg BID on discharge. She was also
started on Seroquel 25mg BID to help with the anxiety related to
her seizures. Her VNS was also interrogated.
TRANSITIONAL ISSUES:
1) She will need an MRI WITH SEIZURE CLINIC PROTOCOL once her
seizures are better controlled.
2) She will need EKG monitoring given her seroquel.
3) Consider repeating the SPECT once seizures are more
controlled.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lacosamide 200 mg PO BID
2. LaMICtal XR (lamoTRIgine) 800 mg Oral daily
3. Lorazepam 2 mg PO Q4H:PRN seizure
4. levETIRAcetam 3750 mg Oral daily
5. TraZODone 100 mg PO HS
6. Mirena (levonorgestrel) 20 mcg/24 hour ___ years) injection ___
years
7. Loratadine 10 mg PO DAILY:PRN allergies
8. FoLIC Acid 1 mg PO DAILY
9. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Lacosamide 200 mg PO BID
2. LaMICtal XR (lamoTRIgine) 800 mg Oral daily
3. Lorazepam 1 mg PO Q8H:PRN seizure/anxiety
4. TraZODone 100 mg PO HS
5. Clobazam 15 mg PO BID
RX *clobazam [Onfi] 10 mg one and one-half tablet(s) by mouth
twice a day Disp #*90 Tablet Refills:*3
6. QUEtiapine Fumarate 25 mg PO BID
RX *quetiapine 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
7. FoLIC Acid 1 mg PO DAILY
8. levETIRAcetam 3750 mg Oral daily
9. Loratadine 10 mg PO DAILY:PRN allergies
10. Mirena (levonorgestrel) 20 mcg/24 hour ___ years) injection ___
years
11. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you while you were admitted to
___. You were admitted because of increasing seizure clusters.
While you were here you were monitored on EEG and you were
found to have multiple consecutive seizures. We tried to obtain
a SPECT scan, but this was limited by motion artifact from
back-to-back seizures. You were stared on Clobazam (Onfi) to
help decrease your seizure frequency. You were tolerating this
well and you should continue this when you return home. You
will follow up with our Epileptologists. You can take Ativan 1mg
as needed for seizures if they start to cluster again.
Followup Instructions:
___
|
10298415-DS-8 | 10,298,415 | 29,910,438 | DS | 8 | 2120-06-25 00:00:00 | 2120-06-25 11:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
multiple gunshot wounds
Major Surgical or Invasive Procedure:
1. Irrigation and debridement of left forearm proximal radius
fracture.
2. Open reduction, internal fixation of left forearm volar
proximal radius fracture.
3. Arthrotomy right knee, exploration, and debridement.
4. Fasciotomies of volar and flexor compartments, left forearm.
History of Present Illness:
___ w/ multiple GSW to posterior neck, right pectoralis, right
patella and left forearm transferred from ___ intubated and
sedated. Patient has entrance and exit wounds noted on right
patella and left forearm. Additional history unable to be
obtained from patient due to intubation/sedation status.
Past Medical History:
No ___
Social History:
___
Family History:
Non-contributory family history
Physical Exam:
Gen: middle aged male sitting in chair in NAD
CV: RRR
Pulm: No respiratory distress
Extremities:
RLE: NVI
LLE: SILT in m/u, decreased over ___ dorsal webspace, - EPL, -
FPL, + Finger Flexion of digits ___, able to abduct ___
digits, no abduction or extension of ___ digits
Neuro: Alert and oriented to person, place, date, medical
situation, ambulates with assistance of a crutch
Pertinent Results:
___ 09:30PM ___ PTT-26.4 ___
___ 09:30PM PLT COUNT-200
___ 09:30PM WBC-20.3* RBC-4.05* HGB-12.4* HCT-36.7*
MCV-91 MCH-30.7 MCHC-33.8 RDW-13.9
___ 09:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:30PM LIPASE-41
___ 09:30PM UREA N-9 CREAT-1.2
___ 09:36PM freeCa-1.04*
___ 09:36PM HGB-12.7* calcHCT-38
___ 09:36PM GLUCOSE-133* LACTATE-1.9 NA+-138 K+-4.3
CL--101
___ 09:36PM PO2-39* PCO2-68* PH-7.21* TOTAL CO2-29 BASE
XS--2 INTUBATED-INTUBATED
___ 11:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 11:05PM URINE COLOR-Straw APPEAR-Clear SP ___
Brief Hospital Course:
The patient was admitted to the Acute Care Surgery service on
___ and had the following procedures on ___:
1. Irrigation and debridement of left forearm proximal radius
fracture.
2. Open reduction, internal fixation of left forearm volar
proximal radius fracture.
3. Arthrotomy right knee, exploration, and debridement.
4. Fasciotomies of volar and flexor compartments, left forearm.
The patient tolerated the procedures well.
Neuro: Post-operatively, the patient received Dilaudid IV/PCA
with good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. Foley was removed on POD#1. Intake
and output were closely monitored.
ID: Post-operatively, the patient was started on IV cefazolin,
then switched to PO cephalexin on POD#2 for a total of 3 doses.
The patient's temperature was closely watched for signs of
infection.
Extremities:
RLE: NVI
LUE: SILT in m/u, decreased over ___ dorsal webspace, - EPL, -
FPL, + Finger Flexion of digits ___, able to abduct ___
digits, no abduction or extension of ___ digits
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
The patient saw OT, he now has a posterior orthoplast splint
with involvement of the wrist. OT recommends outpatient OT,
which the patient has a prescription for, and they also
recommend a dynamic split for LUE. The patient also saw ___, who
worked with the patient towards ambulating with a crutch. ___
will continue as an outpatient to work on strength and mobility
in the left upper extremity and the right lower extremity.
At the time of discharge on POD#4, HD#7, the patient was doing
well, afebrile with stable vital signs, tolerating a regular
diet, ambulating using a crutch, voiding without assistance, and
pain was well controlled.
Medications on Admission:
None
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*28
Tablet Refills:*0
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
3. DiphenhydrAMINE 25 mg PO HS
RX *diphenhydramine HCl [Benadryl Allergy] 25 mg 1 tablet(s) by
mouth at bedtime Disp #*10 Tablet Refills:*0
4. Lorazepam 0.5 mg PO HS:PRN anxiety, insomnia
Follow up with your primary care regarding this medication
RX *lorazepam 0.5 mg 1 tab by mouth at bedtime Disp #*10 Tablet
Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*28 Tablet Refills:*0
Discharge Disposition:
Home with Service
Discharge Diagnosis:
left radius fracture, right patella fracture and distal femur
fracture, rib fractures
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:
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* You may take a shower after 24 hours from your surgery have
passed, but do not bathe or go swimming until instructed by your
surgeon.
* No strenuous activity until instructed by your surgeon.
Followup Instructions:
___
|
10298431-DS-15 | 10,298,431 | 23,004,676 | DS | 15 | 2153-10-14 00:00:00 | 2153-10-14 17:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo woman w/ sick sinus syndrome s/p dual chamber pace-maker
in ___, afib not on anticoagulation, HTN, hx DMII (but last
A1c 5.7% ___, spinal stenosis p/w AMS.
Of note, pt was discharged to ___
___ in ___ after being admitted to
medicine from ___ with dysarthria and confusion of unclear
etiology which improved by ___. She was found to have a PNA
(Abx course of azithro/cefpodoxime completed ___, and
hypoglycemia. EEG during this admission notable for possible
epileptogenic focus which resolved. Home Furosemide 20 mg PO
every other day held at discharge.
Brought in from rehab due to worsening mental status since
___, relatively acute in nature. Has been having lethargy,
less verbal, unable to swallow pills due to increased lethargy
and concern for aspiration. Also has had periods of hypoglycemia
and hypotension. Had CXR ___ which showed bilateral patchy
infiltrates more c/w pneumonia than CHF. Pt had urine culture
collected ___ which grew Enterococcus >100 cfu resistant to
cipro and levofloxacin, but sensitive to vancomycin and
ampicillin. She was started on ceftriaxone ___, at 1g/24 hr.
In the ED, initial vitals: 97.3 93 131/94 18 100% Nasal Cannula
Labs were significant for: WBC 8.1 Hgb 9.0 platlets 188 INR 1.0
AST 73 ALT 72 Cr 0.8, Lactate:1.4, pH 7.36 pCO2 52
UA w/ large leuks, neg nitrites, large blood; >182 WBC, 152 RBC,
trace ketones, many bacteria
ekg: no change in TWIs in precordial leads and inferior leads
Physical Exam:
AOx2, EOMI, ___, sensation intact to light touch of b/l ___.
Has periods where she is more somnolent and leaves her mouth
open without airway compromise, but remains arousable.
Focally tender right of umbilicus, hernia augments with valsalva
but unable to appreciate it reducing, no overlying skin changes
Dry, LLL crackles, Healing laceration on tongue and roof of
mouth
Imaging showed:
- CT Head w/ no acute intracranial abnormalities.
- CT A&P w/ large stool ball in the rectosigmoid colon with mild
perirectal edema likely representing stercoral colitis.
Thickening of the bladder compatible with cystitis. Diffuse and
scattered ground-glass changes and consolidative changes in the
bilateral lower lungs are concerning for PNA vs less likely
pulmonary edema.
- CXR w/ stable mild cardiomegaly. Diffuse ground-glass
opacities in the lungs concerning for pulmonary edema, less
likely pneumonia.
In the ED, pt received : 1L NS, vancomycin and cefepime
Vitals prior to transfer: 96.3 83 106/58 18 96% Nasal Cannula
Currently, she is unable to provide additional information.
ROS:
As per HPI
Past Medical History:
1. Hypertension
2. Hypothyroidism
3. Diabetes type II - diet controlled
4. Sick sinus syndrome s/p dual chamber pace-maker implantation
in ___
5. Asymptomatic atrial fibrillation discovered at ___
interrogation
6. Arthritis
7. Cervical stenosis s/p laminectomy/fusion ___
Social History:
___
Family History:
Mother - stroke
Father - CAD, CABG at ___
MGF - vascular disease
PGM - CAD
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 113 / 74 L Lying 77 20 100 3L
GEN: Lethargic, lying in bed breathing at a regular rate with
mouth open, arousable to verbal stimuli like stating her name
but responds in single words only. When asked where she is,
states "hospital" in dysarthric speech, no further orientation
questions were answered
HEENT: Dry lips and tongue, anicteric sclerae, no conjunctival
pallor
NECK: Supple without LAD
PULM: Diffuse crackles throughout both lung fields, scattered
expiratory wheezing
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, firm in LLQ with slight grimace to deep pal[ation.
non distended
EXTREM: trace edema to b/l LEs, no rash
NEURO: unable to participate in neuro, moving all extremities to
pain, PERRL and facial musculature symmetric
RECTAL: heme positive stool, able to remove soft brown stool as
well as small amount of impacted stool with manual disimpacted
PHYSICAL EXAM:
VS: 97.5 132/71 62 21 94% 1L
weight ___ (unclear dry weight, possibly 81.3 kg)
GEN: sleepy and lying in bed, a/o x2, no acute distress
HEENT: dry lips/mouth, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD, JVP at clavicle at 30 degrees
PULM: faint crackles throughout both lung fields, otherwise CTA
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, nontender, non distended
EXTREM: Trace edema b/l ___, no rash
NEURO: CNII-XII grossly intact. Moving all 4 extremities with
purpose, strength ___
RECTAL: (from ___ and ___ heme positive stool, able to remove
soft brown stool as well as small amount of impacted stool with
manual disimpacted
Pertinent Results:
ADMISSION LABS:
___ 01:18PM ___ PTT-41.9* ___
___ 01:18PM PLT COUNT-188
___ 01:18PM NEUTS-72.3* LYMPHS-18.3* MONOS-7.8 EOS-1.1
BASOS-0.1 NUC RBCS-1.1* IM ___ AbsNeut-5.85# AbsLymp-1.48
AbsMono-0.63 AbsEos-0.09 AbsBaso-0.01
___ 01:18PM WBC-8.1 RBC-2.75* HGB-9.0* HCT-26.8* MCV-98
MCH-32.7* MCHC-33.6 RDW-18.6* RDWSD-64.3*
___ 01:18PM TSH-0.77
___ 01:18PM ALBUMIN-3.4* CALCIUM-9.4 PHOSPHATE-3.2
MAGNESIUM-1.7
___ 01:18PM proBNP-881*
___ 01:18PM LIPASE-11
___ 01:18PM ALT(SGPT)-72* AST(SGOT)-73* ALK PHOS-152* TOT
BILI-0.4
___ 01:18PM estGFR-Using this
___ 01:18PM GLUCOSE-74 UREA N-28* CREAT-0.8 SODIUM-142
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-28 ANION GAP-17
___ 01:54PM LACTATE-1.4
___ 01:54PM ___ PO2-80* PCO2-52* PH-7.36 TOTAL
CO2-31* BASE XS-2 COMMENTS-GREEN TOP
___ 02:48PM URINE WBCCLUMP-MANY
___ 02:48PM URINE RBC-152* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-0 TRANS EPI-2
___ 02:48PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0 LEUK-LG
___ 02:48PM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 02:48PM URINE UHOLD-HOLD
___ 02:48PM URINE HOURS-RANDOM
___ 05:47PM HCT-26.4*
DISCHARGE LABS
___ 06:18AM BLOOD WBC-6.6 RBC-2.62* Hgb-8.6* Hct-25.9*
MCV-99* MCH-32.8* MCHC-33.2 RDW-18.5* RDWSD-65.8* Plt ___
___ 06:18AM BLOOD Glucose-85 UreaN-21* Creat-0.7 Na-139
K-4.2 Cl-98 HCO3-33* AnGap-12
___ 06:18AM BLOOD ALT-35 AST-37 LD(LDH)-405* AlkPhos-152*
TotBili-0.8
___ 06:18AM BLOOD Albumin-3.5 Calcium-8.9 Phos-3.1 Mg-1.5*
IMAGING:
___ HEAD CT - No acute process
___ CXR
Stable mild cardiomegaly. Diffuse ground-glass opacities in the
lungs
concerning for pulmonary edema, less likely pneumonia.
___ CT ABD/PELVIS
1. Large stool ball in the rectosigmoid colon with mild
perirectal edema.
Findings may reflect stercoral colitis. Consider gentle
disimpaction.
2. Inflamed urinary bladder consistent with cystitis.
3. Multifocal pneumonia in the imaged lower lungs with trace
left pleural
effusion.
4. Cardiomegaly with pacemaker leads in place.
5. Large hiatal hernia.
6. Ankylosis of the L2 and L3 vertebral bodies with 5 mm
retrolisthesis of L2
over L3. In the absence of prevertebral soft tissue thickening,
these findings
are likely chronic. No evidence of acute fracture.
MICRO
___ 2:48 pm URINE CATHETER.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
Brief Hospital Course:
___ yo woman w/ sick sinus syndrome s/p dual chamber pace-maker
in ___, afib not on anticoagulation, HTN, hx DMII (but last
A1c 5.7% ___, spinal stenosis p/w AMS.
ACTIVE ISSUES:
# Encephalopathy: Upon admission was lethargic and minimally
verbal, minimally responsive. She remained this way overnight,
but by HD1 was a/o x3, alert, conversant. Work up for her AMS
revealed multiple toxic-metabolic insults: UTI, pneumonia vs
pulmonary edema, and stercoral colitis (see below for details).
Of note her prior admission this month with a similar
presentation involved extensive w/u including neuro
consultation, brain/neck MRI/MRA without infarct, EEG notable
for possible epileptogenic cortex on ___ (which resolved by the
subsequent day, so neuro did not recommend any AEDs). Recurrent
hypoglycemia may also have played a role in her AMS -- she was
made NPO before coming in by her rehab because of dificulty
swallowing and had multiple low blood sugars on the days leading
up to admission. She was treated for the above conditions as
described below. By hospital day one her mental status cleared
and she remained a/o x3, able to provide a detailed history,
throughout her stay.
# Acute Hypoxic respiratory failure due to
# Healthcare associated multifocal pneumonia: During her recent
admission to ___ she had completed a course of
azithromycin/cefpodoxime for CAP. Upon this admission noted to
have evidence of multifocal pneumonia vs pulmonary edema on CXR
and seen on upper cuts of CT abdomen. Given residence at ___,
was at high risk of resistant organisms and was started on
vanc/cefepime/azithro. She failed bedside swallow evaluations
___ and ___ -- it is possible that she developed a UTI, causing
increasingly lethargy, then aspirated. Speech and swallow
reevaluated her formally and recommended a modified diet.
antibiotics were narrowed from vanc/cefepime to augmentin ___
and her O2 requirement was weaned. There was likely also a
component of pulmonary edema: initial BNP 881 and mildly
overloaded on exam. As she was NPO during her first two hospital
days when unable to swallow safety, diuresis was initially held.
Ultimately diuresis initiated with 20 IV Lasix was initiated on
___. but only required 1 day of IV diuresis before switching
back ot her home regimen of PO Lasix. Finished course of
augmentin for pneumonia on ___.
# UTI: UA at rehab was positive on ___, after ___ she was
started on ceftriaxone. However, ultimately grew enterococcus
sensitive to vanc and mult other meds but resistant to
ceftriaxone so was being inadequatley treated. Here, started on
vancomycin which was narrowed to augmentin after vanc no longer
needed for her pneumonia. Finished course for pneumonia on ___.
#Stercoral colitis: CT a/p with large stool ball in the
rectosigmoid colon with mild perirectal edema likely
representing stercoral colitis. Abd exam reassuring throughout
her stay. Underwent manual disimpaction ___ and ___ then
started on bowel regimen when able to take POs.
#Anemia: Hct down to 26 from prior baseline ~30. Stool guiac
positive but brown, no e/o active brisk GIB. Labs consistent
with anemia of chronic disease but also with question of
subacute hemolytic process (hapto 29, retic 3.0) with no clear
trigger, but there were no schistocytes on RBC smear. Hgb
stablized and she did not require transfusion.
#Hypoglycemia: Intermittent episodes of hypoglycemia to ___ at
rehab and during last admission. W/u in past included normal AM
cortisol and normal TSH. No clear contributing factors aside
from poor PO intake - normal kidney fx, LFTs wnl. Improved in
past with regular PO intake. While NPO she was on D5W at 30/hr
with sugars running in the ___. After initiating PO intake her
sugars remained >70.
#Transaminitis: AST/ALT elevated on admission in the ___.
Unclear etiology: no h/o liver disease. DDX was congestive
hepatopathy vs due to transient hypotension/sepsis. Alk phos was
at baseline of 150 and tbili 0.4 pointing against obstructive
pattern. Her home statin and allopurinol were held. Discussed
with her daughters - no gout flare for ___ years so prefer to
stop allopurinol going forward. Statin held at discharge; can
discuss with PCP whether resuming is within ___.
#paroxysmal AFIB: CHADSVASC 6, not on anticoagulation at patient
request. She reports after discussing anticoagulation in the
past, she did not wish to be on AC despite known stroke risk (is
a retired med/surg ___) due to belief that risk of fall/bleed
outweighs stroke risk. Rates controlled without medication -
intermittently in Afib while inpt. Continued home asa.
CHRONIC ISSUES:
#HTN: initially held but then restarted home lisinopril
#SSS s/p PPM: last interrogated ___ without acute events. In
NSR initially, then afib with intermittent paced beats.
#GLAUCOMA: Continued home timolol and home lumigan (NF)
#GOUT: held home allopurinol given LFT elevation
#GERD: held home omeprazole while NPO, restarted when able to
take POs
#HYPOTHYROIDISM
- Continued home levothyroxine
TRANSITIONAL ISSUES:
- Consieder repeat EEG if episodic dysarthria or stupor.
Consider starting flumazenil if confusion recurs as per Dr.
___ (see most recent neurology note)
- Patient had an initial Hgb drop which stabilized during
admission. Her guiac was positive without evidence of acute GI
bleed, and could consider outpatient colonoscopy if within ___.
- After discussion with patient, her daughters, and PCP we
discontinued allopurinol and atorvastatin at discharge. Patient
was advised to communicate with PCP is she develops gout flare
and is amenable to restarting allopurinol if needed.
- Given h/o enterococcal UTIs, consider gram positive coverage
in the future if +UA.
- Patient has history of hypoglycemia which remains unexplained.
She had some workup during her previous admission with normal
TSG an cortisol. Her daughters and very interested in an
endocrine referral for hypoglycemia, which we have placed as an
outpatient appointment.
- Patient had elevations in AST/ALT on admission, which
normalized during her hospitalization, of unclear etiology.
-Consider TTE as an outpatient; none in our system and she
required diuresis while inpatient
-Dsicharged with o2 sats in low ___ on RA, intermittently
requiring 1L O2. Suspect this is due to atelectasis and
resolving pneumonia. Continue to wean at rehab.
-Discharged with foley in place
-Pt had severe constipation and associated stercoral colitis.
She *needs to have a daily BM.* Please uptitrate bowel reg as
needed, consider soap suds enemas which worked while while
inpatient.
# CODE STATUS: full (confirmed w/HCP ___
# CONTACT: ___ ___
___ ___
both ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
5. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Atorvastatin 20 mg PO QPM
8. Lumigan (bimatoprost) 0.01 % ophthalmic BID
9. Multivitamins 1 TAB PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. Docusate Sodium 100 mg PO BID
12. Senna 17.2 mg PO QHS:PRN constipation
13. CefTRIAXone 1 gm IV Q24H
Discharge Medications:
1. Bisacodyl 10 mg PR QHS:PRN constipation
2. Furosemide 20 mg PO EVERY OTHER DAY
3. Polyethylene Glycol 17 g PO DAILY
4. Aspirin 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Lisinopril 2.5 mg PO DAILY
8. Lumigan (bimatoprost) 0.01 % ophthalmic BID
9. Multivitamins 1 TAB PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. Senna 17.2 mg PO QHS:PRN constipation
12. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Altered Mental Status
UTI
Stercoral colitis
PNA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___:
You were admitted to ___ because you had confusion. This was
most likely due to a combination of things: you had a urinary
tract infection, a lung infection, and had very bad
constipation. You became less confused as we treated these
things.
While you were here you had trouble urinating on your own. The
rehab can remove the foley in a few days and make sure you can
urinate normally.
We stopped the two medications allopurinol and atorvastatin as
we discussed with you and your primary care doctor. If you have
any gout symptoms, please tell your doctor immediately.
It was a pleasure to care for you!
Your ___ Team
Followup Instructions:
___
|
10298431-DS-16 | 10,298,431 | 29,239,425 | DS | 16 | 2154-08-22 00:00:00 | 2154-08-22 15:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
shortness of breath, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ y/o woman with PMH notable for SSS s/p
dual-chamber PPM in ___, paroxysmal AF on warfarin, HTN, and
diet-controlled T2DM, presenting with chief complaint of
weakness
and shortness of breath.
Per discussion with patient and review of records, it appears
that the patient has not felt herself for nearly a month now.
She
was in her normal state of health around the beginning of
___, when she suffered what seems like a mechanical fall.
She
states that she was on the toilet and trying to get up, when
upon
pulling her slacks up, she tripped and fell head first into the
bathtub. She denies any LOC, but did have a small headstrike.
She
denies any antecedent symptoms of N/V, diaphoresis,
lightheadedness, chest pain/pressure, SOB, DOE. She also states
that prior to this fall, she was functioning well, able to walk
50 feet at a time without limitations in terms of her
respiratory
status.
She was briefly hospitalized at ___ for this fall and
eventually discharged to rehab, given need for ___ and concern
for
possible mild TBI/concussion. At rehab, the patient felt that
her
functional status was actually deteriorating. Despite aggressive
participation in rehab, after leaving and going home on ___,
she was only able to walk about 25 feet without needing to stop
to catch her breath. Initially in the ED, she had endorsed
feeling perhaps days of weakness and increasing DOE, but in
retrospect, she thinks she was having at least ___ days of
these
symptoms, which were progressively worsening. For the couple
days
PTA, she was also having more non-productive coughing without
any
hemoptysis. However, she denies any chest pain/pressure,
palpitations, SOB at rest, increased ___ swelling, increased
abdominal bloating/distention, orthopnea (baseline 2 pillows
since her cervical vertebral fusion), or PND. She also denies
any
recent anorexia (eating well at home), dysuria, changes in
urinary habits, constipation, diarrhea, fevers, chills, melena,
hematochezia, dietary indiscretion (very careful about what she
eats).
She does state that her blood pressure has been on the lower
side, 90-100's at rehab with increased fatigue during episodes
of
lower BP's, having since recovered to the 100-110's since being
home. In terms of medications, she has not had any changes over
the past month apart from frequent titrations of her warfarin
given persistently elevated INR. She did have her home
lisinopril
stopped last ___ for frequent hypotension and has been on a
lower dose of Lasix 20mg PO QOD (from 40mg PO QOD) since the
late
___ (per her PCP).
Given her DOE and coughing, as well as progressive generalized
weakness at home, she called her PCP and was recommended to seek
care in the ED.
In the ED, initial VS were: 95 76 182/126 24 99%
On subsequent check: 72 153/78 20 97% 4L NC
Exam notable for: nothing documented
ECG per my read shows sinus rhythm with ventricular rate of 74
bpm; physiologic left axis; first degree AV delay; probably left
atrial abnormality with LVH per lead aVL; poor baseline with
motion artifact, but possible prior inferior infarct given Q
waves in III and aVF; otherwise, diffuse non-specific ST-TW
changes; compared with prior on ___, p waves appear
different
in morphology (similar, however to those in ECG from ___
but
otherwise similar
Labs showed:
-Chem10 notable for BUN/Cr 33/0.8, glucose 138
-LFTs notable for AST/ALT 41/20, Alk phos 204, normal Tbili and
albumin
-CBC with Hgb 8.4 (most recent Hgb 11 in ___, but previously
baseline 8.5-9)
-Coags notable for INR 5.6, ___ 59.9, PTT 66.3
-Repeat Coags were INR 4.2, PTT 60.8, ___ 45.3
-lactate 1.7
-Trop <0.01 x2
-bland U/A
-Flu A/B negative
-BNP 1197 (previously 881)
-Urine culture drawn, pending
Imaging showed:
-PA/LAT CXR showing: Severe pulmonary edema. Underlying
consolidation is difficult to rule out.
-TTE showing essentially normal biventricular function
-Bilateral LENIs showing right mid-femoral vein non-occlusive
thrombus (verified on repeat ___, but per attending radiologist
of unclear age and potentially chronic with recannulation,
impossible to tell)
Cardiology was consulted and felt patient's presentation to be
consistent with acute CHF exacerbation in absence of formal
prior
CHF diagnosis without clear trigger. IV diuresis was recommended
with inpatient work-up and management after admission to ___.
Patient received:
-Furosemide 40mg IV x1
-Nitro gtt (ordered but not clear if ever started)
-500cc IVF
-Levothyroxine 125mcg PO x1
-Aspirin 81mg PO x1
-Omeprazole 20mg PO x1
On arrival to the floor, patient reports feeling much better
with
her breathing. She denies any acute complaints and endorses the
above history.
Past Medical History:
1. Hypertension
2. Hypothyroidism
3. Diabetes type II - diet controlled
4. Sick sinus syndrome s/p dual chamber pace-maker implantation
in ___
5. Asymptomatic atrial fibrillation discovered at ___
interrogation
6. Arthritis
7. Cervical stenosis s/p laminectomy/fusion ___
Social History:
___
Family History:
Mother - stroke
Father - CAD, CABG at ___
MGF - vascular disease
PGM - CAD
Physical Exam:
ADMISSION EXAM
===================
VS: 94 108/67 72 18 86 RA (96% on 3L)
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM; tongue midline on protrusion with symmetric palatal
elevation, smile, and eyebrow raise
NECK: supple, no LAD, JVP ~9cm
HEART: slowed rate, regular rhythm, S1/S2, no murmurs, gallops,
or rubs
LUNGS: Good air movement throughout with crackles up to mid-lung
on right and at base in left; no wheezes or rhonchi, breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, BS+
EXTREMITIES: 2+ pitting edema at least up to knees bilaterally;
tender to palpation; WWP
PULSES: 2+ DP pulses bilaterally
NEURO: Alert, appropriately interactive on exam, strength ___ in
b/l UE and able to lift both legs up against gravity; sensation
to light touch grossly intact and symmetric throughout
SKIN: warm and well perfused
DISCHARGE EXAM
============================
24 HR Data (last updated ___ @ 501)
Temp: 98.3 (Tm 98.3), BP: 98/66 (93-123/55-74), HR: 60
(59-60), RR: 18 (___), O2 sat: 93% (92-94), O2 delivery: Ra,
Wt: 184.96 lb/83.9 kg (184.96-187.39)
ADMISSION WEIGHT: 89.6kg (bed weight)
GENERAL: Lying in bed, NAD, alert and interactive
HEENT: NC/AT, sclera anicteric, MMM
NECK: Supple, JVD not appreciated
HEART: RRR, no murmurs, rubs, or gallops
LUNGS: Good air movement in anterior fields, unlabored
respirations, bilateral trace crackles at lateral lung bases
ABDOMEN: Non-distended, BS+, soft, no TTP
EXTREMITIES: 1+ pitting edema to knees bilaterally; tender to
palpation; WWP
NEURO: A/Ox3, no facial asymmetry, moves all four extremities
with purpose
Pertinent Results:
ADMISSION LABS
=========================
___ 11:00PM BLOOD WBC-7.0 RBC-2.85* Hgb-8.4* Hct-27.0*
MCV-95 MCH-29.5 MCHC-31.1* RDW-18.9* RDWSD-65.1* Plt ___
___ 11:00PM BLOOD Neuts-76.9* Lymphs-14.9* Monos-6.4
Eos-1.3 Baso-0.1 NRBC-1.4* Im ___ AbsNeut-5.40
AbsLymp-1.05* AbsMono-0.45 AbsEos-0.09 AbsBaso-0.01
___ 11:00PM BLOOD ___ PTT-66.3* ___
___ 11:00PM BLOOD Glucose-138* UreaN-33* Creat-0.8 Na-138
K-4.4 Cl-96 HCO3-28 AnGap-14
___ 11:00PM BLOOD ALT-20 AST-41* AlkPhos-204* TotBili-0.7
___ 11:00PM BLOOD cTropnT-<0.01 proBNP-1197*
___ 05:00AM BLOOD cTropnT-<0.01
___ 11:00PM BLOOD Albumin-4.0
___ 05:00PM BLOOD Calcium-9.3 Phos-3.5 Mg-2.0
RELEVANT STUDIES
========================
___ TTE:
The left atrium is elongated. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF =
65%). Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of tricuspid regurgitation may
be significantly UNDERestimated.] There is no pericardial
effusion.
___ Bilateral LENIs:
1. Nonocclusive thrombus in the right mid femoral vein. The
right
calf veins and the left peroneal veins are not visualized.
Otherwise, no evidence of deep venous thrombosis in the
remaining
right or left lower extremity veins.
2. Severe subcutaneous edema extending from the bilateral knees
to the bilateral calves.
___ CXR PORTABLE AP:
Lungs are low volume with worsening pulmonary edema. Extensive
degenerative changes involving both shoulder joints right
greater than left are unchanged. Left-sided pacemaker is
unchanged. Cardiomediastinal silhouette is stable. Small
bilateral effusions right greater than left are unchanged. No
pneumothorax is seen
___ RUQ U/S:
1. Please note that the exam is limited due to patient's
inability to perform breath holds.
2. Unremarkable visualized parenchyma without evidence of
cirrhosis.
3. The common bile duct was not visualized. No intrahepatic
bile duct
dilation. No cholelithiasis.
___ CXR PORTABLE AP:
Comparison to ___. Lung volumes remain low. The
parenchymal
opacities, more severe on the right and on the left, stable.
Moderate
cardiomegaly persists. No new parenchymal changes. No larger
pleural
effusions. No pneumothorax. Stable position of the pacemaker
leads.
___ CT HEAD W/O CONTRAST:
1. No acute intracranial process.
___ CT CHEST W/O CONTRAST:
Extensive mixed ground-glass and consolidative changes with
interlobular
septal thickening predominantly involving the bilateral upper
lobes, right
middle and right lower lobes, with relative sparing of the left
lower lobe.
Differential considerations include noncardiogenic pulmonary
edema (ARDS)
versus acute interstitial pneumonia. Other etiologies of
diffuse infiltrates such as pulmonary hemorrhage and atypical
infection should also be considered.
___ RLE DOPPLER U/S:
On a review of the study an error was discovered. The Findings
and
Impression should have stated no deep vein thrombosis within the
veins of the right leg.
___ CXR PORTABLE AP:
Pacemaker leads terminate in the expected location of right
ventricle and
right atrium. And doubt extensive perihilar consolidations are
demonstrated. Severe degenerative changes glenohumeral joint
are demonstrated. If compare to ___ the heart
consolidation has decreased in the extent has slightly improved
in particular on the right. Large opacity projecting behind the
cardiac silhouette represents hernia and the stomach within the
chest.
MICROBIOLOGY
========================
___ 9:54 pm URINE Source: Catheter.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
__________________________________________________________
___ 6:16 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Inadequate specimen for respiratory viral culture.
PLEASE SUBMIT ANOTHER SPECIMEN.
Respiratory Viral Antigen Screen (Final ___:
Less than 60 columnar epithelial cells;.
Inadequate specimen for DFA detection of respiratory
viruses..
Interpret all negative DFA and/or culture results from
this specimen
with caution..
Negative results should not be used to discontinue
precautions..
Recommend new sample be submitted for confirmation..
PLEASE SUBMIT ANOTHER SPECIMEN.
Reported to and read back by ___ ___ ___ AT
12:09P.
__________________________________________________________
___ 5:57 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 9:02 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:02 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:02 am URINE Source: Catheter.
**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------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
__________________________________________________________
___ 12:40 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS
========================
___ 07:20AM BLOOD WBC-6.6 RBC-3.08* Hgb-9.2* Hct-29.3*
MCV-95 MCH-29.9 MCHC-31.4* RDW-16.9* RDWSD-58.4* Plt ___
___ 07:20AM BLOOD Glucose-83 UreaN-25* Creat-0.9 Na-141
K-4.8 Cl-99 HCO3-29 AnGap-13
___ 03:22AM BLOOD ALT-14 AST-31 LD(LDH)-569* AlkPhos-150*
TotBili-0.9
___ 07:20AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.9
Brief Hospital Course:
Ms. ___ is an ___ woman with ___ notable
for SSS s/p dual-chamber PPM in ___, paroxysmal A. Fib on
warfarin, HTN, and diet-controlled DM II who was admitted for
signs and symptoms consistent with acute CHF exacerbation with
unclear trigger. She was also noted to have RLE DVT despite
supratherapeutic INR upon admission.
ACUTE ISSUES:
================================
# New O2 requirement:
# Bland pulmonary hemorrhage:
CXR upon admission concerning for pulmonary edema with elevated
BNP. Cardiology evaluated patient and recommended diuresis for
presumed CHF exacerbation. She had never been formally diagnosed
with CHF but clinical picture was suggestive of CHF
exacerbation. Had increased urine output to IV diuresis but
developed pre-renal ___. Despite adequate diuresis, her O2
requirement did not improve. TTE showed normal biventricular
function. CXR remained unchanged and CT chest w/o contrast was
done showing ground-glass opacities consistent with hemorrhage
v. atypical infection. Pulmonology evaluated patient and
suspected bland alveolar hemorrhage from increased pulmonary
venous pressures and supratherapeutic INR. Respiratory status
improved and her O2 requirement decrease to ___. Her O2
requirement is expected to resolve over the next few days to
week per Pulmonology. She will need follow-up CT chest w/o
contrast to document resolution of ground-glass opacities.
# Right Mid-femoral Vein Thrombosis:
RLE Doppler U/S upon admission showed RLE DVT despite
supratherapeutic INR. Patient had recently been started on
Warfarin but had difficulty maintaining therapeutic INR.
Hematology evaluated patient since there was concern for
anti-coagulation failure. DVT was thought to be in the setting
of labile INRs rather than developing in the setting of
therapeutic INRs. Repeat RLE Doppler U/S showed no evidence of
DVT. APLS work-up was negative at time of discharge other than
pending Beta-2-Glycoprotein 1 Antibodies IgG. Patient and her
daughter/HCP ___ expressed desire on ___ to stop
anti-coagulation since they felt risks outweighed benefits
(please see note with well documented discussion). This was
discussed further with PCP ___ who was in agreement.
Warfarin was discontinued on ___.
# Leukocytosis:
# Urinary tract infection:
Urine culture from ___ positive for pan-sensitive E. coli. She
had been on Vancomycin/Cefepime/Flagyl starting ___ for new
leukocytosis. Patient had her foley catheter replaced and
antibiotics were changed to IV Ceftriaxone 1 g q24h on ___. She
was transitioned to ciprofloxacin 250 mg q12h PO with 7-day
course finishing ___. Leukocytosis downtrended with
antibiotics.
# Hypoactive Delirium:
Patient was triggered multiple times for episodes of
waxing/waning responsiveness and confusion with unclear trigger.
Work-up included CT head w/o contrast showing no abnormalities
and multiple VBGs without significant hypercarbia. Alteration of
sleep-wake cycle and UTI were inciting factors. She has history
of similar episodes during previous admissions. Neurology
work-up in ___ included unremarkable EEG and MRI. Her
mental status improved with ramelteon QHS, delirium precautions,
and treatment of UTI.
# Acute urinary retention
Potentially in setting of infection, failed voiding trial on
___ so foley replaced. Patient can reattempt another voiding
trial while at rehab as she gets stronger and as infection fully
treated or should follow-up with urology with appointment
pending at time of discharge.
# Hypernatremia:
Speech language pathology (SLP) evaluated patient during episode
of somnolence and recommended NPO. Her Na peaked at 153 while
NPO and improved with D5W PRN. SLP re-evaluated patient and
recommended regular solids and thin liquids.
# Normocytic anemia:
Unclear baseline but Hgb 8.4 upon admission with appropriate
reticulocyte count of 2.7%. Iron studies were suggestive of
anemia of chronic disease. She required transfusion on ___ with
appropriate response. Hgb remained stable and she did not
require further transfusions.
# Dsyphagia:
SLP initially evaluated patient and recommended NPO. She was
re-evaluated on ___ and diet was changed to pureed solids and
nectar pre-thickened liquids.
# Coagulopathy:
INR supratherapeutic on admission. INR was labile since starting
warfarin. Per above, decision was made by patient to stop
anti-coagulation since she felt the risks outweighed the
benefits. This was discussed with her daughter/HCP who was in
agreement.
CHRONIC ISSUES:
=============================
# Paroxysmal A. Fib:
# SSS s/p PPM: CHADS2-VASc 5. She is AV-paced. Paroxysmal A. Fib
incidentally noted on pacemaker interrogation. Telemetry showed
she was in sinus rhythm and intermittently AV paced. Warfarin
was discontinued per patient's decision. Rate control was
deferred since she was in sinus rhythm.
# T2DM: Diet controlled.
# Hypothyroidism: Continued home levothyroxine
# Home vitamin supplementation: continued home MVI and vitamin D
TRANSITIONAL ISSUES:
========================
Discharge weight: 83.9 kg
Code Status: Full Code
Health care proxy: ___ (daughter), Phone:
___
[] ___ placed ___ for urinary retention with multiple PVR >
300. She will be discharged with Foley and has Urology
follow-up. However, can also consider another voiding trial in
rehab.
[] Restarted on QOD Lasix ___, would check Chem-10 within 1
week to ensure electrolytes/Cr stable
[] Please consider repeat CT chest w/o contrast in 6 weeks
before Pulmonology outpatient follow-up to evaluate for
resolution of GGOs.
[] Note discussion as above with patient, HCP, and PCP that
patient ___ discontinue treatment with warfarin with feelings
that bleeding risk outweighs benefit in clot prevention and
stroke that patient is at high risk for.
[] Follow-up with PCP and continue goals of care discussion,
patient endorsed she would rather have this discussion with PCP
rather than in hospital as she is feeling well
[] Recommend continued speech and swallow evaluation as patient
gets stronger to liberalize diet further, discharged on regular
diet with thin liquids.
> 30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
3. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) QHS
4. Warfarin 0.5 mg PO DAILY16
5. Furosemide 20 mg PO EVERY OTHER DAY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Levothyroxine Sodium 125 mcg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. cranberry Dose is Unknown mg oral DAILY
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q12H Duration: 2 Days
2. Nystatin Oral Suspension 5 mL PO TID
3. Ramelteon 8 mg PO QHS
4. Tamsulosin 0.4 mg PO QHS
5. Aspirin 81 mg PO DAILY
6. cranberry Dose is Unknown oral DAILY
7. Furosemide 20 mg PO EVERY OTHER DAY
8. Levothyroxine Sodium 125 mcg PO DAILY
9. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) QHS
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Bland alveolar hemorrhage
Urinary tract infection
Delirium
Secondary diagnosis:
Sick sinus syndrome s/p PPM
Diabetes mellitus, diet controlled
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why was I here?
- You came to the hospital because you had been fatigued and
short of breath. You were admitted because for more work-up that
found that you had a clot in your leg. You were also found to
have blood in your lungs that may have been from your blood
being too thin.
- You were seen by our cardiologists and pulmonologists.
- You were also found to have a urinary tract infection that
also caused some confusion and was treated
What was done for me while I was here?
- You were given medications to reduce the fluid in your body
- After discussion with your family, your primary care doctor
and you, the decision was made to discontinue your blood thinner
warfarin knowing the risk for clots to form or stroke
- You will continue to finish treatment with antibiotics for
your urinary tract infection
- You were unable to urinate completely on your own so a foley
had to be replaced so please follow-up with urology to evaluate
further to removed the foley
WHAT SHOULD YOU DO WHEN YOU GET HOME?
1) Please follow up at your outpatient appointments that
includes pulmonology, urology and cardiology.
2) Please take your medications as prescribed.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10298431-DS-17 | 10,298,431 | 21,447,216 | DS | 17 | 2154-12-09 00:00:00 | 2154-12-09 19:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / amoxicillin
Attending: ___.
Chief Complaint:
hypotension, lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo woman w/ SSS s/p dual-chamber PPM in ___, pAF NOT on
Coumadin (had recent pulmonary hemorrhage ___ supratherapeutic
INR), HTN, and diet controlled T2DM who presents with lethargy
and hypotension at rehab. Per report, patient was difficult to
arouse for hours and had a transient low BP to SBP of ___. Per
daughter, this is identical to prior "episodes" for which she
has
had multiple workups. Denies f/c, but does endorse cough. Denies
focal weakness or numbness, falls, headache, vision changes.
Does
endorse vomiting, but denies abd pain or diarrhea.
In the ED, initial VS were: 95.3 68 121/49 20 98% RA
Exam notable for:
AAOx3, motor ___ b/l upper and lower extremities, sensation
intact to light touch, CTAB, RRR, abd benign, b/l ___ edema
(baseline per daughter)
___ showed: TSH 0.05, WBC 15.9 w/ 12% bands, Hgb 9.6,
Lactate:1.0, Trop-T: <0.01, BUN 38 Cr 0.9, UA all in black
Imaging showed:
Patient received:
___ 00:03 IVF NS ___ Started
___ 00:37 IVF NS 500 mL ___ Stopped (___)
___ 01:20 IV CefTRIAXone ___ Started
___ 01:58 IV CefTRIAXone 1 gm ___ Stopped (___)
___ 01:59 IV Azithromycin ___ Started
___ 03:08 IV Azithromycin 500 mg ___ Stopped (1h
___
Transfer VS were: 95.0 63 102/43 14 97% RA
On speaking to rehab ___ at ___ at ___, her BP was in the ___ and she was very lethargic all
late morning until afternoon. Initially thought that she was
sleepy, then realized that something was wrong and called ___.
BP
normally runs 120s-130s. Notably rcd Lasix 20mg this AM before
being transferred to ED (QOD dosing). Was afebrile at rehab
(temp
97.7).
On the floor, she reports that she has had a new cough that
started about 2 days ago. It is nonproductive and certainly
nonbloody. She denies any fevers. She felt like she was coming
down with a cold and also endorses an earache. She denies any
dysuria. She denies any shortness of breath. She denies any
chest pain. She denies any diarrhea or abdominal pain. She
does
endorse some nausea and one episode of vomiting.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
1. Hypertension
2. Hypothyroidism
3. Diabetes type II - diet controlled
4. Sick sinus syndrome s/p dual chamber pace-maker implantation
in ___
5. Asymptomatic atrial fibrillation discovered at ___
interrogation
6. Arthritis
7. Cervical stenosis s/p laminectomy/fusion ___
Social History:
___
Family History:
Mother - stroke
Father - CAD, CABG at ___
MGF - vascular disease
PGM - CAD
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: 96.4Temporal 138/76 68 96 RR 20
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MM
dry
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: bibasilar crackles, breathing comfortably without use of
accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, 1+ edema bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
========================
VS: ___ T 96.5 BP: 115/75 HR: 60 RR: 18 O2 sat: 96% O2
delivery: Ra FSBG: 74
GENERAL: no acute distress, pleasant and conversant
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MM
dry, minimal ethmoid and maxillary sinus tenderness
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTABL, no wheezes, rales or ronchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: trace pitting edema to shins bilaterally, no
cyanosis or clubbing
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION ___
===============
___ 11:00PM BLOOD WBC-15.9* RBC-3.48* Hgb-9.6* Hct-30.7*
MCV-88 MCH-27.6 MCHC-31.3* RDW-18.7* RDWSD-57.9* Plt ___
___ 11:00PM BLOOD Neuts-75* Bands-12* Lymphs-10* Monos-3*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-13.83*
AbsLymp-1.59 AbsMono-0.48 AbsEos-0.00* AbsBaso-0.00*
___ 11:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 11:00PM BLOOD Plt Smr-NORMAL Plt ___
___ 11:00PM BLOOD Glucose-130* UreaN-38* Creat-0.9 Na-136
K-4.7 Cl-94* HCO3-27 AnGap-15
___ 11:00PM BLOOD ALT-19 AST-26 AlkPhos-150* TotBili-0.4
___ 11:00PM BLOOD cTropnT-<0.01
___ 11:00PM BLOOD Albumin-3.7
___ 11:00PM BLOOD TSH-0.05*
DISCHARGE ___
=================
___ 05:45AM BLOOD WBC-7.0 RBC-3.33* Hgb-9.1* Hct-29.6*
MCV-89 MCH-27.3 MCHC-30.7* RDW-19.3* RDWSD-60.0* Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD Glucose-58* UreaN-30* Creat-0.8 Na-142
K-4.6 Cl-102 HCO3-28 AnGap-12
___ 05:45AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.9
IMAGING
==========
R ___ ___
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
CXR ___
FINDINGS:
There is a left-sided dual lead cardiac pacing device, with
leads projecting over the expected locations of the right atrium
and right ventricle. Lung volumes are low. There are no focal
consolidations. The cardiomediastinal and hilar silhouettes are
unchanged. No pleural effusions. No pneumothorax. A large
hiatal hernia is again seen.
IMPRESSION:
No acute intrathoracic process.
CXR ___
FINDINGS:
Again seen is a left-sided dual lead pacer with leads projecting
over the
right atrium and right ventricle. There is persistent bilateral
low lung
volumes. Pulmonary vascular congestion is worse compared to
prior exam.
Complete left lower lobe collapse is unchanged. No pleural
effusion or
pneumothorax. Moderate cardiomegaly. Chronic bilateral humeral
head
deformities are unchanged compared to multiple priors.
IMPRESSION:
Interval worsening of pulmonary vascular congestion.
Brief Hospital Course:
SUMMARY STATEMENT
===================
Ms. ___ is an ___ year old woman with SSS status post
dual-chamber PPM in ___, paroxysmal atrial fibrillation not
on Coumadin (had recent pulmonary hemorrhage secondary to
supratherapeutic INR), HTN, and diet controlled T2DM who
presents with lethargy and hypotension at rehab, found to have
leukocytosis and hypothermia, admitted for an infectious workup.
Problems addressed during her hospitalization are as follows:
#Leukocytosis
#Sepsis:
At rehabilitation facility was noted to be lethargic and
difficult to arouse, found to have hypotension (systolic blood
pressure ___, baseline 120-130s). On arrival to the emergency
department, her hypotension resolved with 500 cc fluid
administration, her temperature was < 35'C and she was found to
have leukocytosis with immature forms (WBC 15.9, 12% bands). Her
lactate was normal. She endorsed a new productive cough, some
left ear pain with normal otoscopic examination, sinus
tenderness, and an otherwise unremarkable review of systems. A
chest X-Ray demonstrated no infectious process. MRSA,
legionella, strep, urine, and blood cultures were all
unremarkable. She received one dose of ceftriaxone and
azithromycin for empiric community acquired pneumonia coverage
which was not continued due to low suspicion for pneumonia. Off
antibiotics, her temperature normalized and leukocytosis
resolved. She remained normotensive with no additional fluid
administration and required no oxygen supplementation. Her
initial presentation may have been from an underlying viral
respiratory infection.
#Paroxysmal Atrial fibrillation:
#SSS s/p PPM:
Remained in sinus rhythm. Given frequent dropped V beats in MVP
mode, patient was changed to DDD with paced AV interval 340ms
and
sensed AV interval 310ms. Patient not on anticoagulation in the
setting of history of alveolar hemorrhage and labile INRs.
#Chronic diastolic heart failure:
No evidence of exacerbation. Continued home Lasix.
#Hypothyroidism:
TSH suppressed at 0.05. Decreased home levothyroxine dose to 100
mcg.
#T2DM:
Diet controlled, continued diabetic diet
TRANSITIONAL ISSUES:
=====================
[] Weight at discharge: 85.5 kg
[] Follow-up pending blood cultures
[] Continue to monitor sinus tenderness, left ear pain, and
cough
[] TSH found to be low, decreased home levothyroxine dose,
repeat TSH in 6 weeks (___)
[] Pacemaker: if continues to have high burden of V-pacing
despite present settings, consider lower sensed/paced AV delays
to allow for better atrial-ventricular synchrony (at the cost of
further increasing the ventricular pacing burden)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 125 mcg PO DAILY
2. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
3. Docusate Sodium 100 mg PO BID
4. Furosemide 20 mg PO EVERY OTHER DAY
5. bimatoprost 0.01 % ophthalmic (eye) DAILY
6. Aspirin 81 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Cranberry Concentrate (cranberry conc-ascorbic
acid;<br>cranberry extract) 140-100 mg oral DAILY
10. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU BID
3. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Aspirin 81 mg PO DAILY
6. bimatoprost 0.01 % ophthalmic (eye) DAILY
7. Cranberry Concentrate (cranberry conc-ascorbic
acid;<br>cranberry extract) 140-100 mg oral DAILY
8. Docusate Sodium 100 mg PO BID
9. Furosemide 20 mg PO EVERY OTHER DAY
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Sepsis
# Leukocytosis
# Hypotension
# Chronic diastolic heart failure
# Atrial fibrillation
# Diabetes
# s/p Pacemaker placement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at the ___
___. You came to the hospital because you were more
tired and had low blood pressure in your housing facility.
WHAT HAPPENED WHEN I WAS IN THE HOSPITAL?
--You had a low body temperature, low blood pressures, blood
work, and a cough concerning for an infection. You were briefly
treated with antibiotics. You quickly started to feel better and
we discontinued your antibiotics. You continued to feel better
and improve without any additional treatment.
--Your pace maker was evaluated and reprogrammed by our
cardiology team.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
--You should continue to take your medications as prescribed and
to follow-up with your doctors as ___.
We wish you all the best!
Your ___ care team
Followup Instructions:
___
|
10298740-DS-18 | 10,298,740 | 26,644,920 | DS | 18 | 2130-12-20 00:00:00 | 2130-12-20 20:13:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a ___ y/o G7P2123 at 13w0d who presents with right
sided abdominal pain since yesterday. Pt states the pain is in
her mid abdomen and wraps to her back/flank. Initially the pain
was constant, but has gotten decent relief with IV pain meds in
the ED. Pain is associated with nausea. Denies fevers/chills. No
dysuria. Recently reports seeing specks of blood in her urine.
Pt
denies any hx of stones. She denies any complications with the
pregnancy until this point. Denies abd cramping or vaginal
bleeding.
Pt presented to ED last night and initially had workup for
appendicitis. She had a normal pelvic ultrasound, although the
appendix was not visualized and kidneys were not assessed.
Subsequent MRI revealed a normal appendix, but right sided
hydronephrosis and hydroureter were noted. Given the concern for
nephrolithiasis, urology was consulted and recommended
conservative management for now.
Upon arrival to ___, pt continues to have right sided pain.
Feels
that Dilaudid provided better relief than the Morphine. She also
continues to feel nausea when pain medication wears off. Pt has
not had anything to eat or drink since arrival to ED last night
(~7pm).
In ED, pt received:
Zofran x 2
Morphine x 2
Reglan x 2
Dilaudid x 2
PRENATAL COURSE
___ ___ by 7wk U/S
*)Labs: O+/Ab-,HbsAg-,dec HIV,RPRnr,RI,GC/CT-
*)Screening: random glucose nl (91)
- previously negative CF and Jewish panel
- AMA: declined ERA
Past Medical History:
ObHx:
___ 39w, 6#11oz
___ 39w6d, 7#5oz
___ demise (unexplained) -> D&E
___ 36w6d, 7#1oz
SAB x 1
TAB x 1
GynHx:
- hx abn pap, subsequent nl
PMH: denies (no hx of nephrolithiasis)
SurgHx:
- D&E x 1
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
GEN: appears moderately uncomfortable
VS: 106/68, 72, 18, T 98.0, O2 99% RA
LUNGS: CTAB
HEART: RRR
ABD: soft, nontender, nondistended; no rebound/guarding
R CVAT, no L CVAT
EXT: no edema, no calf tenderness
Pertinent Results:
___ 08:11PM WBC-14.5* RBC-4.28 HGB-13.2 HCT-38.1 MCV-89
MCH-30.9 MCHC-34.7 RDW-12.3
___ 08:11PM NEUTS-83.3* LYMPHS-12.7* MONOS-3.4 EOS-0.4
BASOS-0.3
___ 08:11PM PLT COUNT-316
___ 08:11PM GLUCOSE-105* UREA N-9 CREAT-0.5 SODIUM-140
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-20* ANION GAP-20
Brief Hospital Course:
Ms. ___ was admitted to the antepartum service for pain
control. She was seen in consultation by urology. Her pain was
controlled with po pain medications on hospital day 2 and she
was tolerating a regular diet. Fetal status remained
reassuring.
Medications on Admission:
PNV
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain
2. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every six (6)
hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain, likely kidney stone
13 week pregnancy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the antepartum service for observation of
your pain, which is likely the result of a kidney stone. You
were seen by obstetrics and urology. Your pain improved with
pain pills and you were discharged home. The ultrasound of the
fetus was reassuring. Please take the pain medicine as
prescribed.
Followup Instructions:
___
|
10299002-DS-15 | 10,299,002 | 22,047,933 | DS | 15 | 2178-05-13 00:00:00 | 2178-05-14 13:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Shellfish Derived
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
ERCP ___
laparoscopic cholecystectomy , umbilical hernia repair ___
History of Present Illness:
Mr. ___ is a ___ male patient with past medical
history positive for paroxysmal A fib, restless leg syndrome and
diverticulosis with episodes of diverticulitis treated with
antibiotics who reports started presenting abdominal pain 24
hours ago. He reports yesterday after dinner a severe right
upper quadrant pain which he reports has happened before but not
this severe, when he has had these episodes of pain before he
reports that they subsided without any pain medication. He has
never been told that he has stones in his gallbladder. He
denies any nausea or emesis. He denies any fever or chills. He
denies any changes in bowel movements. Patient reports that he
has had multiple episodes of acute diverticulitis treated with
antibiotics, so he thought this was 1 of these episodes. Due to
symptoms worsening and patient having decreased appetite he
presented to our ED for further management.
Past Medical History:
- recent diagnosis of pericarditis thought to be secondary to
viral pericarditis with course c/b Aflutter
requiring CV.
- recent PNA treated with levofloxacin
- Hyperlipidemia
- GERD
- Hypertension
- Possible GI bleed in past (patient reports he was admitted and
monitored, had an upper endosocpy, had gastritis). Also with
hemorrhoids.
- Restless leg syndrome
- Tonsillectomy
Social History:
___
Family History:
Patient's father passed away from melanoma "at an old age," and
his mother of a renal cancer in her ___. No history of heart
disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs
Temp 97.7 HR 104 BP 142/87 RR 18 O2Sat: 95% RA
Physical Exam
General: resting comfortably in NAD
HEENT: EOMI, PERRL, anicteric
Neck: supple, no LAD
Chest: CTAB, no respiratory distress
Heart: RRR, normal S1&S2
Abdomen: protuberant abdomen, moderately distended, tender to
palpation in RUQ, (+) ___ sign, no rebound or guarding
Neuro: alert and oriented x3
Extremities: no edema
DISCHARGE PHYSICAL EXAM:
Vital Signs
T 98.7 HR 80 BP 162/75 RR 18 SpO2 95RA
General: NAD, A&Ox3
HEENT: EOMI, PERRL, anicteric
Neck: supple, no LAD
Chest: CTAB, no respiratory distress
Heart: RRR, normal S1&S2
Abdomen: soft, nontender, nondistended, no rebound or guarding,
incisions c/d/i
Neuro: no focal deficit, strength and sensation grossly intact
Extremities: no edema
Pertinent Results:
Imaging
CT abd/pelvis
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 distended and there is pericholecystic fluid as well as
stranding surrounding the gallbladder.Stones are visualized
within the gallbladder (series 2, image 34).
___ RUQ US:
Gallbladder continues to demonstrate imaging features of acute
cholecystitis. There is an impacted 13 mm calculus at the
gallbladder neck.
Patient is status-post ERCP. There is mild pneumobilia. No
intrahepatic bile duct dilatation. The CBD is only partially
visualized and measures up to 9 mm in diameter. Stent placed at
time of ERCP is not confidently identified, likely due to
partial visualization.
Brief Hospital Course:
Mr. ___ is a ___ yo M who presented to the emergency
department with right upper quadrant pain. White blood cell
count was elevated at 19.2, LFTs were normal except elevated
AlkPhos to 136. Urinalysis negative for infection. CT scan
abdomen/pelvis showed distended gallbladder with stones and
surrounding inflammation is concerning for acute cholecystitis.
The patient was made NPO, given IV fluids, and IV antibiotics
and admitted to the surgical floor.
On HD1 he was diaphoretic and hypotensive to the 70's systolic,
tachycardic to 120's. EKG showed sinus tach. He was mentating
well. He was given 1 L IV fluid bolus and BP's improved to 90's,
HR decreased to low 100's. Repeat labs showed a normal troponin
and newly elevated LFTs with total bilirubin 4.5. ERCP was
urgently consulted and he was taken for ERCP with placement of a
stent (INR 1.7). On HD2, LFTs trended down, and therefore
informed consent was obtained and he was taken to the operating
room and underwent laparoscopic cholecystectomy and umbilical
hernia repair. His diet was then advanced as tolerated. He was
continued of antibiotics for 24 hours postoperatively and his
LFTs were followed and downtrended. He was in and out of Afib
intraoperatively and was monitored on telemetry while recovering
on the floor. A foley was replaced for retention and Flomax was
started. He was discharged with ___ for a JP drain and a Foley.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Medications - Prescription
ALBUTEROL SULFATE - albuterol sulfate HFA 90 mcg/actuation
aerosol inhaler. INHALE ___ PUFFS INHALED EVERY ___ HRS AS
NEEDED
FOR COUGH
DICYCLOMINE - dicyclomine 20 mg tablet. TAKE 1 TABLET BY MOUTH
TWICE A DAY
DOXYCYCLINE HYCLATE - doxycycline hyclate 100 mg tablet. TAKE 1
TABLET BY MOUTH TWICE A DAY
IPRATROPIUM BROMIDE - ipratropium bromide 42 mcg (0.06 %) nasal
spray. SPRAY ONCE IN EACH NOSTRIL DAILY IF NEEDED
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. TAKE ONE
CAPSULE BY MOUTH BEFORE BREAKFAST AND SUPPER
ONDANSETRON - ondansetron 4 mg disintegrating tablet. DISSOLVE 1
TABLET UNDER TONGUE ONCE A DAY
OXYCODONE-ACETAMINOPHEN - oxycodone-acetaminophen 10 mg-325 mg
tablet. 1 tablet(s) by mouth qid prn - Entered by MA/Other
Staff
PEG-ELECTROLYTE SOLN [PEG-3350 WITH FLAVOR PACKS] - PEG-3350
with
flavor packs 420 gram oral solution. one unit by mouth as
directed follow instructions from MD office
RANITIDINE HCL - ranitidine 300 mg tablet. 1 tablet(s) by mouth
at bedtime
RIFAXIMIN [XIFAXAN] - Xifaxan 550 mg tablet. 1 tablet(s) by
mouth
qd as needed - Entered by MA/Other Staff
ROSUVASTATIN [CRESTOR] - Crestor 5 mg tablet. 1 tablet(s) by
mouth daily for cholesterol
Medications - OTC
ASPIRIN - aspirin 81 mg chewable tablet. 1 tablet(s) by mouth
once a day - (OTC)
FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1
tablet(s) by mouth daily for anemia
GUAR GUM [BENEFIBER (GUAR GUM)] - Benefiber (guar gum) packet. 1
Packet(s) by mouth once a day - (Prescribed by Other Provider)
(Not Taking as Prescribed)
Discharge Medications:
1. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*5 Tablet Refills:*0
2. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once a day Disp #*10
Capsule Refills:*0
Medications - Prescription
ALBUTEROL SULFATE - albuterol sulfate HFA 90 mcg/actuation
aerosol inhaler. INHALE ___ PUFFS INHALED EVERY ___ HRS AS
NEEDED
FOR COUGH
DICYCLOMINE - dicyclomine 20 mg tablet. TAKE 1 TABLET BY MOUTH
TWICE A DAY
DOXYCYCLINE HYCLATE - doxycycline hyclate 100 mg tablet. TAKE 1
TABLET BY MOUTH TWICE A DAY
IPRATROPIUM BROMIDE - ipratropium bromide 42 mcg (0.06 %) nasal
spray. SPRAY ONCE IN EACH NOSTRIL DAILY IF NEEDED
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. TAKE ONE
CAPSULE BY MOUTH BEFORE BREAKFAST AND SUPPER
ONDANSETRON - ondansetron 4 mg disintegrating tablet. DISSOLVE 1
TABLET UNDER TONGUE ONCE A DAY
OXYCODONE-ACETAMINOPHEN - oxycodone-acetaminophen 10 mg-325 mg
tablet. 1 tablet(s) by mouth qid prn - Entered by MA/Other
Staff
PEG-ELECTROLYTE SOLN [PEG-3350 WITH FLAVOR PACKS] - PEG-3350
with
flavor packs 420 gram oral solution. one unit by mouth as
directed follow instructions from MD office
RANITIDINE HCL - ranitidine 300 mg tablet. 1 tablet(s) by mouth
at bedtime
RIFAXIMIN [XIFAXAN] - Xifaxan 550 mg tablet. 1 tablet(s) by
mouth
qd as needed - Entered by MA/Other Staff
ROSUVASTATIN [CRESTOR] - Crestor 5 mg tablet. 1 tablet(s) by
mouth daily for cholesterol
Medications - OTC
ASPIRIN - aspirin 81 mg chewable tablet. 1 tablet(s) by mouth
once a day - (OTC)
FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1
tablet(s) by mouth daily for anemia
GUAR GUM [BENEFIBER (GUAR GUM)] - Benefiber (guar gum) packet. 1
Packet(s) by mouth once a day - (Prescribed by Other Provider)
(Not Taking as Prescribed)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
acute cholecystitis
umbilical hernia
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 ___
with abdominal pain and found to have an infection and stones in
your gallbladder. The stones were blocking the flow of bile and
therefore you underwent endoscopy to clear the ducts and allow
the bile to flow. You then underwent laparoscopic
cholecystectomy to remove your gallbladder. An umbilical hernia
was discovered and repaired at the time of your cholecystectomy.
You are recovering well from surgery, tolerating a regular diet
and pain is better controlled. You are now ready to be
discharged home with the following discharge instructions:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o 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. You should also start taking
Flomax as prescribed for urinary retention.
Followup Instructions:
___
|
10299107-DS-12 | 10,299,107 | 29,924,674 | DS | 12 | 2141-04-07 00:00:00 | 2141-04-08 20:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
sulfite
Attending: ___.
Chief Complaint:
Seizure, altered mental status, L side headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ old right-handed man with a past
medical history of HTN, ___, DVT and pafib on Coumadin who
presents with sudden onset left sided headache. History is
obtained by the wife at the bedside as no documents provided
from
OSH and patient too lethargic to speak.
Prior to this episode, patient was in his usual state of health
all morning. Around 1:45pm, he was sitting on the couch when he
had sudden onset left temple pain and he grabbed the left side
of
his head and called out in pain and told his wife he needed to
go
to the hospital. He is from ___ but spends his summers on
___. His wife drove him over to ___ and he was able to give her directions during the car
ride over which lasted about 4 minutes. The headache continued
in
severity and his wife reported slurred speech around 2:10pm. He
was also acting more confused and muttering in words that didn't
make sense. He had a head CT and a CTA ___ which were reportedly
unremarkable, but there are no discs provided to view. Around
3:10pm, he stiffened, opened his mouth, extended himself in the
bed and had tonic-clonic movements in the bed for < 5 minutes.
He
was reportedly given Ativan 1mg and Keppra 1g, though there is
no
documentation of this. He was med-flighted to ___ for further
care. En route, he becase significantly agitated, requiring
Haldol 2.5mg IV x 1 with improvement in his agitation. He then
became significantly agitated again with SBP up to 180 in the ED
and he was given Labetalol 10mg IV x 1. His wife denies recent
illness, though he has been sleeping more than usual lately. No
sleep deprivation. No recent change in medications. He has not
had his INR checked in over a month, though wife reports it is
usually in range. No prior history of seizures.
Of note, he has a history of left temple pain for over ___ years,
but this bothers him only rarely. He never been treated for
these
headaches. He was seen once by Dr. ___ in the neurology
clinic and diagnosed with bilateral carpal tunnel syndrome.
Past Medical History:
Hypertension
Hypothyroidism
Benign prostatic hypertrophy
Hypotestosteronemia
Renal stones
Paroxysmal atrial fibrillation on coumadin
History of pulmonary embolus, DVT.
Possible CAD, with WMA on most recent echo
dCHF
Atypical and nonexertional left chest discomfort
Social History:
___
Family History:
No family history of seizures
Physical Exam:
******************
EXAM ON ADMISSION
******************
Physical Exam:
Vitals: T: 98.2 P: 89 R: 16 - 24 BP: 179/95 SaO2: 93 RA
General: Sleepy, arouses to loud voice, but quickly falls back
asleep and needs to be constantly stimulated to maintain arousal
HEENT: NC/AT, no scleral icterus noted, kept eyes closed for
most
of the exam, dry MM, dried blood around lips, did not stick out
tongue to assess for tongue bite
Neck: Supple. No nuchal rigidity
Pulmonary: non-labored breathing
Cardiac: RRR
Abdomen: soft, ND
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Sleepy, arouses to loud voice, but quickly falls
back asleep and needs to be shaken to awake and follow commands.
Able to say his full name when asked, but falls asleep between
words. Can say date of birth when asked, but then perseverates
on
it and answers his DOB for next 3 questions. Speech moderately
dysarthric, need to ask him to repeat things to understand him.
Follows simple commands with lots of coaching such as open eyes,
close eyes, open mouth, squeeze fingers, wiggle toes, lift arms,
lift legs, thumbs up. Occasionally mumbled and it was not
intelligible.
-Cranial Nerves:
PERRL 3 to 2mm and brisk. Full range of motion of horizontal eye
movements. Bilateral blink to threat. Grimaces to noxious
without
obvious facial droop. Unable to assess palate but tongue
protrudes midline.
-Motor:
Pushed and pulled me with equal force in the arms, antigravity
in
both leg.
-Sensory: Withdrew hands and feet to noxious in all extremities.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 0
R 2 2 2 3 0
Plantar response was flexor bilaterally.
-Coordination: Reaches for NC with left hand, pulls covers with
right hand.
-Gait: Deferred
******************
EXAM AT DISCHARGE
******************
Unchanged except:
General: Alert and oriented
Cardiac: RRR, S3 gallop heard over L upper sternal border
Neurologic:
-Mental Status: Alert and oriented to self, time and place.
Fluent language with no dysarthria or paraphasic errors and
comprehension intact. Repetition intact. Can follow midline and
appendicular commands. Intact naming of high and low frequency
objects. Does MOYB and serial subtractions.
Cranial Nerves:
I: not tested
II: pupils equally round and briskly reactive to light.
III-IV-VI: Normal conjugated, extra-ocular eye movements in all
directions of gaze. End-gaze nystagmus which rapidly
extinguishes bilaterally. No diplopia.
V: Symmetric perception of LT in V1-3
VII: Face is symmetric at rest and with activation; symmetric
speed and excursion with smile.
VIII: Hearing intact to finger rub bl
IX-X: Palate elevates symmetrically
XI: Shoulder shrug ___ bl
XII: No tongue deviation or fasciculations
Motor: Normal muscle bulk and tone throughout. No pronator drift
or rebound. No asterixis or myoclonus noted.
Strength:
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
Sensory: normal and symmetric perception of light touch,
vibration and temperature. No extinction to DSS.
Coordination: Finger to nose without dysmetria bilaterally. No
intention tremor. RAM and finger tapping slow, possibly due to
arthritis and bilateral carpal tunnel as reported by patient.
Pertinent Results:
___ WBC-7.8 RBC-4.20* Hgb-13.3* Hct-39.4* MCV-94 MCH-31.7
MCHC-33.8 Plt ___
___ ___
___ PTT-31.7
___ Glucose-110* UreaN-11 Creat-1.1 Na-138 K-3.6 Cl-100
HCO3-28
AnGap-14 Calcium-9.5 Mg-1.8
___ ALT-15 AST-27 AlkPhos-80 TotBili-1.1
___ TropnT-0.02*
___ TSH-3.0
___ T4-6.3 T3-70*
___ CRP-21.4*
___ 08:06PM BLOOD WBC-10.9* RBC-4.21* Hgb-13.3* Hct-41.8
MCV-99* MCH-31.6 MCHC-31.8* RDW-12.9 RDWSD-46.8* Plt ___
___ 03:00PM BLOOD Glucose-123* UreaN-12 Creat-1.0 Na-139
K-3.4 Cl-100 HCO3-28 AnGap-14
___ 03:00PM BLOOD CK-MB-6 cTropnT-0.02* proBNP-3458*
___ 05:29AM BLOOD ___ Folate-9.1
___ 05:05AM BLOOD %HbA1c-4.9 eAG-94
___ 05:05AM BLOOD Triglyc-63 HDL-56 CHOL/HD-2.8 LDLcalc-89
___ 08:06PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:00PM BLOOD SED RATE- 2
___ 06:21AM URINE RBC-43* WBC-12* Bacteri-FEW Yeast-NONE
Epi-0 TransE-<1
___ 06:21AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-MOD
___ 06:21AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 12:28AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-27
___ ___ 12:28AM CEREBROSPINAL FLUID (CSF) TotProt-60*
Glucose-78
___ 11:54AM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR- HSV 1 and HSV2 negative.
Lyme IgG and IgM: Negative
___ Urine culture: No growth, final
___ CSF culture: No growth, final
Imaging:
CT head ___: 1. No acute intracranial abnormalities.
2. Global atrophy and evidence of chronic small vessel ischemic
disease.
3. Sinus disease as described above.
MRI MRA Brain ___: 1. Punctate focus of restricted diffusion
in the right temporal lobe (16;15) is concerning for a small
acute infarction. No acute intracranial hemorrhage.
2. Attenuated flow within the fetal type left PCA, may be
secondary to
intracranial atherosclerotic disease. Otherwise, unremarkable
MRA of the
brain.
3. Hypoplastic left transverse sinus is likely congenital in
etiology.
4. Unremarkable MRA of the neck.
5. Moderate bilateral pleural effusions as seen on the recent
chest radiograph from ___.
6. Chronic microangiopathy.
CXR ___:
Lung volumes are grossly normal however there is diffuse hazy
opacity bibasal E likely reflecting layering pleural effusions.
Bilateral basal airspace opacity likely therefore represents a
atelectasis but infection cannot be excluded. Even allowing for
the projection, the heart appears mildly enlarged. Possible
pulmonary vasculature consistent with pulmonary vascular
congestion. Difficult to exclude pulmonary edema given the
pleural effusions. No pneumothorax seen.
CT chest w/ contrast ___: 1. Large bilateral pleural
effusions with compressive atelectasis
2. Slight interval increase in size of the previously
characterized
benign-appearing thymic cyst. This lesion does not demonstrate
any suspicious features.
3. No rib fractures identified
4. Hypodense nodules in both lobes of the thyroid, measuring
less than 1.5 cm. No further evaluation is necessary as per ACR
guidelines.
CT abd/pelvis with contrast ___:
1. No masses or lesions concerning for neoplasm.
2. Tubular structure superior to the prostate, which may be
arising from the seminal vesicles or a utricle cyst. This
appears to correspond to a similar structure seen in ___, but
is not well characterized.
3. Large bilateral pleural effusions with near complete collapse
of the lower lobes are better assessed on same-day CT chest.
4. Edema in the bilateral flanks may represent contusions. No
acute fractures identified.
5. Scrotal edema and small free fluid in the pelvis is likely
related to fluid overload.
6. Mild wall thickening near the pyloric duodenal junction is
nonspecific, and may be related to fluid status although can
also be seen in the setting of duodenitis. If persistent
clinical concern, endoscopy could could be considered for
further evaluation.
CXR ___:
Previous mild pulmonary edema has resolved, top- normal heart
size and
mediastinal venous engorgement have also improved. Moderate
bilateral pleural effusions however are still present; the right
layers posteriorly, the left may be substantially fissural.
EEG ___: This continuous video-EEG monitoring study captured
no pushbutton
activations, electrographic seizures, or epileptiform
discharges. The
background findings indicated a mild to moderate diffuse
encephalopathy, which
implies widespread cerebral dysfunction but is nonspecific as to
etiology.
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
focal slowing or epileptiform discharges are present. Compared
to the prior day's recording, there is no significant change.
Echo ___: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Moderate pulmonary artery systolic hypertension. Mild-moderate
mitral regurgitation. Moderate tricuspid regurgitation.
Increased PCWP. Compared with the prior study (images reviewed)
of ___, the estimated PA systolic pressure is now higher.
Regional and global biventricular systolic function are similar
(prior reported regional dysfunction is not seen on review of
the prior study).
Brief Hospital Course:
Mr. ___ is a ___ yo man with history of HTN, dCHF, DVT
c/b PE and paroxysmal afib on Coumadin who is admitted with
first time GTC preceded by progressive onset of left sided
headache with associated slurred speech. His initial history was
concerning for ___ because wife initially described headache as
sudden onset, and focal neurologic findings. Therefore CT head
was repeated in the ED without evidence of bleeding and, given a
high suspicion and concerning examination, he underwent LP to
evaluate for xanthrochromia, which was negative. Eventually,
headache onset was clarified with patient when he was
cooperative, and he explained that the headache onset had been
progressive over the course of a day.
Inpatient workup also demonstrated negative tox screen, no
electrolyte/metabolic/liver abnormalities as demonstrated by
Chem 10, thyroid hormones and LFT within normal limits. CSF
analysis yielded negative gram stain and culture, negative Lyme
antibodies and HSV-1 PCR was found to be negative, and empiric
acyclovir was therefore discontinued.
Of note, lactate was elevated as expected after a convulsive
seizure.
In addition, patient was monitored on EEG for 24 hours, which
was then discontinued given progressive improvement of symptoms
with no new episodes, and low suspicion for a recurrent event.
There were no further clinical or subclinical seizures.
On admission he was volume overloaded by exam and imaging (large
bilateral pleural effusions), and he was diuresed with IV Lasix
until clinical volume status improved, and he was then
stabilized on home PO Lasix regimen.
MRI brain showed a punctate acute/subacute ischemic stroke in
the R temporal region. Stroke workup was pursued including
normal HbA1c, TSH, Lipid panel (LDL <100)and echo without source
of cardioembolism. Given the distribution, etiology was felt to
be most likely small vessel atherosclerotic disease. Given small
size and subcortical location, this was not felt to be causative
of his seizure. However, it was postulated that the convulsions
may have precipitated plaque rupture in a small vessel and cause
the stroke, however this is purely speculative.
The differential diagnosis for first time seizure includes
toxic, metabolic, endocrine, malignant and infectious causes,
which have all been ruled out as detailed above. First time
seizures, however, are known to have a binomial distribution
with a second peak during the ___, especially in the setting of
diffuse small vessel atherosclerotic disease, as evidenced in
this patient by periventricular hyperdensity on MRI. His slurred
speech prior to GTC may have represented a focal left sided
seizure, causing confusion, with subsequent secondary
generalization. The mild residual difficulties on cognitive
tasks on the two following inpatient days may be due to
prolonged post-ictal period in the setting of age,
comorbidities. In addition, patient received multiple
psychoactive medications on medflight transfer to ___, which
could have exacerbated his confusion. Importantly, all deficits
noted on admission have resolved.
Lastly, patient was started on LevETIRAcetam 750 mg PO BID to
reduce the likelihood of further seizures, and this should be
continued in the outpatient setting.
==================================================
Transitions of care:
- Follow up with neurology clinic in as scheduled. While
levetiracetam is known to have no drug-drug interactions, it has
been associated with cognitive decline in the elderly in some
trials, though the evidence is conflicting. Therefore, the
decision to continue the medication if the patient remains
asymptomatic at follow up should be individualized based on
patient preference.
- Regarding his chest wall pain, it is felt to be likely related
to muscle spasm. He was started on tizanidine 2 mg q6h prn on
the day of discharge. If this is ineffective, consider
rechecking QTc prior to considering increasing the dose. If he
is unable to tolerate this, would recommend consideration of low
dose narcotic in the short term only. Recommend against NSAIDS
due to CKD, and against tramadol due to risk of lowering the
seizure threshold.
=============================================================
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? () Yes (LDL = ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. azelastine 137 mcg (0.1 %) nasal BID
3. Furosemide 20 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Timolol Maleate 0.25% 1 DROP BOTH EYES DAILY
7. Triamterene 50 mg PO DAILY
8. Warfarin 3 mg PO 5X/WEEK (___)
9. Warfarin 5 mg PO 2X/WEEK (___)
10. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES TID
11. Acetaminophen ___ mg PO TID:PRN Pain - Mild
12. Vitamin D 4000 UNIT PO DAILY
13. B-12 DOTS (cyanocobalamin (vitamin B-12)) 1000 mcg oral
DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
Hold for loose stools
2. LevETIRAcetam 750 mg PO BID
3. Tizanidine 2 mg PO Q6H:PRN pain
RX *tizanidine 2 mg 1 capsule(s) by mouth every 6 hours as
needed Disp #*30 Capsule Refills:*0
4. Acetaminophen ___ mg PO TID:PRN Pain - Mild
5. Atorvastatin 20 mg PO QPM
6. azelastine 137 mcg (0.1 %) nasal BID
7. B-12 DOTS (cyanocobalamin (vitamin B-12)) 1000 mcg oral
DAILY
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES TID
9. Furosemide 20 mg PO DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Tamsulosin 0.4 mg PO QHS
13. Timolol Maleate 0.25% 1 DROP BOTH EYES DAILY
14. Triamterene 50 mg PO DAILY
15. Vitamin D 4000 UNIT PO DAILY
16. Warfarin 3 mg PO 5X/WEEK (___)
17. Warfarin 5 mg PO 2X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seizure
Ischemic Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to a seizure. We started a seizure
medicine to help prevent this from happening again.
The brain scan showed a tiny ACUTE ISCHEMIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
is blocked. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
High Cholesterol
High blood pressure
Atherosclerosis (hardening of the arteries)
Atrial fibrillation
We are changing your medications as follows:
You are on the right medications to help reduce your risk of
stroke.
Start an anti-seizure medicine called Levetiracetam, (aka
Keppra).
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:
___
|
10299815-DS-20 | 10,299,815 | 20,453,091 | DS | 20 | 2113-08-21 00:00:00 | 2113-08-22 16:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain/Perforated diverticulitis
Major Surgical or Invasive Procedure:
Sigmoid colectomy, end descending colostomy and
abdominal washout
History of Present Illness:
Ms. ___ is a ___ year old female with a history of metastatic
lung cancer (ongoing radiation therapy) with brain metastases
s/p craniotomy for tumor removal in ___, COPD not on
O2,Hepatitis C cirrhosis, GERD, and fibromyalgia who presents
with diffuse abdominal pain since 6AM this morning. Of note, the
patient is a poor historian. She reports associated nausea but
denies vomiting. Her last bowel movement was this morning and
was reportedly normal. She first went to ___ for
evaluation where abdominal CT showed extensive free air with
likely sigmoid perforation and associated abscess. She received
flagyl and 2L of NS, and was transferred to ___ for further
management given her medical comorbidities.
In the Emergency Department, the patient is afebrile,
tachycardic to 100s, and hemodynamically stable. She appears
uncomfortable and is complaining of diffuse abdominal pain. On
exam, her abdomen is diffusely tender with rebound and guarding.
Labs are notable for WBC 6.2, ALT 85, AST 46, ALP 85, Tbili 1.2,
and
albumin 2.6. Surgery was consulted for further care.
Past Medical History:
Metastatic adenocarcinoma of the right upper lung with brain
metastases s/p craniectomy, COPD (not on home O2), Hepatitis C
cirrhosis, GERD, fibromyalgia, and opiate use disorder on
maintenance therapy.
PSH:
Cholecystectomy
Salpingoopherectomy
Craniectomy ___
Tubal ligation
Tonsillectomy
Social History:
___
Family History:
No family history of lung cancer.
Physical Exam:
Physical Exam on Admission (___):
Vitals: Temp 99.1, HR 106, BP 145/98, RR 18, SpO2 94% 4L NC
General: fatigued by arousable, moderate distress, AAOx2 (not to
time)
CV: sinus tachycardia
Pulm: normal respiratory effort
GI: abdomen soft, distended, diffusely tender to palpation with
rebound and guarding
Extremities: 2+ pitting edema bilaterally, warm and well
perfused
Physical Exam on Discharge (___):
GENERAL: Appears older than stated age, awake, sleepy
ABDOMEN: mildly tender
bilaterally, tender to palpation.
SKIN: Warm, +ecchymoses, +dry crackling skin, small weeping
sores
Rest differed for patient comfort.
Pertinent Results:
Patient is being discharged with hospice care. Reports and lab
values may be requested from medical records if needed.
Brief Hospital Course:
___ w/ metastatic lung cancer (to brain, s/p radiation to the
right upper lobe, craniotomy ___, radiation to her right
frontal lobe), HCV cirrhosis, COPD (not on home O2), asthma,
GERD, fibromyalgia, and history of opiate use disorder with
prior intravenous drug use on maintenance therapy who presented
on ___ with sigmoid perforation in setting of
diverticulitis s/p exploratory laparotomy with end sigmoid
___ Pouch. Her hospital course was notable for
ICU stay postop for >3 days, bilateral upper extremity
cellulitis, hyponatremia, persistent and worsening
multifactorial hypoxemic respiratory failure (severe emphysema,
pulmonary edema, bilateral PEs, atelectasis), bilateral PEs,
moderate protein calorie malnutrition, and bilateral upper
extremity DVTs. There were numerous goals of care conversations
with family and the patient involving palliative care during her
complicated and prolonged hospital course which ultimately
resulted in switching focus of care to comfort measures on
___. The patient is now being discharged home with hospice
care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam 1000 mg PO BID
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Dexamethasone 4 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Methadone 72 mg PO DAILY
6. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
QID
Discharge Medications:
1. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
2. LORazepam 0.5 mg PO Q8H:PRN anxiety
3. OxyCODONE Liquid 5 mg PO Q4H
4. Methadone 20 mg PO TID
5. LevETIRAcetam 1000 mg PO BID
6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
QID
7. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
8.Nebulizer
Dx: Severe Emphysema, Metastatic Lung Cancer
ICD-10: J43.9, C34.90
Please provider patient with nebulizer machine.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
=================
Perforated diverticulitis with purulent peritonitis
Multifactorial hypoxic respiratory failure
Severe emphysema
Bilateral pulmonary embolism
Metastatic adenocarcinoma of the right upper lung (per outside
records)
Moderate protein calorie malnutrition
Right upper extremity deep vein thrombosis
Left upper extremity deep vein thrombosis
Right upper extremity cellulitis
Left upper extremity cellulitis
Oral thrush
Secondary Diagnoses
===================
Hepatitis C cirrhosis
GERD
History of opiate use disorder on maintenance therapy
Hypertension
Fibromyalgia
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 Ms. ___,
It was a pleasure taking care of you in the hospital!
Why was I admitted to the hospital?
-You came to the hospital because you had a perforated colon and
underwent extensive emergency surgery
What happened while I was admitted to the hospital?
-You had a prolonged and complicated hospital course because of
your history of lung cancer, severe emphysema, major surgery and
need for intensive care
-You are required a lot of oxygen and underwent extensive
testing that revealed blood clots in your lungs and both of your
arms
-You had several infections in your arms and abdomen that were
treated with antibiotics
You were evaluated by multiple specialists and palliative care
specialist
Several family meetings were held with your medical team and
palliative care specialist that gave you and your family medical
updates about your conditions and potential care options
You and your family expressed your wish to no longer pursue
your current plan of care and instead change the focus on
symptom management which would allow you to spend more time with
your family and loved ones
-Your lab numbers were closely monitored and you were given
medications to treat your various medical conditions
What should I do after I leave the hospital?
-You are being discharged with hospice care services that will
care for your needs closely
-Spend time with your family and loved ones while having your
symptoms managed
We wish you the very best!
Your ___ Care Team
Followup Instructions:
___
|
10300536-DS-19 | 10,300,536 | 22,037,373 | DS | 19 | 2185-12-27 00:00:00 | 2186-01-01 15:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a pleasant ___ year old woman with a past medical
history significant for hyperlipidemia, and recent admission
(___) for diverticulitis with pericolonic abscesss, not
amenable to drainage, treated with IV antibiotics, discharged on
a 10 day course of Augmentin, who presented to Dr. ___
today endorsing abdominal pain.
During her last admission, she had presented to the hospital on
___ with continued lower abdominal pain after completing a
course of augmentin for uncomplicated diverticulitis diagnosed
10 days prior. CT demonstrated sigmoid colitis/ diverticulitis
with a 3.5 cm pericolonic abscess extending into the pouch of
___, not amenable to drainage. She was initially treated
with IV
antibiotics, and discharge home on a 10 day course of Augmentin
(last day ___.
She presents today to clinic endorsing generalized malaise,
abdominal pain with no resolution or improvement of her symptoms
since discharge. She also is now endorsing air out of her
vagina, frequency, and suprapubic pain. She feels as if
sometimes when she wipes there is also stool on the toiler paper
after voiding. Denies burning on urination. She denies fever,
chills, chest pain, shortness of breath. No nausea or vomiting.
Continues to have loose bowel movements. No blood in her stool.
Her last colonoscopy was ___ years ago, and she states she is due
for another one. Last colonoscopy demonstrated a "precancerous"
polyp.
Review of systems negative except for otherwise noted in the
HPI.
Past Medical History:
PMH:
-Hyperlipidemia
-Diverticulitis
-Depression
PSH:
-Abdominoplasty, several years ago
-Total hip arthroplasty, ___
Social History:
___
Family History:
Family History:
-Son with diverticulitis requiring emergency surgery, colostomy,
and ultimately reversed. No history of colon cancer in the
family. Sister with gynecologic cancer.
Physical Exam:
Physical Exam on Admission:
Vitals: 97.7, 86, 107/57, 14, 100% RA
Gen: NAD, A/Ox3
Lungs: Equal symmetric chest rise, no gross chest wall
deformities
CV: RRR
Abd: Soft, nondistended, +lower quadrant tenderness, no rebound,
no guarding, no palpable masses. Prior abdominoplasty scars
appear well healed
Ext: warm and well perfused
Pertinent Results:
CT ABD & PELVIS WITH CONTRAST Study Date of ___
1. Inflamed sigmoid colon, likely diverticulitis, with a 2.3 x
1.5 x 1.5 cm extraluminal focus of gas with an equivocal
indentation to the adjacent
bladder wall, as well as a moderate amount of bladder gas,
suspicious for a colovesicular fistula. A direct communication
is not definitely seen on CT, however this area is obscured by
streak artifact from a right hip prosthesis. Please confirm that
there has not been recent catheterization to explain the gas
within the bladder.
2. Mild intra and extrahepatic biliary ductal dilation with no
distal
stone/stricture or ampullary mass visualized.
___ 06:46AM BLOOD WBC-4.9 RBC-3.79* Hgb-10.4* Hct-34.1
MCV-90 MCH-27.4 MCHC-30.5* RDW-15.2 RDWSD-50.0* Plt ___
___ 07:08AM BLOOD WBC-3.1* RBC-3.49* Hgb-9.8* Hct-31.9*
MCV-91 MCH-28.1 MCHC-30.7* RDW-15.5 RDWSD-51.7* Plt ___
___ 03:49PM BLOOD WBC-5.4 RBC-3.83* Hgb-10.8* Hct-37.5
MCV-98 MCH-28.2 MCHC-28.8* RDW-15.5 RDWSD-55.5* Plt ___
___ 03:49PM BLOOD Neuts-64.2 ___ Monos-7.4 Eos-3.0
Baso-0.4 Im ___ AbsNeut-3.47 AbsLymp-1.33 AbsMono-0.40
AbsEos-0.16 AbsBaso-0.02
___ 07:08AM BLOOD ___ PTT-28.5 ___
___ 03:49PM BLOOD Plt ___
___ 06:46AM BLOOD Glucose-102* UreaN-5* Creat-0.6 Na-141
K-4.2 Cl-104 HCO3-25 AnGap-12
___ 03:49PM BLOOD Glucose-89 UreaN-16 Creat-0.7 Na-136
K-4.5 Cl-104 HCO3-19* AnGap-13
___ 06:46AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.2
Brief Hospital Course:
Patient is a ___ yo female with diverticulis with non-drainable
abscess admitted ___, completed IV/PO ABX, now with sx
concerning for possible ___ vs ___ fistula
with continued abdominal pain, and pneumaturia.
She was placed on IV antibiotics, NPO and IV hydration. Her
abdominal pain improved after initiation of antibiotics. The
next day, she was advanced to clear liquid diet, which she
tolerated; her antibiotics were switched to PO Cipro/flagyl. on
___ c.diff sample was sent prior to discharge and the
patient was instructed to call and follow up on results ___
___. During this hospitalization, the patient voided without
difficulty and ambulated early and frequently. The patient was
adherent with respiratory toilet and incentive spirometry and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well. She was
afebrile and their vital signs were stable. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and their pain was well controlled. The patient was
discharged home services. Discharge teaching was completed, and
follow up appointments were scheduled and reviewed with reported
understanding and agreement.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Atorvastatin 40 mg PO QPM
3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
5. PARoxetine 20 mg PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO/NG Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
3. Phenazopyridine 100 mg PO TID Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a
day Disp #*9 Tablet Refills:*0
4. Acetaminophen 1000 mg PO Q8H
5. Atorvastatin 40 mg PO QPM
6. PARoxetine 20 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis, colovesicular fistula
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for
evaluation of abdominal pain and were found to have recurrent
diverticulitis. You were evaluated by the acute care surgery
team and admitted to the hospital for IV antibiotics. You are
recovering well and are now ready for discharge. Please follow
the instructions below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10300976-DS-13 | 10,300,976 | 20,333,294 | DS | 13 | 2199-12-31 00:00:00 | 2199-12-31 18:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
"the bed and floor was dancing"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ reports he was in his usual state of health
neurologically until waking up ___ with dizziness. He
reports never having had this sensation before. He woke up at
___ feeling like "the bed and floor was dancing." He
describes a sense of motion despite lying down at rest. It
initially persisted for hours, and he was unable to do more than
sit up on the edge of the bed. Over the course of the day, this
sensation became more intermittent, lasting for minutes to hours
at a time, with periods of relief in between. However he never
felt truly back to normal. He denied room-spinning vertigo,
denied lightheadedness, denied any new weakness (chronic leg
heaviness), denied any new sensory changes (chronic left foot
tingling), denied any changes to his hearing (chronic reduced
hearing), denied nausea/vomiting, denied tinnitus. It was
exacerbated when sitting upright and standing, often but not
always improved with lying supine.
___ evening he did have a fall when he went to go to the
bathroom. He fell backward onto the foot of the bed, landing on
his buttocks, without head strike or LOC.
Mr. ___ came to the ED ___ morning because his symptoms
have continued. By the time he was taken in from triage, he felt
some improvement at rest, but by the time of my evaluation the
dizziness has returned and patient is unable to get out of bed.
Patient reports ongoing disequilibrium, mild at rest and
exacerbated when sitting upright. Unable to stand even with a
walker. On neuro ROS, the pt reports b/l blurry vision as above.
Denies headache, loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt reports bilateral watery
eyes. Denies recent fever or chills. No night sweats or recent
weight loss or gain. Denies cough, shortness of breath. Denies
chest pain or tightness, palpitations. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Denies rash.
Past Medical History:
HTN
hyperlipidemia
GERD
hyperparathyroidism
"congentital retinal anomaly"
cataracts
DM, poor control
stroke
sciatica
Anemia
B12 deficiency
Prostate cancer s/p external beam radiation and Zomeda
melanoma resected from the left leg
Social History:
___
Family History:
Daughter with diabetes. No family history of stroke.
Physical Exam:
*** gait exam
-Mental Status: Alert, oriented (person, place, event leading
up), increased response latencies, baseline cognitive
impairment. Able to relate history with some mild difficulty
remembering the order of events. Language is fluent with intact
comprehension. Normal prosody. There were no paraphasic errors.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. There was no evidence of apraxia or
neglect.
-HINTS
Head impulse: Positive with left catch up saccades on L head
turn
Nystagmus: Few beats of horizontal left sided nystagmus
Test of skew: negative
-Cranial Nerves:
II, III, IV, VI: b/l irregular pupils and minimally reactive.
EOMI with few beats of left sided nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted.
Delt Bic Tri Wr E FF l FE IO IP Quad Ham TA
L 5 dfrd 5 ___ ___ 5 5 5 5
R 5 dfrd 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch.
-DTRs:
___
-___: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally; though right side FNF motions
are smoother than left side. Normal rapidly alternating hand
movement b/l.
-***Gait: Deferred due to significant and persistent dizziness
following position change from laying to sitting.
Discharge Physical Exam:
24 HR Data (last updated ___ @ 818)
Temp: 97.7 (Tm 99.0), BP: 132/68 (132-158/62-74), HR: 73
(64-73), RR: 18 (___), O2 sat: 95% (95-100), O2 delivery: RA
General: awake and alert, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx
Neck: Supple. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, normal S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema, L foot wrapped in clean bandage.
Skin: R leg with well healed skin graft at site of prior
melanoma resection, no other rashes or lesions.
Neurologic:
-Mental Status: Alert, oriented (person, place, event leading
up), increased response latencies, baseline cognitive
impairment.
Language is fluent with intact comprehension.
Normal prosody. There were no paraphasic errors. Speech was not
dysarthric. Able to follow both midline and appendicular
commands.
-Cranial Nerves:
II, III, IV, VI: b/l irregular pupils and minimally reactive.
EOMI Normal saccades. No nystagmus noted
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
antigravity and spontaneous in all 4 extremities
-Sensory: No deficits to light touch.
-DTRs:
___
-___: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally; though right side FNF motions
are smoother than left side. Normal rapidly alternating hand
movement b/l.
-Gait: Deferred
Pertinent Results:
___ 01:29PM WBC-7.6 RBC-3.50* HGB-8.4* HCT-28.6* MCV-82
MCH-24.0* MCHC-29.4* RDW-16.8* RDWSD-47.8*
___ 01:29PM TRIGLYCER-62 HDL CHOL-47 CHOL/HDL-2.6
LDL(CALC)-63
___ 01:29PM ALT(SGPT)-46* AST(SGOT)-32 CK(CPK)-93 ALK
PHOS-88 TOT BILI-0.4
___ 01:29PM GLUCOSE-156* UREA N-28* CREAT-1.0 SODIUM-142
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-26 ANION GAP-12
___ 03:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 04:48PM %HbA1c-7.6* eAG-171*
___ 06:32PM cTropnT-0.02*
Imaging
========
MRI Head ___
No evidence of hemorrhage or recent infarction. T2/FLAIR signal
hyperintensity without slow diffusion in the left frontal lobe
is new compared with MRI ___, likely reflecting sequela
of chronic infarction. Additional foci T2/FLAIR signal
abnormality in the cerebral hemispheres and pons are not
significantly changed, again likely representing sequela of
chronic small vessel ischemic disease. Chronic bilateral
lacunar infarcts and prominent perivascular spaces within the
bilateral basal ganglia are again noted. Punctate focus of
chronic microhemorrhage in the right parietal lobe is unchanged.
There is prominence of the ventricles and sulci suggestive of
age-related involutional changes. These have progressed since
___ the major intracranial flow voids are preserved.
There is mild mucosal thickening in the ethmoid air cells, and
chronic mucosal thickening in the left sphenoid sinus. There is
no abnormal fluid signal in the remainder of the paranasal
sinuses. Patient is status post left lens replacement. The
orbits are otherwise grossly unremarkable.
IMPRESSION:
1. No evidence of hemorrhage or recent infarction.
2. Atrophy, chronic left frontal tissue loss, likely due to
infarction and
likely sequela of chronic small vessel ischemic disease.
Brief Hospital Course:
Mr. ___ is a ___ year old man with history of prior episode of
disequilibrium found to have a left vertebral artery occlusion,
cognitive impairment, HTN, DMII, HLD, prior left ___ toe
amptuations, PAD s/p LLE angio with balloon angioplasty of the L
peroneal artery ___, recent discharge following LLE
angiogram for non-healing left hallux wound, who presents with 1
day history of dizziness and disequilibrium.
#Unsteadiness
#Vertigo
CTA remonstrated left vertebral occlusion and diffuse
atherosclerotic disease of the head and neck but did not reveal
any acute infarction or bleed. MRI was negative for any central
ischemic or hemorrhagic insult. MRI did show chronic left
frontal atrophy likely chronic small vessel disease. In addition
to imaging, his exam was suggestive of peripheral etiology with
catch up saccades with head impulse. Patient's symptoms were
initially worse with standing so possibly orthostasis as a cause
of unsteadiness. His Lasix was initially held but restarted at
time of discharge. Differential includes BPPV vs vestibular
neuritis vs meniere's disease. Leading diagnosis is vestibular
neuritis provided rapid onset, head impulse testing, gait
instability without loss of ability to ambulate assisted with
walker, hearing is unaffected. Risk factors were checked, HgbA1c
7.6, LDL 63. He was continued on home Plavix and aspirin.
#HTN: Given his unsteadiness his home antihypertensives were
held. He was initially started back on half amlodipine 2.5mg,
his lisinopril was held. His blood pressure was mildly elevated
in SBP 130-150s, but given instability and risk of falls it was
felt that higher blood pressure should be tolerated. He was
restarted on home Lasix 20mg every other day at time of
discharge
#Insulin dependent diabetes: HgbA1C 7.6, given age goal <8. He
was continued on home insulin glargine 10unis at night. He was
also on sliding scale insulin during admission.
#s/p partial first ray amputation on the left foot
#PVD: Podiatry followed during admission. He was continued on
home antibiotics and was followed by wound care during
admission. He will follow up with podiatry as an outpatient.
Transitional Issues
====================
[] f/u with neurology as an outpatient
[] Home lisinopril was held at time of discharge, restart if
needed for blood pressure control
[] Discharged on half amlodipine (on 2.5mg), can increase if
needed, though would tolerate higher blood pressure to weight
risks and benefits of falls and tight blood pressure control
Medications on Admission:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. amLODIPine 7.5 mg PO DAILY
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
4. Aspirin 325 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
10. Furosemide 20 mg PO DAILY
11. trospium 20 mg oral DAILY
Discharge Medications:
1. amLODIPine 2.5 mg PO DAILY
2. Glargine 10 Units Bedtime
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Clopidogrel 75 mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Furosemide 20 mg PO EVERY OTHER DAY
8. Levothyroxine Sodium 25 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
#Vestibular neuritis
Secondary Diagnosis:
#Hypertension
#Insulin dependent diabetes
#PVD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr ___,
You were hospitalized due to symptoms of dizziness. Laboratory
and imaging tests were performed in order to evaluate the cause
of your dizziness. These test demonstrated that you did NOT
experience an ischemic stroke and showed that your dizziness was
more likely due to a problem outside of the brain. The dizziness
that you are experiencing is most appropriately managed by a
neurologist outside of the hospital. We will provide you with an
appointment with a neurologist to further manage your dizziness.
We have determined that it is safe for you to be discharged from
the hospital.
**We are not changing your medications:
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:
___
|
10300976-DS-9 | 10,300,976 | 20,739,085 | DS | 9 | 2199-04-26 00:00:00 | 2199-04-26 21:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left toe ulceration
Major Surgical or Invasive Procedure:
___ L third toe debridement
___ L third toe amputation
History of Present Illness:
Patient is an ___ with history of T2DM, HTN, dyslipidemia,
overactive bladder, and likely peripheral vascular disease who
presents with a worsening ulcer of the L third toe.
Of note, patient was seen ___ the ___ ED ___ for the same
complaint, evaluated podiatry who performed a bedside
debridement. Patient was discharged home and given a one week
course of Augmentin.
Since his recent ED visit, patient describes increasing pain,
and
erythema from around site of prior debridement site and
extending
into his L foot/ankle despite having taking his antibiotics
regularly. No trauma or falls at home. Patient denies any
fever/chills. He went to his PCP earlier today and was told he
should present to the ___ ED given concern for evolving
infection.
Past Medical History:
HTN
hyperlipidemia
GERD
hyperparathyroidism
"congentital retinal anomaly"
cataracts
DM, poor control
stroke
sciatica
Anemia
B12 deficiency
Prostate cancer s/p external beam radiation and Zomeda
melanoma resected from the left leg
Social History:
___
Family History:
- Daughter with diabetes. No family history of stroke.
Physical Exam:
ADMISSION EXAM:
===============
VS: 98.2 151/64 80 17 99 RA
GENERAL: NAD, lying comfortably ___ bed
HEENT: EOMI, anisocoria L>R, anicteric sclera, pink conjunctiva,
MMM
NECK: JVP not visible above the clavicle with head of bed at
45degrees.
HEART: RRR, S1/S2, ___ systolic crescendo/decrescendo murmur
heard throughout the precordium, no rubs or gallops.
LUNGS: CTABL.
ABDOMEN: Normoactive BS throughout, nondistended, nontender ___
all quadrants, no rebound/guarding, no hepatosplenomegaly.
EXTREMITIES: Slightly cool hands and feet. No pitting edema.
s/p large excision/skin graft over anterior L shin, well-healed.
Xerosis and chronic inflammatory hyperpigmentation changes of
the
lower extremities b/l. L ___ toe s/p debridement, covered with
kerlix, macerated soft tissue ___ the associated toe spaces.
Slight swelling and warmth of the L ankle to low shin with mild
TTP. R and L ___ pulses are fully dopplerable bilaterally.
NEURO: A&Ox3, moving all 4 extremities with purpose.
DISCHARGE EXAM:
===============
VITALS: ___ 0037 Temp: 97.6 PO BP: 123/55 L Lying HR: 80
RR:
18 O2 sat: 99% O2 delivery: Ra
GENERAL: Well-appearing, well-nourished gentleman, laying ___
bed,
wincing with pain intermittently, ___ moderate distress
HEENT: NC/AT, EOMI, anisocoria L>R, anicteric sclera, pink
conjunctiva, MMM
HEART: RRR, S1/S2, ___ systolic crescendo/decrescendo murmur
heard throughout the precordium, no rubs or gallops
LUNGS: CTAB, breathing comfortably on RA without use of
accessory
mm, no wheezes/rhonci/rales
ABDOMEN: Soft, non-tender to palpation, active bowel sounds
EXTREMITIES: Warm, no edema, s/p large excision/skin graft over
anterior L shin, well-healed, xerosis and chronic inflammatory
hyperpigmentation changes of the lower extremities b/l, s/p L
___
toe amputation, covered with kerlix c/d/i, L ankle covered with
kerlix
NEURO: A&Ox3, moving all 4 extremities with purpose, no facial
asymmetry
Pertinent Results:
ADMISSION LABS:
===============
___ 04:02PM URINE MUCOUS-RARE*
___ 04:02PM URINE HYALINE-4*
___ 04:02PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 04:02PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 04:02PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:02PM URINE UHOLD-HOLD
___ 04:02PM URINE HOURS-RANDOM
___ 05:50PM PLT COUNT-317#
___ 05:50PM NEUTS-63.1 ___ MONOS-11.5 EOS-0.6*
BASOS-0.2 IM ___ AbsNeut-5.19 AbsLymp-2.01 AbsMono-0.95*
AbsEos-0.05 AbsBaso-0.02
___ 05:50PM WBC-8.2 RBC-3.76* HGB-10.2* HCT-32.8* MCV-87
MCH-27.1 MCHC-31.1* RDW-12.3 RDWSD-39.5
___ 05:50PM calTIBC-248* VIT B12-965* HAPTOGLOB-337*
FERRITIN-330 TRF-191*
___ 05:50PM IRON-27*
___ 05:50PM LD(LDH)-522*
___ 05:50PM estGFR-Using this
___ 05:50PM GLUCOSE-165* UREA N-28* CREAT-1.1 SODIUM-143
POTASSIUM-5.3* CHLORIDE-106 TOTAL CO2-27 ANION GAP-10
___ 06:05PM LACTATE-1.3
MICROBIOLOGY:
=============
___ 4:02 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
PROTEUS SPECIES. IDENTIFIED AS PROTEUS HAUSERI.
10,000-100,000 CFU/mL.
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PROTEUS SPECIES
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R <=2 S
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- =>64 R
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
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 2 S
___ BLOOD CX: Negative
___ 9:50 am TISSUE LEFT ___ TOE.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
CONSISTENT WITH
CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
TISSUE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
IMAGING/DIAGNOSTICS:
====================
___ LENIS:
No evidence of deep venous thrombosis ___ the left lower
extremity veins.
___ FOOT XR:
Findings concerning for osteomyelitis involving the terminal
phalanx of the third ray.
___ ART EXT:
Significant bilateral superficial femoral artery and tibial
disease.
___ FOOT MRI:
1. Findings highly suspicious for osteomyelitis of the distal
phalanx of the third toe with associated cellulitis.
2. Fatty atrophy of the intrinsic muscles of the forefoot.
3. Heterogenous enhancement of the soft tissues likely reflect
peripheral
vascular disease.
___ FOOT XR:
Three views of the left foot are compared to pre amputation
views, ___.
Left third digit has been amputated distal to the metatarsal.
No abnormal
soft tissue swelling or subcutaneous gas is noted. Other bones
of the foot are unremarkable and unchanged.
___ TOE PATHOLOGY:
1. Toe, left third, amputation:
Bone with acute osteomyelitis.
Skin and connective tissue with evidence of chronic ischemia.
2. Toe, left ___ toe proximal phalynx, amputation: Unremarkable
bone and cartilage.
DISCHARGE LABS:
================
___ 07:40AM BLOOD WBC-8.0 RBC-3.89* Hgb-10.4* Hct-33.9*
MCV-87 MCH-26.7 MCHC-30.7* RDW-13.4 RDWSD-41.6 Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-111* UreaN-22* Creat-1.1 Na-142
K-5.1 Cl-104 HCO3-25 AnGap-13
Brief Hospital Course:
Mr. ___ is an ___ with past medical history of type II
diabetes mellitus complicated by diabetic foot ulcers,
hypertension, dyslipidemia, overactive bladder, and peripheral
vascular disease who presents with a worsening ulceration of the
L third toe, found to have osteomyelitis with overlying
cellulitis.
ACTIVE ISSUES:
==============
# L ___ toe ulceration complicated by osteomyelitis and
overlying cellulitis
Patient presented with worsening ulceration of his left third
toe despite recent debridement and week-long course of oral
antibiotics. ___ the ED, he was seen by podiatry and L toe was
debrided. LENIS were obtained and were negative for DVT. A foot
x-ray was obtained and was concerning for osteomyelitis. A foot
MRI was then obtained and showed osteomyelitis with overlying
cellulitis. Patient was started on IV vancomycin/ceftazadime and
oral flagyl which was continued through ___.
Non-invasive vascular studies (ABIs) were notable for decreased
blood flow to the foot, so vascular surgery was consulted for
angiography, which was done on ___. Patient underwent stenting
of the peroneal artery and was started on Plavix for a 30day
course. Patient was taken to the operating room by podiatry on
___ for L third toe amputation which was uncomplicated. Cultures
returned with 4+ gram positive rods and 1+ gram positive cocci
___ pairs representing likely skin flora. Pathology returned with
clear margins suggesting no residual osteomyelitis. The patient
was discharged on a 7-day course of augmentin (___) per
podiatry.
# Normocytic Anemia
Patient found to have hemoglobin of 10.2, from baseline of 11.7
on most recent labs. Likely multifactorial iso anemia of chronic
disease and iron deficiency anemia given low iron level. Patient
had no signs of active bleeding and hemolysis labs were
negative. A B12 level was checked and within normal limits.
Hemoglobin remained stable during admission.
CHRONIC/STABLE ISSUES:
======================
# Type II Diabetes Mellitus
Moderate control. Most recent HbA1C 7.5% ___ ___. Treated with
home lantus and insulin sliding scale during admission. Notably,
patient was occasionally hyperglycemic to the ___, and at
these times would refuse to eat. He was provided with education
and reassured that he could eat, but continued to refuse meals
if his blood sugar was elevated. Diabetic education should be
pursued as outpatient.
# Hypertension
Continued home amlodipine and lisinopril
# Dyslipidemia
Continued home pravastatin
# Cardiovascular primary prevention
Continued home pravastatin and aspirin
TRANSITIONAL ISSUES:
====================
[] New medications: Plavix 75mg daily for 30 day course (Course:
___ would discuss with vascular if they would like to
continue or not), Augmentin 875mg PO BID (Course ___,
Atorvastatin 40mg PO daily
[] Discontinued medications: Pravastatin 80mg PO daily (replaced
with atorvastatin)
[] Home Lasix 20mg daily was held - unclear why patient is
taking this. Determine whether this medication is needed, and
consider re-starting if indicated.
[] Repeat iron studies as outpatient when patient is not
actively infected - if Fe low, consider starting ferrous sulfate
325mg daily vs. IV iron for repletion
[] Please consider referral to diabetic nutritionist - patient
believed he could not eat if his blood sugar was elevated,
despite reassurance that his meal-time sliding scale insulin
would cover him during meals.
[] Weight bearing to left heel ___ surgical shoe
[] Dry betadine dressing to L toe every three days
#CODE: Full (confirmed)
#CONTACT: ___son) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Pravastatin 80 mg PO QPM
4. Furosemide 20 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. trospium 20 mg oral DAILY
7. Glargine 10 Units Breakfast
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 #*11 Tablet Refills:*0
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 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 daily Disp #*26
Tablet Refills:*0
4. Glargine 10 Units Breakfast
5. amLODIPine 5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. trospium 20 mg oral DAILY
9. HELD- Furosemide 20 mg PO DAILY This medication was held. Do
not restart Furosemide until discussing it with your primary
care doctor.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- L third toe osteomyelitis with overlying cellulitis
- Peripheral vascular disease
Secondary diagnosis:
- Type II diabetes mellitus
- Hypertension
- Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because your foot ulcer was
not improving.
WHAT WAS DONE FOR YOU ___ THE HOSPITAL?
- You had an x-ray of your foot that was concerning for an
infection ___ the bone. You had a follow-up imaging study called
an MRI that confirmed that you had an infection ___ your bone and
___ the surrounding skin.
- You had a study that showed there was poor blood flow to your
foot.
- You were seen by the vascular surgeons and had a study called
an angiogram to assess the blood flow to your foot. They placed
a stent ___ one of your blood vessels to help open it up and
improve the blood flow to your foot.
- You were treated with antibiotics through your vein to treat
your infection.
- You were taken to the operating room and had your toe removed
to prevent spread of the infection.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- You should continue taking your medications, as prescribed.
You were discharged on Augmentin for a 7 day course. You should
continue this medication through ___.
- You should follow up with your primary care physician and
podiatry (appointment information below).
- You should examine your feet daily and tell your doctor right
away if you develop any additional ulcers or breaks ___ your
skin.
- You should bear weight on your left heel while wearing a
surgical shoe until instructed otherwise by podiatry.
It was a pleasure taking care of you, and we wish you well!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10301609-DS-12 | 10,301,609 | 21,707,591 | DS | 12 | 2126-08-11 00:00:00 | 2126-08-11 13:30:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Azithromycin
Attending: ___.
Chief Complaint:
Intractable vommiting
Major Surgical or Invasive Procedure:
___ Colonoscopy with ileocolic dilitation.
___ Laparotomy with enterocolostomy
History of Present Illness:
Mr ___ is a ___ with a history of bowel obstruction in setting
of metastatic colon cancer s/p multiple surgeries including
palliative partial colon resection (___), hemicolectomy with
end to end ileocolostomy (___), and duodenal and ureteral
stenting (___) now presenting from OSH with 48 hrs of
intractable nausea, vomiting, and abdominal pain. He reports
vomiting a total of 14 times and describes contents as bilious
or undigested food (if recently eaten). Pt is currently
undergoing chemotherapy (C1D4 of irinotecan, last dose on ___,
for which he takes zofran for expected nausea, but he was unable
to keep meds down. Denies hematochezia, fever, chills. Last meal
before symptoms began consisted of chicken; no new or uncooked
foods.Abdominal pain is concentrated in the periumbilical area
and relieved with emesis. Last BM was this morning and was
rather small consisting of a few drops (after beginning chemo,
pt has had constant diarrhea). Last time pt passed gas was
during BM in
AM. Since then, pt denies passing any gas. OSH's KUB revealed
air/fluid levels consistent with obstruction.
Past Medical History:
Hypertension
Social History:
___
Family History:
grandfather w/ colon cancer around ___ year old
Physical Exam:
VS:Tmax: 99 T: 98.5 HR 113 BP:136/84 RR:20 SpO2: 100% RA
Gen:NAD. Patient is lying comfortably in bed.
Resp:CTAB, good air movement
CV: Tachycardic. Normal S1 and S2. No m/r/g
Abd: There is an well healed older midline vertical incision
site. To the left of the old incision is the recent vertical
incision site intact with staples. There is are no signs of
infection around the recent incision. Abdomen is minimally
tender to palpation. Normoactive bowel sounds. Nondistended. No
rebound tenderness. No palpable masses.
Ext: No c/c/e
Pertinent Results:
___ 06:30AM BLOOD WBC-5.5 RBC-4.12* Hgb-10.4* Hct-31.8*
MCV-77* MCH-25.4* MCHC-32.9 RDW-17.5* Plt ___
___ 06:30AM BLOOD Plt ___
___ 05:59AM BLOOD Glucose-86 UreaN-11 Creat-0.8 Na-139
K-4.0 Cl-106 HCO3-25 AnGap-12
___ 05:59AM BLOOD Calcium-9.0 Phos-5.1* Mg-1.5*
___ 10:35PM-CT scan- Interval progression of the
small-bowel obstruction with small bowel loops now dilated up to
5.3 from previously 4.1 cm (___). 2. Large
contiguous tumor mass extending from the duodenum into the
rightlower quadrant causing small-bowel obstruction by encasing
a right lower quadrant small bowel loop and extending anteriorly
into the rectus muscle(L>R), umbilicus and linea ___, and
peritoneum, unchanged since ___. 4. There is no free
fluid and no free air. 5. Mild-to-moderate right hydronephrosis,
progressed since ___. 6. Splenomegaly measuring 14 cm.
Brief Hospital Course:
The patient was admitted on ___ to the General Surgical
Service for evaluation and treatment of his small bowel
obstruction. Patient was initially managed conservatively with
bowel rest. He had a nasogastric tube inserted and was NPO/ IV
fluids with antiemetics for nausea. On ___ the patient had a
colonoscopy performed along with dilitation of the ileocolonic
anastamosis. Following the procedure the patient continued to be
NPO and on IV fluids. Over the course of the next few days the
patient had episodes of emesis of both "feculent material" and
bilious material. A repeat CT scan on ___ showed progression
of the small bowel obstruction with dilatation of the small
bowel loops up to 5.3 cm from the previous 4.1 cm. The patient
had a PICC line inserted and was started on TPN. On ___ he
was taken to the operating room for an intestinal bypass. The
operation went well without complication. Please refer to the
Operative Note for details. After a brief, uneventful stay in
the PACU, the patient arrived on the floor NPO, on IV fluids,
with a foley catheter, and an epidural and PCA for pain control.
The patient was hemodynamically stable.His hospital course
following the jejunocolostomy is described below:
Neuro: The patient received an epidural and pca with good effect
and adequate pain control. When tolerating oral intake, the
patient was transitioned to oral pain medications. The patient
complained of pain with several pain medication regimens. His
pain was well controlled with Methadone PO 10 mg q 8 hours and
methadone IV 10 mg every 8 hours. The patient was discharged on
this regimen and advised not to take any of his home
narcotics(morphine), sedatives, or alcohol with this medication.
The patient was neurologically stable during this admission.
CV: Following the operation the patient had episodes of sinus
tachycardia with heart rates as high as 130-140's. Patient was
asymptomatic and continued to produce good urine output. Over
the following days the patient's tachcardia improved and fell to
the low 100's and high 90's. He was started on metoprolol 25 mg
bid and was discharged on this medication. Patient was
hypertensive throughout this hospital admission with blood
pressures as elevated as high 160's/ high 80's. He does have a
past medical history of hypertension. 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: Post-operatively, the patient was made NPO/TPN/IV
fluids. The patient tolerated the TPN well and as his bowel
function returned his diet was advanced appropriately. Patient's
intake and output were closely monitored, and IV fluid was
adjusted when necessary. Electrolytes were routinely followed,
and repleted when necessary. Given that he was experiening
frequent bowel movements of 5 loose bowel movements per day, he
was restarted on Lomotil 1 tablet every 4 hours as needed for
diarrhea with a goal of no more than 2 bowel movements per day.
Patient had his indwelling foley removed on post-op day 4 when
his epidural was removed. Patient had no difficulty voiding
afterwards. Patient was transitioned to a regular diet and was
taken off TPN. He had no issues tolerating the regular diet.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Wound was routinely
monitored and showed no signs of infection.
Endocrine: The patient's blood sugar was monitored throughout
his stay;
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin;He was
encouraged to get up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. He was discharged with
nursing for ___ care with the understanding that his PICC would
likely be removed on ___ in his followup visit with Dr.
___. He received 1 B12 injection while in house and was
advised that he would need these injections monthly as an
outpatient. Patient was instructed that his narcotic regimen and
metoprolol would be adjusted with his PCP or oncologist on the
follow-up visit. His oncologist was verbally informed about the
plan and agreed to manage his narcotics on an outpatient basis.
Medications on Admission:
Diphenoxylate-Atropine 2.5-.025 PRN, Esomeprazole 40 qday,
Lorazepam 0.5 q8h PRN, Morphine 15 PRN,
Ondansetron 8 PRN, Zolpidem 5 PRN, Docusate sodium 100 PRN,
Sennosides 8.6 PRN
Discharge Medications:
1. Diphenoxylate-Atropine 1 TAB PO Q4H diarrhea
Please stop if patient is experiencing constipation.
2. Methadone 10 mg PO Q8H
RX *methadone 10 mg 10 mg by mouth every 8 hours Disp #*54
Tablet Refills:*0
3. Metoprolol Tartrate 25 mg PO BID
Please hold medication if heart rate is less than 60 or blood
pressure less than 100.
RX *metoprolol tartrate 25 mg 1 Tablet(s) by mouth every 12
hours Disp #*36 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 Tablet(s) by mouth three times a day
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bowel obstruction- malignant
Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted for management of a bowel obstruction. During
your hospitalization you first underwent a colonoscopy with
ileocolic dilitation. You continued to experience emesis(
vommiting) and a repeat CT scan showed continuing bowel
obstruction. You then underwent a jejunocolostomy on ___ for
the obstruction. You tolerated the operation well with a return
of bowel function. You tolerated a regular diet and are now
ready to return home.
General Discharge Instructions:
Please resume all regular home medications. Please
take any new medications as prescribed.Please take the
prescribed analgesic medications as needed. You may not drive
or operate heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed,but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water.
Gently pat the area dry.
Your staples will be removed at your followup appointment with
Dr. ___ on ___ at 2pm.
You received an injection of B12 during this hospitalization.
You are to continue receiving B12 injections monthly as an
outpatient.
If you fail to tolerate your diet at home, become febrile, or
fail to have bowel movements you are to call your physician
immediately or report to the local emergency deparment. If you
are having too frequent bowel movements (more than 2 bowel
movements per day), notify your physician. Take your Lomotil as
prescribed. Stop taking it if you experience constipation.
Your PICC line will be removed at your follow up appointment on
___ ___.
Note your heart rate was elevated during this hospitalization,
you were started on Metoprolol 25 mg BID. You are to continue
this medication until you follow up with your primary care
physician and have your medications reconciled. You are stop
taking this medication if your heart rate measures less than 60
beats per minute or your blood pressure is less than 100/60 at
the time of your scheduled dose.
Your pain medications were changed to Methadone 8 mg orally
every 8 hours. This is your new pain medication regimen. You are
to STOP taking any other narcotics while on this regimen. Follow
up with your primary care physician to have your pain
medications reconciled.
Followup Instructions:
___
|
10301864-DS-6 | 10,301,864 | 21,608,682 | DS | 6 | 2181-11-10 00:00:00 | 2181-11-10 17:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ M with hx of CVA ___ no residual
deficits,
EtOH use, psoriasis and gout who is as a transfer from ___ who initially presented s/p mechanical fall.
On ___ pt fell in bedroom to the ground and tried to pull
himself up with the cane but a heavy dresser fell on top of him
and he was unable to get up. He was approximately down for 10
hours.
The patient was found the next morning by his daughter and taken
to
___. At OSH he was initially hypotensive with SBP
___ but was fluid responsive. Due to an elevated creatinine
(>2.0) he had a CT without contrast of the head, chest, abdomen
and pelvis which was unremarkable aside from hydronephrosis. He
remained in a C-collar and was transferred to ___.
At ___, was evaluated by ___. No MSK injuries, but
rhabdomylosis with CK > 8000 and Cr 2.2. Also found to be
retaining significant about of urine, Foley placed with > 1L
output. Per patient no history of urinary retention however was
on finasteride previously, but not currently. Urine culture
positive for yeast and was started on fluconazole by the surgery
team.
Course also complicated by dysphagia, altered mental status. Pt
was transferred to medicine for further workup and management.
Patient reports that he feels better than when he was first
admitted to the hospital. He denies any CP, SOB, abd pain,
fever/chills, cough, or recent illness. He does have R arm pain
that is worse with movement. Pt unable to answer all questions
as
he is a poor historian and would occasionally fall asleep
between
questions.
Obtained collateral from daughter ___, who states that her
father has "slowed down" in the past month and has not gone to
church for about 4 wks. He lives alone in independent ___
living. He is able to cook simple meals, usually only eat once a
day. He ambulates with a cane outside of the home, but
independently at home. At baseline has lower extremity edema and
often sleeps during the day. He also drinks about 8 beers a
night
per patient last drink was about a month ago which his daughter
reported that this was false. He also had a fall about 2 wks ago
as well as the one sustained prior to this admission.
REVIEW OF SYSTEMS: A 10 point review of systems was performed
in
detail and negative except as noted in the HPI.
Past Medical History:
CVA
Psoriasis
Gout
No hx of heart failure
Social History:
___
Family History:
Reviewed. none pertinent to this hospitalization
Physical Exam:
ADMISSION PHYSICAL EXAM:
Gen: NAD, AxOx3
Card: RRR, normal S1 and S2
Pulm: CTAB, no respiratory distress
GU: Foley in place, producing well, dark urine
Abd: Soft, non-tender, non-distended
Ext: No edema, warm well-perfused, LLE abrasive wound
DISCHARGE PHYSICAL EXAM:
VITALS: ___ 1514 Temp: 97.4 PO BP: 134/71 HR: 91 RR: 18 O2
sat: 91% O2 delivery: RA
HEENT: Sclerae anicteric, poor dentition, EOMI, thick neck,
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally on anterior lung
fields, normal work of breathing
Abdomen: Obese, soft, non-tender, +normal BS, no palpable
organomegaly, no rebound or guarding
GU: foley in place, urine clear yellow
Ext: Warm, diffuse anasarca with dependent edema to thighs. R
wrist with removable splint. R medial elbow and medial upper arm
mildly edematous and erythematous around former PIV site in AC
fossa.
Skin: Warm, diffuse xerosis and scale.
Neuro: AOx3. Upper extremity able to raise arms against gravity
however R arm limited ROM due to pain. Able to wiggle toes.
Pertinent Results:
ADMISSION LABS:
___ 09:48PM BLOOD WBC-17.2* RBC-3.93* Hgb-11.9* Hct-37.8*
MCV-96 MCH-30.3 MCHC-31.5* RDW-15.7* RDWSD-55.8* Plt ___
___ 09:48PM BLOOD ___ PTT-25.4 ___
___ 05:50PM BLOOD ALT-49* AST-231* CK(CPK)-6959*
AlkPhos-123 Amylase-29 TotBili-0.6
___ 09:48PM BLOOD CK-MB-60* MB Indx-1.0
___ 02:25AM BLOOD CK(CPK)-4060*
___ 12:21PM BLOOD CK(CPK)-2813*
___ 09:48PM BLOOD CK-MB-60* MB Indx-1.0
___ 02:25AM BLOOD CK-MB-47* MB Indx-1.2
___ 12:21PM BLOOD Calcium-8.3* Phos-3.2 Mg-1.7
DISCHARGE LABS:
===============
___ 07:45AM BLOOD WBC-8.7 RBC-3.21* Hgb-9.5* Hct-31.0*
MCV-97 MCH-29.6 MCHC-30.6* RDW-15.2 RDWSD-53.6* Plt ___
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD Glucose-81 UreaN-22* Creat-1.4* Na-140
K-4.5 Cl-102 HCO3-23 AnGap-15
___ 07:40AM BLOOD CK(CPK)-37*
___ 07:45AM BLOOD Mg-1.6
___ 07:40AM BLOOD Free T4-1.0
___ 07:45AM BLOOD Vanco-21.2*
___ 12:57PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 12:57PM URINE Blood-TR* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG*
___ 12:57PM URINE RBC-5* WBC-155* Bacteri-FEW* Yeast-NONE
Epi-0
___ 12:57PM URINE Hours-RANDOM Creat-65 Na-75
IMAGING:
========
___ UP EXT VEINS US
IMPRESSION:
1. No evidence of deep vein thrombosis in the right upper
extremity.
2. Superficial thrombophlebitis of a focal segment of the right
cephalic vein
just above the antecubital fossa.
___ EXTREMITY LIMITED SO
IMPRESSION:
Superficial edema in the region of the right antecubital fossa
however no
focal fluid collection is identified.
___ U.S.
IMPRESSION:
1. Increased cortical echogenicity and diffuse cortical thinning
bilaterally
suggestive of underlying medical renal disease.
2. There is left-sided caliectasis without hydronephrosis.
___ + VIEWS) RIGHT
IMPRESSION:
There is a nondisplaced fracture through the ulnar styloid.
There are severe
degenerative changes of the triscaphe and first carpometacarpal
joints and
moderate degenerative changes of the radiocarpal joint.
Additional milder
degenerative changes are seen throughout the wrist. There are
atherosclerotic
calcifications.
___ HIPS (AP, LAT, &
IMPRESSION:
1. No evidence of acute fracture or dislocation of either hip.
2. Mild degenerative changes of the hips bilaterally.
___ (AP, LAT & OBLIQU
IMPRESSION:
There is a nondisplaced fracture through the radial head with an
associated
elbow joint effusion. No dislocation is identified. There are
moderate
degenerative changes of the ulnohumeral and radiohumeral joints
as well as the
proximal radioulnar joint. Enthesopathic changes are seen at
the insertion of
the triceps tendon.
___ SHOULDER & HUMERUS
IMPRESSION:
1. Cortical step-off at the radial head which may represent a
fracture.
Further evaluation is recommended with dedicated radiographs of
the right
elbow.
2. No acute fracture of the right shoulder or right humerus.
3. Superior subluxation of the humeral head in relation to the
glenoid, which
may represent rotator cuff tear.
4. Moderate degenerative changes of the acromioclavicular and
glenohumeral
joints.
MICROBIOLOGY:
=============
___ 5:24 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 10:38 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 10:17 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 6:05 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 CFU/mL.
Brief Hospital Course:
___ M with hx of CVA ___ no residual deficits, EtOH use,
psoriasis and gout who is as a transfer from ___
who initially presented s/p mechanical fall with prolonged
immobility. Care was initially managed by trauma surgery then
was transferred to medicine as there was no need for surgical
intervention
ACUTE ISSUES:
=============
#hypotension
#orthostatic hypotension
During admission pt had multiple triggers for hypotension.
During these episodes pt was usually sitting up in chair and
reported that he felt dizzy. BP would improve once in bed and
laying flat. Hypotension likely secondary to over diuresis as
well as initiation of tamsulosin, which was discontinued.
Orthostatic VS were monitored. Pt given IVF as needed.
Hypotension resolved prior to discharge.
#R arm swelling
#R arm cellulitis
Had a PIV in R AC fossa that was removed as area was
erythematous with ?purulence. Edema and erythema worsened but no
change in pain. s/p RUE U/S w/o DVT or fluid collection. Blood
cultures negative. Initially treated with IV vanc, narrowed to
PO doxycycline and cephalexin on day of discharge to complete 5
day total course (___). Please continue to monitor
for resolution.
#R arm pain
#Subluxation of humeral head
#Radial head fracture
#Nondisplaced facture of ulnar styloid
Likely due to fall. Pt complains of generalized RUE pain,
difficult exam given diffuse anasarca. Per Ortho eval, closed
proximal R radial head fracture was nondisplaced,
neurovascularly intact. Also had nondisplaced ulnar styloid
fracture. No acute intervention needed. Sling and removable
wrist splint provided. Activity limited to <5 lb weightbearing
RUE, range of motion as tolerated. Will f/u with ortho trauma
clinic. ___ and OT evaluated patient and recommended rehab.
# Lower extremity edema
Pt with LLE with weeping. Per pt and family has been ongoing. No
hx of HF had ECHO in ___ with EF 60-65% NL LV fxn, moderate
aortic annular valve dilation. Unable to asses JVD due to body
habitus. Has risk factors for HF of weight, EtOH use, likely
OSA. Diuresis was attempted, however pt developed orthostatic
hypotension as above and ___. Albumin notated to be low, suspect
third spacing exacerbated by copious IV fluids received for
rhabdomyolysis iso fall and prolonged immobility. Poor
nutritional status also likely contributing. Patient never
developed dyspnea or O2 requirement, further diuresis deferred
following recovery of blood pressures.
# Urinary retention, ___ placed
# Hydronephrosis
Unknown hx of urinary retention or kidney issues, however given
age and a history of Rx for tamsulosin likely secondary to BPH.
Finasteride was started for BPH. Foley was kept in place because
urinary retention has been a recurrent issue, to follow up with
urology as outpatient for void trial and possible further
work-up. Repeat renal US with resolution of hydronephrosis
# Pyuria
# Yeast postive urine
Pt was started on fluconazole for yeast in urine. Pt denies any
dysuria at home. S/p fluconazole on ___ was then DC'd. ___
was exchanged on ___.
# Dysphagia
No history of dysphagia. Hx of stroke in ___ with no residual
deficits. AAOx3. S&S evaluated and initially recommended NPO. MS
improved and was able to advance diet.
#Falls
#Deconditioning
#multiple pressure wounds
Family reports that for the past month pt has experienced a
decline in physical functioning. Had fall a couple weeks ago no
head strike, prior to fall that brought him to the hospital. ___
consulted recommend ___ rehab. Wound care was consulted to
help care for wounds sustained during the fall and prolonged
immobility.
# R tongue ulcer
Patient reports chronic tongue pain; exam with shallow 2cm
ulcer; consider outpatient ENT/OMFS referral for consideration
of biopsy/workup.
#EtOH Use
#elevated AST
Pt with significant EtOH use at home. Pt reports last drink
about a month ago, however family certain that he drank the
night of this fall. Pt placed on CIWA, did not score do was
discontinued. Continued folate and thiamine.
CHRONIC ISSUES:
==============
#Psoriasis: Continued Triamcinolone Ointment.
#hx of CVA: Continued ASA 81mg.
#hx of gout: DC allopurinol as pt not taking at home.
TRANSITIONAL ISSUES:
====================
[] Complete 5 day antibiotic (doxy, Keflex) course for R medial
arm cellulitis (___).
[] ETOH cessation
[] Nutrition (low albumin, anasarca)
[] Ensure f/u with urology for urinary retention, void trial
[] Ensure f/u with ortho for R distal arm fractures within 2
weeks of discharge.
[] Anemia w/u
[] F/u pressure ulcer wound healing
[] Consider derm referral for diffuse psoriasis
[] Consider ENT vs OMFS referral for biopsy/workup of chronic
tongue ulcer
[] Started finasteride while inpatient for suspected BPH that
may be contributing to recurrent urinary retention
[] Discontinued allopurinol for gout as pt not taking at home.
CORE MEASURES:
==============
#CODE: Full presumed
#CONTACT: HCP ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
3. Omeprazole 20 mg PO DAILY
4. LORazepam 0.5 mg PO Q8H:PRN anxiety
5. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN
psoriasis
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cephalexin 500 mg PO QID
3. Doxycycline Hyclate 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Thiamine 100 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:___
psoriasis
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
rhabdomyolysis
SECONDARY DIAGNOSIS:
===================
___
R nondisplaced radial head fracture
R nondisplaced ulnar styloid fracture
R arm cellulitis
Orthostatic hypotension
Lower extremity edema
Malnutrition
EtOH use
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 privilege caring for you at ___.
Please see below for more information on your hospitalization.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You fell and were trapped under a dresser
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- We had our surgeons evaluate you and you did not need surgery.
- You had muscle breakdown products in you blood
(rhabdomyolysis) and we helped your body get rid of them by
giving you fluid.
- You kidney function was impaired due to those muscle
breakdown. Your kidney function improved with fluids.
- You had wounds from your fall. We had our wound team help care
for them.
- Your body was swollen, so we gave you medicine to help you
make urine.
- You were having difficulty urinating, so we placed a foley
catheter to drain your bladder.
- Your right arm was sore and we found fractures in your elbow
and wrist. You will follow up with the orthopedic team as an
outpatient.
- Your right arm became red and swollen, we are treating you for
a skin infection with antibiotics.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention,
fever, shortness or breath, falls, or worsening arm pain.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10302129-DS-17 | 10,302,129 | 21,829,798 | DS | 17 | 2113-08-16 00:00:00 | 2113-08-29 15:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
___ Retrograde nail Right femur, EUA Left femoral head,
Incision & Drainage Right knee
History of Present Illness:
___ year old male s/p unrestrained driver ___ transferred from
OSH for liver laceration and open right femur fracture. The
vehicles windshield was "exploded", and patient had extensive
repetitive questioning at the scene. Pt arrives A+O and able to
engage in conversation. Pt has known ___ and 6th rib
fractures, open femur fracture, sternum fracture, liver
laceration and a right pneumothorax.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam on admission:
Constitutional: Awake
HEENT: Laceration over left eyebrow, occipital hematoma, Pupils
equal, round and reactive to light Trachea midline, c-collar
applied on arrival
Chest: Breath sounds left>r, no crepitus, tenderness chest wall
Abdominal: Soft, Nontender, Nondistended
Rectal: Normal tone
Extr/Back: Positive DP and ___ pulses bilaterally
Skin: Large laceration over right knee
Neuro: GCS 14 Intact distal motor upper and lower extremity
Physical Exam upon discharge:
VS: T 98.5, 86, 112/60, 18, 100/RA
NEURO: AAOx4, NAD.
CV: RRR, Normal S1, S2. No MRG.
PULM: Lungs CTA Bilaterally.
ABD: Soft/nondistended, minimally tender to palpation.
WOUND: ACE bandage applied over abrasions Right knee. C/D/I.
EXT: + pedal pulses +CSM. No edema, cyanosis, clubbing.
Pertinent Results:
___: BLOOD Hct-25.2*
___: BLOOD Plt ___ BLOOD Calcium-7.9* Phos-2.2* Mg-1.8
___ 08:29PM BLOOD ___ Glucose-130* Lactate-2.8*
Na-139 K-3.8 Cl-107 calHCO3-22 Hgb-12.5* calcHCT-38 freeCa-0.97*
___ Radiology CHEST (PORTABLE AP)
IMPRESSION: There is a tiny right apical pneumothorax after
chest tube removal.
___ CT A/P: liver laceration, Right displaced femoral shaft
fx, nondisplaced fracture Left femoral head
___ CT chest: Right ___ rib fracture, sternal fracture.
___ FEMUR A/P: Mid femoral comminuted fracture and avulsion
fracture from the lateral femoral condyle.
Brief Hospital Course:
Mr. ___ was initially admitted to the ICU for care s/p
unrestrained driver of vehicle involved in MVC with prolonged
___ transferred to ___ ED, with the following
injuries: Nondisplaced sternal fx, Right rib fx 5,6
nondisplaced, Grade 3 liver lac (7cm), Right femur shaft fx,
Left femoral head fx, Right pneumatocele, pulmonary contusion,
and Left ear laceration.
He had a relatively uneventful ICU course. His hematocrit was
checked every ___ hours; he did have an episode of decreasing
hct on ___ postoperatively after orthopaedic intervention for
debridement via arthrotomy of right open knee and retrograde
nailing segmental femur fracture and underwent CTA demonstrating
no acitve arterial extravasation. His Chest tube was placed to
waterseal which he tolerated well. Patient was stable and
transferred to the floor on ___. On ___, his chest tube was
pulled and CXR showed a tiny stable right apical pneumothorax
after chest tube removal. Patient was anticoagulated with
subcutaneous heparin, but was transitioned to Lovenox on the day
of discharge that he will continue for next several weeks.
Physical therapy evaluated patient and deemed him safe to be
discharged home with ___ services. Patient was voiding large
amounts of urine. Pain was well controlled with Oral pain
medications. He was tolerating a regular diet. Vital remained
stable and patient was afebrile upon discharge. He will followup
outpatient in ___ weeks.
Medications on Admission:
None
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
Hold for increase sedation and RR<10.
RX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours Disp
#*40 Tablet Refills:*0
2. Enoxaparin Sodium 40 mg SC DAILY
RX *enoxaparin [Lovenox] 40 mg/0.4 mL 40 MG Daily Disp #*30
Syringe Refills:*0
3. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Nondisplaced sternal fratures
Right rib fx 5,6 nondisplaced
Grade 3 liver lac (7cm)
Right femur shaft fracture
Left femoral head fracture
Right pneumatocele, pulmonary contusion
Left ear laceration
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:
* Your injury caused several 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 antiinflammatory 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 ).
DO NOT TAKE PAST IN ANY PHYSICAL CONTACT SPORTS FOR THE NEXT ___
WEEKS.
IF YOU FEEL LIGHTHEADED OR DIZZY, GO TO NEAREST EMERGENCY ROOM.
Followup Instructions:
___
|
10302157-DS-16 | 10,302,157 | 22,665,336 | DS | 16 | 2189-07-11 00:00:00 | 2189-07-11 15:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
- Intubation
- S/p ___ ml right thoracentesis ___
- S/p ___ ml right thoracentesis with PleurX drain placement on
___
- S/p ___ ml left thoracentesis with PleurX drain placement on
___
- S/p bronchoscopy with friable left-sided airway, but without
obstructive lesion.
- S/p paracentesis with peritoneal drain placement by ___ on
___ with intermittent drainage
History of Present Illness:
___ ___ woman with h/o recent right MCA CVA (c/b
residual left sided weakness, metastatic ovarian cancer with
peritoneal spread, HFrEF (34%) and malnutrition who presents
respiratory distress. Per daughter, patient was feeling short of
breath over the past few days with audible wheezing but then
acutely worsened today. Her PCP recommended increasing her home
Lasix dose to 40mg from 20mg. The family was later told that
some of her lab values showed that she was dehydrated and were
instructed to hold the Lasix. EMS called today for severe
respiratory distress and noted her to be wheezing with RR in the
___. Given nebs without improvement. No recent fevers, chills,
n/v, cp, abd pain. She was quickly intubated for concern of
acute respiratory failure.
Per her granddaughter, she doesn't walk but does work with ___
and OT. Spends an hour or so in wheelchair every day with
family. At normal baseline mental status with no recent change.
Able to talk and recognize family members, memory intact, no
waxing/waning of mental status during the day and night. Just
not oriented to date.
Of note, she had a recent prolonged hospital admission from
___ after a fall resulting in extensive cervical
fractures. She was intubated for respiratory distress thought to
be secondary to a pneumonia and CHF exacerbation. Oncology was
consulted and felt she would not be a poor candidate for
chemotherapy, and palliative care was also consulted. Surgery
was discussed extensively, but given high risk, was ultimately
not thought to be within her goals. She was extubated and
transferred to the floor where her hospital course was further
complicated by agitation and delirium, recurrent CHF
exacerbation requiring an ICU transfer, and dysphagia requiring
tube feeds (initially NG but advanced to ___ iso of emesis).
Significant goals of care conversations were had during the
hospital course and the patient was transitioned to DNI/DNR but
on the day of discharge, she was reverted to full code by the
family.
Past Medical History:
- Stroke (___)
- Metastatic Ovarian cancer (mullerian tumor, carcinomatosis
peritonei)
- Osteoporosis- L wrist fracture
- c5-c7 fracture, t12 compression fracture ___
- HFrEF (TTE ___ w/ EF 34%)
- hypothyroidism
- dysphagia requiring tube feeds
- L distal radius and ulnar styloid fractures
- Anemia
Social History:
___
Family History:
- non-contributory as it relates to his current presentation
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp:95.5, HR: 92, BP: 74/34, RR:41, O2: 92% intubated
GENERAL: intubated and sedated. NAD. Frail appearing.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection. NG present.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Intubated, Lungs anteriorly with diffuse wheezing
bilaterally
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
DISCHARGE PHYSICAL EXAM:
T 99.1 BP 106 / 72 P 89 RR 18 ___ NC
GENERAL: Alert. In minimal respiratory distress at rest. Lying
almost flat with soft neck brace and dobhoff in place
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. NG tube
present.
CV: Heart regular, no murmur. Radial and DP pulses 2+.
RESP: Lungs with bibasilar crackles. Decreased air entry in left
lung; scattered bronchial breath sounds.
Good air entry at right base compared with prior to PleurX
placement.
Bilateral PleurX present with clean and intact dressing,
nontender.
GI: Abdomen is protuberant, soft, mild diffuse tenderness.
Bowel sounds appreciated.
GU: No focal suprapubic tenderness, pure wick in place
MSK: Strength generally decreased.
SKIN: No rashes or ulcerations noted
NEURO: Alert. Oriented to person, place, partial situation. Not
moving left side.
PSYCH: Pleasant
Pertinent Results:
ADMISSION LABS:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ 02:31PM BLOOD WBC-22.6* RBC-3.50* Hgb-8.4* Hct-29.3*
MCV-84 MCH-24.0* MCHC-28.7* RDW-16.0* RDWSD-47.9* Plt ___
___ 02:31PM BLOOD Neuts-85.8* Lymphs-6.8* Monos-4.9*
Eos-0.3* Baso-0.4 NRBC-0.1* Im ___ AbsNeut-19.42*
AbsLymp-1.53 AbsMono-1.11* AbsEos-0.07 AbsBaso-0.09*
___ 02:31PM BLOOD ___ PTT-32.6 ___
___ 02:31PM BLOOD Glucose-145* UreaN-31* Creat-0.8 Na-136
K-5.1 Cl-97 HCO3-24 AnGap-15
___ 02:31PM BLOOD ALT-15 AST-21 CK(CPK)-57 AlkPhos-76
TotBili-0.2
___ 02:31PM BLOOD CK-MB-5 proBNP-6512*
___ 02:31PM BLOOD cTropnT-0.03*
___ 02:31PM BLOOD Albumin-2.6* Calcium-8.6 Phos-5.1* Mg-2.4
___ 02:31PM BLOOD CRP-144.6*
___ 02:41PM BLOOD ___ pO2-29* pCO2-101* pH-7.08*
calTCO2-32* Base XS--4
___ 02:43PM BLOOD Lactate-4.1* K-6.3*
___ 02:41PM BLOOD O2 Sat-26
DISCHARGE LABS:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ 06:20AM BLOOD WBC-16.1* RBC-3.44* Hgb-8.5* Hct-29.2*
MCV-85 MCH-24.7* MCHC-29.1* RDW-18.5* RDWSD-56.5* Plt ___
___ 06:20AM BLOOD Glucose-108* UreaN-19 Creat-0.5 Na-140
K-5.4 Cl-100 HCO3-27 AnGap-13
___ 06:20AM BLOOD Calcium-7.6* Phos-4.4 Mg-2.1
Repeat K+: 4.5
MICROBIOLOGY:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
BLOOD CULTURE:
___: NG final
___: NG Final
___: NG Final
Pleural Fluid
___: : No growth
___: GPC (rare growth)
URINE CULTURE:
___ GRAM POSITIVE COCCUS, ~3000 CFU/mL
___ MRSA SCREEN: Negative
___ URINE LEGIONELLA: Negative
___ SPUTUM CULTURE:
Coag +ve staph (pan sensitive)
Pseudomonas (pan sensitive)
___: Bronchial Washings:
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 4 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ <=1 S
IMAGING:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Portable CXRs:
Last CXR ___
Retrocardiac opacification most likely representing atelectasis.
Stable
bilateral pleural effusions.
___ CHEST (PORTABLE AP)
Moderate to large layering pleural effusions with compressive
lower lung
atelectasis. Edema is suspected. ET tube positioned
appropriately. OG tube extends inferiorly into the upper
abdomen as does the feeding tube.
___ TTE
There is no evidence for a right-to-left shunt with agitated
saline at rest. There is suboptimal image quality to assess
regional left ventricular function. Overall left ventricular
systolic function is
hyperdynamic. The visually estimated left ventricular ejection
fraction is 80%. There is Grade I diastolic dysfunction. Mildly
dilated right ventricular cavity with normal free wall motion.
Intrinsic right
ventricular systolic function is likely lower due to the
severity of tricuspid regurgitation. There is abnormal
interventricular septal motion c/w right ventricular pressure
and volume overload. The aortic valve leaflets (3) are mildly
thickened. There is mild [1+] aortic regurgitation. The mitral
valve leaflets are mildly thickened with no mitral valve
prolapse. There is moderate mitral annular calcification. Due
to acoustic shadowing, the severity of mitral regurgitation
could be UNDERestimated. The tricuspid valve is not well seen.
No mass/vegetation seen, but cannot exclude due to suboptimal
image quality. There is SEVERE [4+] tricuspid regurgitation.
There is moderate to severe pulmonary artery systolic
hypertension. In the setting of at least moderate to severe
tricuspid regurgitation, the pulmonary artery systolic pressure
may be UNDERestimated. A left pleural effusion is present.
IMPRESSION: Poor image quality. Severe tricuspid regurgitation.
Compared with the prior TTE (images reviewed) of ___ ,
the left ventrivcle is now frankly hyperdynamic. Severe
tricuspid regurgitation is now present, raising the question of
endocarditis.
RECOMMEND: If clinically indicated, and the suspicion for
endocarditis is moderate or high, a TEE is suggested for further
evaluation of newly severe tricuspid regurgitation.
___ TEE
There is no spontaneous echo contrast or thrombus in the body of
the left atrium/left atrial appendage. The left atrial appendage
ejection velocity is normal. No spontaneous echo contrast or
thrombus is seen in the body of the right atrium/right atrial
appendage. The right atrial appendage ejection velocity is
normal. There is no evidence for an atrial septal defect by
2D/color Doppler. There is normal regional left ventricular
systolic function. Overall left ventricular systolic function is
normal. The right ventricle has normal free wall motion. There
are simple atheroma in the aortic arch with simple atheroma in
the descending aorta to from the incisors. The aortic valve
leaflets (3) are mildly thickened. No masses or vegetations are
seen on the aortic valve. No abscess is seen. There is a
centrally directed jet of mild [1+] aortic regurgitation. The
mitral valve leaflets are mildly thickened with no mitral valve
prolapse. No masses or vegetations are seen on the mitral valve.
No abscess is seen. There is trivial mitral regurgitation. The
pulmonic valve leaflets are normal. No masses/vegetations are
seen on the pulmonic valve. No abscess is seen. There is mild
pulmonic regurgitation. The tricuspid valve leaflets are
thickened/myxomatous with systolic prolapse. No mass/vegetation
are seen on the tricuspid valve. No abscess is seen. There is
moderate [2+] tricuspid regurgitation. There is moderate
pulmonary artery systolic hypertension. A left pleural effusion
is present. Ascites is seen.
IMPRESSION: No discrete vegetation or abscess seen. Normal
global biventricular systolic function. Tricuspid valve prolapse
with moderate tricuspid regurgitation. Mild aortic
regurgitation. Mild pulmonic regurgitation.
___ WRIST(3 + VIEWS) LEFT PORT
In comparison with the study of ___, overlying cast
again greatly
obscures detail. There is little change in the alignment of the
radial
fracture and there appears to be some increased sclerosis.
Separation of the ulnar styloid process appears essentially
unchanged.
Brief Hospital Course:
___ years-old ___ female with history of metastatic
ovarian cancer with omental caking, right-sided MCA stroke with
left-sided weakness and dysphagia (___), HFrEF (34%), and
several recent falls resulting in cervical and LUE fractures,
who presents with acute hypoxemic and hypercarbic respiratory
failure. Initially required ICU stay and was transferred to
floor after 3 days. Patient was found to have metastatic pleural
effusions and ascites. Drains placed to palliate symptoms and
allow patient to achieve goal of returning home. Additional
details of hospital course listed below by problem.
# Acute hypoxic respiratory failure, intermittent/improved
overall: multifactorial from pneumonia, acute on chronic HFrEF,
malignant effusion, atelectasis, and mucous plugging. Acute
hypercarbic respiratory failure is largely resolved but pt
continued to have mild intermittent 02 requirement.
CT chest was obtained was suggestive of obstructive pathology of
left lung with collapse and left sided effusion. Chest ___
ordered and attempts were made at weaning supplemental oxygen.
She will return home on oxygen supplement. Patient underwent a
bronchoscopy that did not show obstructed airway, rather
edematous and erythematous airway. To treat the fluid
accumulation, patient underwent the following procedures:
- S/p ___ ml right thoracentesis with chest tube placement ___
- S/p ___ ml right thoracentesis ___
- S/p ___ ml left thoracentesis with chest tube placement ___
- S/p bronchoscopy with friable left-sided airway, but without
obstructive lesion. Cultures represent colonization with
pseudomonas; IP agreed to monitor for clinical correlation but
pt was later tx'd with 5d course of abx (as below).
Continued duonebs and home Montelukast, though no clear
indication for ipratropium (no e/o COPD) so this was not
continued on d/c but pt given albuterol nebulizer.
On initial presentation, she was noted to have shock and lactic
acidosis. These resolved with treatment for pneumonia:
- S/p complete CefTAZidime (___) 7 day course.
- S/p Azithromycin (d1: ___ for a 5 day course.
- s/p Ciprofloaxcin d1: ___ - ) for a 5d course (also covering
for possible SBP based on elevated PMNs on repeat peritoneal
studies)
- Discontinued empiric Vancomycin given culture/MRSA results
Sputum culture growing coag positive staph and pseudomonas
(sparse growth). Strep Pneumonia antigen not detected. TEE
showed no evidence for infective endocarditis. Leukocytosis and
thrombocytosis continued to fluctuate throughout the
hospitalization but was improving prior to discharge. We suspect
this to be reactive to procedures, inflammatory lung, ongoing
abdominal pathology and accelerated cancer process.
# Metastatic ovarian cancer complicated by abdominal pain.
Abdominal pain was likely due to carcinomatosis and ascites. CT
abdomen/pelvis was obtained to evaluate extent of disease burden
and assess for ascites. Cancer was relatively unchanged from
prior. Ascites was moderate. On ___ ___ performed peritoneal
drain placement. Palliative care evaluated the patient and
helped guide goals of care discussions and family care meetings.
Ultimately, patient will be discharged home with services,
including palliative care nurse practitioner who will
communicate with PCP. Despite previously being a DNR/DNI,
patient has more recently been transitioned to full code to
continue treatments and hospitalizations such as this one. See
family care meeting notes for further characterization of
patient/family wishes.
# Acute on chronic HFrEF-->HFpEF. Prior TTE on ___ showed EF
34% with normal left ventricular wall thickness and cavity size
with regional dysfunction consistent with CAD in the LAD
distribution. BNP was 6512 on admission. Repeat TTE revealed EF
80%. Patient treated with intermittent IV lasix; ultimately
transitioned to home PO lasix 20mg every other day. Metoprolol
continued but losartan was d/c on discharge (d/t hypotension)
and no clear indication.
# Malnutrition: Patient continues on tube feeds for primary
etiology of nutrition. Prior video swallow with speech therapy
demonstrated minimal concern with nectar and honey thickened
foods for comfort.
# Acute on chronic anemia. No clear source of bleeding was
identified. This is likely underproduction in the setting of
sepsis. Iron panel was consistent with iron deficiency anemia
(iron 15, Tsat 8%) with plans for supplementation. Haptoglobin
elevated and LDH/Tbili within normal limits, making hemolysis
unlikely.
# Known C-spine fracture and LUE fracture. On initial imaging
___, extensive fractures through C5-7, unstable C6-C7
fracture. After discussion of high surgical risk a surgical
intervention was not within goals. Patient/family have
self-discontinued stabilizing braces at home, but are encouraged
to restart C-collar and ___. It is possible patient does not
need this for entirety, but will need outpatient orthopedic
follow up to guide therapy.
#Fever: Continued to have low grade temps (last 100.5 ___
despite intermittent APAP. C/f possible smoldering infection.
Subjective limited in terms of localization of symptoms.
Possibly ___ atelectasis. Repeat Bcx showed NGTD. Pleural cx
ngtd + peritoneal fluid cultures did show rare GPC though ID
felt difficult to interpret iso chronic indwelling tube, in
light of elevated PMNs on cell count opted to ___ for 5d course
of cipro given bronchial washings and possible SBP. Fever curve
and WBC subsequently improved. In discussion with ID would hold
on suppressive abx for now in light of multiple indwelling tube
and decision to remain full code, but could be considered in the
future. Started cirpo 500bid ___ complete therapy at
home.
Transitional issues:
[ ] 3x weekly MWF pleural drainage with ___ (see IP note)
[ ] Start with 1x weekly abdominal Pleurex drains on ___
would avoid large fluid removal/shifts (ie >2L); freq/volume
targets can be adjusted as needed
[ ] Continue to address GOC (discharged as full code)
[ ] Can consider long term suppressive abx in the future if no
change in GOC
[ ] I instructed pts family that they most provide 24 hr
supervision in light of pts propensity to pull at chest tubes
given potential fatal risks associated with accidental removal;
please continue to reinforce this
[ ] Repeat K+ in 1 week for continued monitoring (borderline
elevated but stable in the days prior to discharge)
>30 minutes were spent in discharge planning and coordination of
care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Metoprolol Tartrate 12.5 mg PO BID
4. melatonin 3 mg oral QHS
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Gabapentin 200 mg PO QHS
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Montelukast 10 mg PO DAILY
10. GuaiFENesin ___ mL PO Q6H:PRN cough
11. Lidocaine 5% Patch 1 PTCH TD QAM
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth Q6H PRN Disp #*30
Tablet Refills:*0
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 Neb Inhalation Q4H
PRN Disp #*20 Vial Refills:*0
3. Ciprofloxacin HCl 500 mg PO BID
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*6 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 50 mg/5 mL 10 ml by mouth twice a day
Refills:*0
5. Sarna Lotion 1 Appl TP QID:PRN itching
RX *camphor-menthol [Anti-Itch (menthol/camphor)] 0.5 %-0.5 %
Apply to areas of itch QID PRN Disp #*1 Tube Refills:*0
6. Simethicone 80 mg PO QID:PRN bloating
RX *simethicone 40 mg/0.6 mL 0.6 ml NG QID PRN Disp #*6
Milliliter Refills:*0
7. Furosemide 20 mg PO EVERY OTHER DAY
8. Lidocaine 5% Patch 1 PTCH TD QPM apply to low back
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 40 mg PO QPM
11. Gabapentin 200 mg PO QHS
12. GuaiFENesin ___ mL PO Q6H:PRN cough
13. Levothyroxine Sodium 100 mcg PO DAILY
14. melatonin 3 mg oral QHS
15. Metoprolol Tartrate 12.5 mg PO BID
16. Montelukast 10 mg PO DAILY
17.Nebulizer machine
Acute hypoxic respiratory failure (J96.01). Patient willing to
use. Ongoing use. Device necessary. Use with medication PRN
wheezing.
18.Durable medical equipment
Diagnosis: Malignant pleural effusions
Concentrator and portable oxygen system
2L 24 hours per day to keep saturations above 90%
For home use.Lifetime use
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute hypoxic respiratory failure
Possible pneumonia
Acute on chronic HFrEF
Malignant effusion
Atelectasis
Mucous plugging
Acute hypercarbic respiratory failure
Fever
Metastatic ovarian cancer
Abdominal pain
Shock and lactic acidosis
Leukocytosis and Thrombocytosis
Malnutrition
Acute on chronic anemia
C-spine fracture
GERD
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 with shortness of breath and low oxygen levels
in the setting of fluid build up around the lungs. We placed
drains to help palliate symptoms of fluid build up in the
setting of your terminal illness and you will be continued on a
course of antibiotics for treatment of infection.
If you develop fevers, chills, chest pain, difficult breathing
not relieved by fluid removal or any other symptoms that return
you, please call your doctor or return to the emergency
department.
It was a pleasure taking care of you!
Followup Instructions:
___
|
10302201-DS-11 | 10,302,201 | 29,087,677 | DS | 11 | 2120-06-24 00:00:00 | 2120-06-25 18:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
zoster vaccine live
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old woman with h/o DMT2, HTN, afib on coumadin presents
with increase in dyspnea with exertion. Her sypmtoms first
started with a cough and some shortness of breath 2 weeks ago
that she thought was bronchitis. Her dyspnea ha slowly worsened
since that time and she has trouble doing most acitivities. She
also feels bloated but she is unsure of any weight gain. Her las
weight recorded in clinic is 120 kg. She visited her
cardiologist prior to the onset of symptoms for follow-up of her
AFib. The note from that visit notes dyspnea with extreme
exertion, and no further work-up. She denies chest pain,
palpitations, headache, fevers, chills, PND, orthopnea. She
sleeps on 3 pillows but this has been her "whole life" and more
for neck comfort. No recent changes in medications.
In the ED, initial vitals were: 98.3 76 144/82 28 97% 3L. She
was given furosemide 40 mg IV x 1.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, myalgias, joint pains. She denies
exertional buttock or calf pain. All of the other review of
systems were negative.
Cardiac review of systems is notable for above, and in addition,
has noted some increased ankle edema. No syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
DMT2: last A1c 6.7 on ___
Asthma
Obesity, morbid
Atrial fibrillation
De Quervain's tenosynovitis, bilateral
Social History:
___
Family History:
Diabetes - Type I; Hypertension; lung disease
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.9 170/95 63 20 95% on RA
General: NAD, pleasant female, sitting comfortably in bed
HEENT: NC/AT, PERRL, sclera anicteric, no conjunctival
injection, oropharynx clear, MMM
Neck: supple, no LAD, JVD at 10cm
CV: irregularly irregular, nl s1/s2, ___ SEM at RUSB, no rubs
or gallops
Lungs: good effort, bibasilar crackles ___ way up
Abdomen: obese, soft, nontender, nondistended, normoactive bowel
sounds
GU: no foley
Ext: warm, 1+ pitting edema to below knees bialterally
Neuro: oriented x 3, moving all 4 extremities
Skin: dry, skin peeling on toes bilaterally, no other rash or
lesions
Pulses: 1+ DP bilaterally
DISCHARGE PHYSICAL EXAM
VS: 97.3 159/87 (140s-170s/80s-90s) 58 (50s-70s) 20 94% on RA
Weight: 125.3kg -> 122.2kg
General: NAD, pleasant female, sitting comfortably in bed
HEENT: NC/AT, PERRL, sclera anicteric, no conjunctival
injection, oropharynx clear, MMM
Neck: supple, no LAD, JVD at 10cm
CV: irregularly irregular, nl s1/s2, ___ SEM at RUSB, no rubs
or gallops
Lungs: good effort, bibasilar crackles ___ way up
Abdomen: obese, soft, nontender, nondistended, normoactive bowel
sounds
GU: no foley
Ext: warm, 1+ pitting edema to mid-shin bialterally
Neuro: oriented x 3, moving all 4 extremities
Skin: dry, skin peeling on toes bilaterally, no other rash or
lesions
Pulses: 1+ DP bilaterally
Pertinent Results:
ADMISSION LABS
==========================
___ 04:32PM BLOOD WBC-8.0 RBC-4.21 Hgb-11.7* Hct-36.8
MCV-87 MCH-27.7 MCHC-31.7 RDW-14.8 Plt ___
___ 04:32PM BLOOD Neuts-79.9* Lymphs-12.7* Monos-3.9
Eos-2.4 Baso-1.1
___ 04:32PM BLOOD ___ PTT-43.9* ___
___ 04:32PM BLOOD Glucose-125* UreaN-12 Creat-0.8 Na-145
K-3.5 Cl-105 HCO3-28 AnGap-16
PERTINENT LABS
==========================
___ 12:17AM BLOOD CK(CPK)-95
___ 12:17AM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:32PM BLOOD proBNP-1776*
IMAGING/STUDIES
===========================
___ ECG
Irregular irregular rhythm without P waves consistent with
atrial fibrillation. Possible left ventricular hypertrophy by
voltage. Diffuse non-specific ST-T wave flattening and T wave
inversion in the lateral leads raising a question of ischemia or
digitalis effect. Clinical correlation is suggested. No previous
tracing available for comparison.
___ CXR PA AND LAT
Pulmonary edema and possible trace right pleural effusion.
Enlarged cardiac silhouette suggestive cardiomegaly noting that
pericardial
effusion is also possible.
Increased density in the subcarinal region raises possibility of
underlying
rounded structure and followup after treatment is suggested to
further
characterize.
___ ECHO
The left atrium is moderately dilated. The right atrium is
markedly dilated. No atrial septal defect is seen by 2D or color
Doppler. The estimated right atrial pressure is ___ mmHg. There
is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). There is no ventricular septal
defect. The right ventricular cavity is dilated with normal free
wall contractility. There is abnormal septal motion/position.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild to
moderate (___) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
DISCHARGE LABS
==========================
___ 05:20AM BLOOD WBC-9.4 RBC-4.43 Hgb-12.0 Hct-37.7 MCV-85
MCH-27.0 MCHC-31.8 RDW-15.0 Plt ___
___ 03:00PM BLOOD ___
___ 03:00PM BLOOD Glucose-103* UreaN-15 Creat-0.8 Na-146*
K-3.6 Cl-105 HCO3-34* AnGap-11
___ 03:00PM BLOOD Calcium-9.7 Phos-3.6 Mg-2.1
Brief Hospital Course:
Ms. ___ was admitted with increasing dyspnea on exertion and
fatigue, consistent with new-onset heart failure. She was
diuresed with improvement in exam and symptoms. Echocardiogram
was consistent with diastolic heart failure. She was discharged
on oral furosemide and her anti-hypertensives were adjusted for
improved blood pressure control.
ACTIVE ISSUES
# Dyspnea
Consistent with new onset heart failure given rales on exam, CXR
with pulmonary edema, elevated BNP, and LVH criteria on EKG.
There was no evidence of pneumonia and PE unlikely given
alternative explanations. Troponins negative, no ischemic
changes on EKG. Symptoms and exam improved with one dose of IV
lasix and transitioned the day after admission to oral lasix.
Echocardiogram revealed evidence of diastolic heart failure;
likely cause of her heart failure was hypertensive
cardiomyopathy. She was started on daily furosemide. Continued
on home beta blocker. Started on daily aspirin.
# Hypertension
Was hypertensive on admisison to 160s systolic. She was
continued on amlodipine and lisinopril. Changed HCTZ to
chlorthalidone to take in the evening separate from lisinopril
to improve BP control throughout the day.
CHRONIC ISSUES
# Atrial Fibrillation
This is a long-standing problem for her. Continued on rate
control with atenolol and anticoagulation with warfarin.
# Type II Diabetes
Well-controlled per last A1c. Continued on metformin at
discharge.
TRANSITIONAL ISSUES
- Monitor diuresis with furosemide
- Blood pressure should be monitored given the changes to her
anti-hypertensive regimen outlined above
- Incidental finding on CXR: "Increased density in the
subcarinal region raises possibility of underlying rounded
structure and followup after treatment is suggested to further
characterize."
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. lisinopril-hydrochlorothiazide ___ mg oral daily
2. Simvastatin 10 mg PO DAILY
3. Warfarin 2.5 mg PO DAILY16
4. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
5. Amlodipine 10 mg PO DAILY
6. Atenolol 100 mg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
9. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Amlodipine 10 mg PO DAILY
You should take this medication in the evening
3. Atenolol 100 mg PO DAILY
4. Simvastatin 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet,delayed
release (___) by mouth daily Disp #*30 Tablet Refills:*0
6. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. Warfarin 2.5 mg PO DAILY16
10. Chlorthalidone 25 mg PO DAILY
RX *chlorthalidone 25 mg 1 tablet(s) by mouth daily, in the
mornings Disp #*30 Tablet Refills:*0
11. Outpatient Lab Work
Please draw chem-7 (sodium, potassium, chloride, bicarb, BUN,
creatinine) on ___. Send results to Dr. ___ at Phone:
___
Fax: ___
12. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
13. Lisinopril 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: acute diastolic heart failure
Secondary: hypertension, diabetes mellitus type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you had shortness of
breath. Your blood work and chest x-ray appeared that you had
fluid backed up in your lungs. This happens when the heart does
not pump all of the blood out with each beat--called heart
failure. The ultrasound of your heart shows that you have a
type of heart failure which is usually caused by long-standing
high blood pressure. You were started on a new medication to
keep the fluid out of the lungs, called furosemide. You should
follow-up with your doctor to make sure you get better control
of the blood pressure.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
___
|
10302356-DS-21 | 10,302,356 | 24,283,977 | DS | 21 | 2148-05-23 00:00:00 | 2148-05-23 16:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Demerol / erythromycin /
Codeine / Percocet / Darvon / Zofran / acetaminophen /
meperidine / propoxyphene
Attending: ___.
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
EGD w/ Pill Endoscopy ___
History of Present Illness:
___ with AF recently started on ___, s/p recent R-sided
ORIF c/b NSTEMI and ?TIA here with Hct drop from 28->24 at SNF.
Patient denies vomiting, hematemesis, diarrhea, dizziness, SOB,
palpitations, weight changes or melena. Has chronic reflux type
chest discomfort and intermittent nausea from hiatal hernia and
is unable to lie flat due to that. Also notes peripheral edema,
worsened over the past several days.
Of note, pt was dc'ed on ___ after hospitalization for
mechanical fall requiring ORIF. Course was c/b NSTEMI and AF
with RVR requiring CCU transfer. Cardiac cath was normal, TTE
showed some regional systolic dysfunction with largely preserved
EF, and pt was started on ___ and ___.
Initial VS in the ED: 99.3 80 112/63 18 98% ra. Exam notable for
guaiac +, melanotic stool. Labs notable for Hct 26.2 (28.2 on
___. CT negative for RP bleed, showed gross anasarca and b/l
pleural effusions. Patient was given PPI bolus and drip. GI saw
pt in ED and want pt NPO for possible EGD in AM. Cards agrees
with scope and wants ASA continued and ___ restarted
afterwards.
On the floor, vitals are 102/43 72 97.7 94%RA 18. She complains
of some right knee pain present since being in the ER but is
otherwise comfortable
Review of systems:
(+) Per HPI
(-) Denies fever, chills, recent weight loss or gain. headache,
numbness, tingling, weakness. Denied cough, shortness of breath.
Denied, palpitations. Denied abdominal pain. No recent change in
bladder habits. No dysuria.
Past Medical History:
Diastolic congestive heart failure
Moderate TR, mild MR, moderate AS
Hypertension
Bilateral leg edema
Hiatal hernia
Cervical cancer
Hip fx s/p ORIF
Afib
H/o NSTEMI
Social History:
___
Family History:
no family history of GI cancerns
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T:97.7 BP:102/43 P:72 R: 18 O2: 94%RA
General: Alert, oriented, irritable but no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Decreased breath sounds at bases b/l, no crackles or
wheezes
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur heard throughout precordium
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, +reducible
ventral hernia
Ext: warm, 1+ pulses, 3+ pitting edema to the thighs b/l
Neuro: grossly intact, not cooperative with exam, no facial
droop noted
DISCHARGE PHYSICAL EXAM
VS: 98.1 110-134/62-70 ___ 18 97-99%RA
GEN: NAD
HEENT: MMM, pale conjuctiva
Neck: Supple, JVP not elevated
Lungs: Decreased breath sounds at bases
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur heard throughout precordium
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, 1+ pulses, 1+ pitting edema in ___ (at baseline)
Pertinent Results:
ADMISSION LABS
___ 07:00PM BLOOD WBC-9.7 RBC-2.83* Hgb-8.4* Hct-26.2*
MCV-93 MCH-29.5 MCHC-31.9 RDW-14.0 Plt ___
___ 07:00PM BLOOD Neuts-88.9* Lymphs-6.6* Monos-3.6 Eos-0.7
Baso-0.2
___ 07:00PM BLOOD ___ PTT-29.0 ___
___ 07:00PM BLOOD Glucose-108* UreaN-32* Creat-0.6 Na-139
K-4.0 Cl-104 HCO3-26 AnGap-13
___ 07:00PM BLOOD ALT-50* AST-45* LD(LDH)-473* AlkPhos-155*
TotBili-0.3
___ 07:00PM BLOOD Albumin-2.9*
___ 09:00AM BLOOD Calcium-7.7* Phos-3.4 Mg-1.8 Iron-43
___ 09:00AM BLOOD calTIBC-257* ___ Ferritn-143
TRF-198*
___ 09:00AM BLOOD %HbA1c-5.5 eAG-111
DICAHRGE LABS
___ 07:30AM BLOOD WBC-7.8 RBC-3.55* Hgb-10.8* Hct-33.2*
MCV-94 MCH-30.5 MCHC-32.6 RDW-14.6 Plt ___
MICRO
None
ECG ___
Sinus rhythm. Diffuse non-specific ST-T wave changes. Otherwise,
compared to the previous tracing of ___ no diagnostic
interim change.
IMAGING
CT Torso ___
IMPRESSION:
1. No evidence of hematoma or hemorrhage in the chest, abdomen
or pelvis.
2. Anasarca.
3. Moderate right and small left non-hemorrhagic pleural
effusions.
4. Large hiatal hernia with multiple air-fluid levels.
5. Cholelithiasis and nephrolithiasis without evidence of
obstruction.
6. Right hip fracture status post ORIF without evidence of
hematoma or
hemorrhagic joint effusion.
Push Enteroscopy ___
Large hiatal hernia.
'Schatzki's ring.
Following enteroscopy an adult gastroscope was used for
endoscopic placement of capsule for capsule endoscopy. The
capsule was loaded onto the delivery device and scope was
advanced to the level of the duodenum without difficulty.
Capsule was deployed in the duodenum.
Otherwise normal small bowel enteroscopy to mid jejunum.
Brief Hospital Course:
___ with AF on ___, recent ORIF c/b NSTEMI with normal
cath, ?TIA p/w with melena.
# Acute blood loss anemia
# GI Bleed: Pt referred to ED when found to have asymptomtaic
drop in hematocrit at rehab. Seen in ED by GI where DRE produced
guaiac + melanotic stool. RP bleed ruled out given recent
interventions (ORIF and cardiac cath during admission in ___
w/ CT Torso. Recently started on ___ given new onset
afib during previous admission for hip fx in ___. ___
was held on admission but pt was continued on Aspirin 81mg.
Patient was HD stable and there were no further signs of GI
bleeding while on the medicine floor. Started on PPI IV given
concern for GI bleed. Pt was transfused one unit of pRBCs on
___ with an appropriate increase in hematocrit. After
discussion between the patient's outpt Cardiologist and the GI
team, decision was made to attempt a colonoscopy +/- EGD and any
other intervention thought needed at the time of the procedures.
Unfortunately, patient was unable to tolerate the prep for the
colonoscopy (x2 days) and thus decision was made to only pursue
a EGD. EGD done on ___ failed to identify a source of
bleeding (only finding was a known hiatal hernia) and at the end
of the EGD, a pill endoscopy was placed. As a result, the outpt
Cardiologist recommended that we retrial the pt on Rivaroxavan
at a lower dose (instead of Lovenox/Coumadin). Pt was observed
over 72 hours without evidence of rebleeding. Discharged on PO
PPI.
# AFib: Admitted in sinus rhythm. H/o afib with RVR c/b
hypotension requiring CCU transfer during previous admission.
Anticoagulation was held as above. Amiodarone was continued but
beta blocker was held 2/t concern for GI bleed. No evidence of
afib on tele during this admission.
# Chronic diastolic CHF: CT Torso shows anasarca and bilateral
pleural effusions and exam notable for peripheral edema which
was initially concerning for CHF exacerbation. Leg swelling was
at baseline, as per pt, with no recent worsening. In addition,
the pleural effusions b/l were present and appeared stable
compared to a previous CT. TTE from last admission showed mild
regional left ventricular systolic dysfunction with focal
hypokinesis, AS, MR ___ TR. ___ mot likely 2/t dCHF, would
have trialed gentle diuresis, however, given GI bleed, held off
on attempting diuresis. H/o Spirinolactone prior to hip fx.
Pleural effusion are being followed by the patient's outpt
providers and is known to both the patient and her family
members. No hypoxia on O2 saturations during admission.
# NSTEMI: Diagnosed with NSTEMI during last admission and had a
normal cath at that time. No complaints of CP during this
admission. Statin previously held due to transaminitis
(attributed to shock liver from previous admission) and
reinitiaition should be reconsidered once LFTs normalize
(currently downtrending).
# Transaminits: Attributed to shock liver during previous
admission. Trending down.
# S/p ORIF: S/p fip fx repair. Pain control with Tylenol. ___
consult was placed but pt refused ___ x3days. Eventually was seen
by ___ prior to discharge. During this admission, pt missed an
outpt ortho f/up appt. Ortho consult team came by and removed
the staples. A f/up appt was rescheduled at time of discharge.
Transitional Issues:
-F/up Pill Endoscopy Study
-F/u for further GI bleeding (if repeat episode, consider
Coumadin given easily reversible nature)
-Consider reinitiation of statin if LFTS wnl as outpt
-Once patient is recovered from hip fx and GI bleed, consider
gentle diuresis/work-up for the pleural effusions
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Caltrate-600 + D Vit D3 (800) *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -800 unit Oral daily
3. ___ 20 mg PO DAILY
4. Metoprolol Tartrate 12.5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Amiodarone 200 mg PO TID
Discharge Medications:
1. Amiodarone 200 mg PO TID
2. Aspirin 81 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. ___ 15 mg PO DAILY
5. Caltrate-600 + D Vit D3 (800) *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -800 unit Oral daily
6. Pantoprazole 40 mg PO Q12H
7. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain/fever
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Gastrointestinal Bleed
Secondary: Atrial fibrillation, HTN, Diastolic heart failure
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 ___ was a pleasure taking care of you during your stay at ___.
You were admitted for concern that you were bleeding from your
gastrointestinal tract. You were seen by a Gastroenterologist
who recommended a colonoscopy and a upper endoscopy. We
attempted to prep you for the colonoscopy but you were unable to
tolerate the prep. The upper endoscopy was done which did not
show any source of bleeding. A pill was dropped and will be
reviewed to see if a source can be identified. After the
endoscopy, it was determined that you were likely not bleeding
from your intestines since you did not have stools that appeared
to have blood. Your blood levels were also stable. We restarted
you on anti-coagulation at a lower dose and you tolerated it
well over 72 hours.
You were seen by physical therapy who believed that you should
be discharged to a rehab facility.
We rescheduled your orthopedic follow-up appointment that you
missed while you were admitted.
Please schedule a follow-up appointment with Dr. ___.
Followup Instructions:
___
|
10302356-DS-24 | 10,302,356 | 26,328,570 | DS | 24 | 2149-10-01 00:00:00 | 2149-10-03 20:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Demerol / erythromycin /
Codeine / Percocet / Darvon / Zofran / meperidine / propoxyphene
/ Haldol
Attending: ___
Chief Complaint:
Diarrhea, abdominal pain
Major Surgical or Invasive Procedure:
none this hospitalization
History of Present Illness:
___ female history of hypertension, diastolic CHF,
atrial fibrillation, post-op NSTEMI who is transferred from
assisted living facility for generalized weakness. Her daughter
provides the history.
Earlier this ___, in late ___, she presented after a
fall at her assisted living, and was found to have a UTI;
discharge with week of Keflex. She became weak during this
infection and in the last month she has not yet regained her
strength and she continued to have urinary frequency; her
daughter feels that this is indicative of incompletely treated
UTI, although the patient was not having ongoing fevers,
dysuria, or hematuria.
She was again hospitalized at ___ ___ - ___ after a
fall in the bathroom at ___ living. She was found to have
another UTI (pan-sensitive E coli), as well as nondisplaced
left fibular fracture (non-op). She was treated with IV
ceftriaxone and transitioned to PO cefpodoxime. She was
discharged to her nursing facility where she developed large
volume foul-smelling diarrhea for the last 2 days, as well as
worsening generalized weakness. Her daughter reports fever to
101 at home, with decreased appetite, poor PO intake, decreased
UOP, and lower abdominal pain.
Of note, while in ___ she was also noted to be hypoxic to
90% on room air, a d-dimer was elevated, CT angiogram showed no
pulmonary embolism, ?non-obs R UPJ stone.
Due to her diarrhea, she was ___ to the ED.
In the ED, initial vitals were: 99.3 80 102/49 18 94% RA
Labs were notable for WBC 18.2 (91% PMNS)
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies vomiting, constipation. No
dysuria. Denies arthralgias or myalgias.
Past Medical History:
1. Diastolic congestive heart failure EF 50-55% with mild
regional left ventricular
systolic dysfunction with focal hypokinesis of the distal septum
( ECHO ___
2. Moderate tricuspid regurgitation, mild mitral regurgitation,
moderate aortic stenosis.
3. Hypertension.
4. Bilateral leg edema with left greater than right at baseline.
5. Hiatal hernia.
6. History of cervical cancer status post radiation therapy.
7. History of hip fracture, status post ORIF.
8. Atrial fibrillation, no longer on anticoagulation ___
bleeding (vaginal and GI bleed); currently on amiodarone
9. History of coronary artery disease, status post non-ST
elevation MI with a normal cardiac cath.
10. Recurrent urinary tract infection
11. Peptic ulcer disease with duodenal ulcer, on PPI.
13. History of delirium, post hip repair with anesthesia.
14. Suspected Bilateral median and ulnar nerve neuropathies
15. Macular degeneration
16. Hard of hearing
Social History:
___
Family History:
mother: thyroid cancer, undetermined arrhythmia
father: MI
Physical ___:
ADMISSION PHYSICAL EXAM:
==================
Vitals: T: T 99.3 BP:126/53 P:83 R:18 O2:93RA
General: Alert, oriented. Sitting comfortably in bed in NAD.
Conversant, answers questions circumstantially but with relevant
responses.
HEENT: NCAT. OP clear without erythema exudates. Dry MM. No
masses. Anicteric sclerae. Conjunctivae white.
Neck: full ROM, supple, no LAD
CV: RRR. IV/VI harsh systolic murmur heard at bilateral upper
sternal borders with radiation to carotids and early diastolic
decrescendo murmur heard over precordium in midclavicular line.
No gallops. No JVD. 1+ lower extremity edema, L>R.
Lungs: CTAB. Poor respiratory effort. Unlabored breathing on RA
Abdomen: tender in bilateral lower quadrants. Mild to moderately
tense and distended. +BS.
Ext: WWP. Chronic lower extremity skin changes and edema.
Bilateral lower legs tender to palpation.
Neuro: A/O x3. Circumstantial speech. CN2-12 intact. Strength
___ in upper and lower extremities, with exception of left foot
weakness with dorsiflexion
Skin: no rashes, excoriations, or other lesions
DISCHARGE PHYSICAL EXAM:
==================
VITALS: 97.6, BP 111/57, HR 83, RR 22, 91% on room air
General: Alert, oriented, anxious. Sitting comfortably in bed in
NAD. Conversant, answers questions with relevant responses.
HEENT: NCAT. OP clear without erythema exudates. Dry MM. No
masses. Anicteric sclerae. Conjunctivae white.
Neck: full ROM, supple, no LAD
CV: RRR. IV/VI harsh systolic murmur heard at bilateral upper
sternal borders (loudest at RUSB) with radiation to carotids and
early diastolic decrescendo murmur heard over precordium in
midclavicular line. No gallops. 1+ lower extremity edema, L>R.
Lungs: CTAB. Unlabored breathing on RA
Abdomen: Normoactive bowel sounds, non tender on deep palpation
of the abdomen.
Ext: Chronic lower extremity skin changes and edema. Bilateral
lower legs tender to palpation. L wrist effusion but much
improved since prior exam, erythema almost totally resolved.
Still some pain w/ passive motion but pt actively lifting wrist
without pain.
Neuro: A/O x3. CN2-12 intact. left foot weakness with
dorsiflexion
Skin: no rashes, excoriations, or other lesions
Pertinent Results:
ADMISSION LABS:
===========
___ 02:10PM BLOOD WBC-18.2*# RBC-3.97* Hgb-11.6* Hct-36.8
MCV-93 MCH-29.3 MCHC-31.5 RDW-14.0 Plt ___
___ 02:10PM BLOOD Neuts-91.7* Lymphs-3.0* Monos-4.6 Eos-0.6
Baso-0.1
___ 02:10PM BLOOD ___ PTT-24.6* ___
___ 02:10PM BLOOD Glucose-92 UreaN-24* Creat-1.0 Na-138
K-3.5 Cl-100 HCO3-22 AnGap-20
___ 02:10PM BLOOD ALT-23 AST-34 AlkPhos-132* TotBili-0.4
___ 02:31PM BLOOD Lactate-1.6 K-4.6
OTHER PERTINENT LABS:
================
___ 05:40AM BLOOD WBC-15.5* RBC-3.85* Hgb-11.5* Hct-35.2*
MCV-92 MCH-29.9 MCHC-32.7 RDW-13.7 Plt ___
___ 05:40AM BLOOD UreaN-20 Creat-0.6 Na-139 K-3.9 Cl-104
HCO3-26 AnGap-13
MICROBIOLOGY:
==========
Blood culture - ___ - NGTD after 48 hours
C. dif - Obtained at ___ prior to tx to
___ - POSITIVE
IMAGING:
======
KUB ___
There is a nonobstructive bowel gas pattern. Evidence of hiatal
hernia containing bowel and stomach partially imaged. Blunting
of the left costophrenic angle is again noted. There is lumbar
levoscoliosis and multi-level degenerative changes along the
spine. Partially imaged is a right hip prosthesis. IMPRESSION:
No evidence of bowel obstruction. No dilated loops of bowel
to suggest megacolon.
CXR PA/LAT ___
Evidence of a large diaphragmatic, hiatal hernia is again seen
with intrathoracic stomach and loops of bowel. There is slight
blunting of the left costophrenic angle and there may be trace
pleural effusion. Retrocardiac opacity likely relates to large
hiatal hernia with associated atelectasis. Underlying
consolidation is not excluded although felt less likely.
CXR PA/LAT ___:
There is a prominent air-filled have a circular opacity
corresponding to a
hiatal hernia best seen on CT dated ___. There is
relatively low
lung volumes with basilar atelectasis. No other parenchymal
consolidation is
seen. No pneumothorax or definite pleural effusion is seen.
IMPRESSION:
Low lung volumes with basilar atelectasis.
Brief Hospital Course:
___ F with hx of atrial fibrillation (no longer on
anticoagulation ___ vaginal and GI bleeding), diastolic CHF with
EF of 50-55%, prior NSTEMI, history of cervical cancer status
post radiation, recurrent UTI s/p multiple courses abx tx, right
hip repair in ___ presenting with diarrhea from assisted living
facility, found to be positive for C.difficile.
ACUTE ISSUES:
==========
# Clostridium Difficile colitis:
Recent hospitalization and antibiotic exposure (especially oral
cephalosporin) w/ elevated white count in conjunction w/
diarrhea, concerning for C diff infection. Outside records
obtained and patient found to be C. DIF POSITIVE. Prior to
admission, patient took Immodium x 2, and since that time had no
further diarrhea until ___ AM. In the interim, no
indication of acute abdomen or any sign of toxic megacolon.
Flagyl contraindicated due to QTc prolongation with amiodarone,
and she is likely to fail treatment on flagyl due to healthcare
exposures and specific resistance patterns of C.diff since she
lives in assisted living.
-Placed on oral vancomycin 125mg PO QID (started ___ for
total of ___ischarged on this regimen.
-Held Pantoprazole as per pharmacy (in context of C. dif), and
asked to restart 48 hours after completing abx
-At time of discharge tolerating PO fluids/food, though appetite
very poor and needs assistance for feedings. Speech/swallow WNL.
# Hiatal Hernia/Hypoxia:
Patient has oxygen saturation in low ___, and xrays show lung
volume restriction. This is likely ___ hiatal hernia with
kyphosis contributing to restrictive lung disease. No evidence
pneumonia on repeat CXR. Important to maintain upright
positioning and assist patient with meals. In addition, acid
suppression as necessary as an outpatient.
# UTI:
Urine culture from ___ showed pan-sensitive E.coli, which
has grown in the last 3 urine cultures from ___. She
received a full 7 day course of antibiotics - cefpodoxime
transitioned to IV ceftriaxone 1g q24h. This course was started
on ___ and discontinued on ___. No dysuria,
hematuria, hesitancy, frequency during hospitalization.
# L wrist pain. On ___ pt had acute onset L wrist pain w/
mild erythema and swelling, ortho attempted tap w/o success,
XRay w/ chondrocalcinosis; picture c/w pseudogout. No
intervention as NSAIDs contraindicated in this pt with CHF and
did not want to give steroids. Pt placed in splint to rest
joint, improved overnight, swelling and erythema resolved by
time of discharge.
# CHF:
History of dCHF, and remained hypo- to euvolemic and
asymptomatic during hospitalization. Continued spironolactone,
assessed fluid status daily. Was discharged euvolemic with no
indication of volume overload.
# A-fib: Not on anticoagulation secondary to recurrent bleeding.
Flipped between afib with RVR and NSR ___. Spoke to outpatient
cardiologist (Dr. ___ who recommended increasing dose of
amiodarone x 4 days. Gave 200mg extra dose ___ and converted
into sustained NSR.
- continue increased dose of 400mg amio x 3 days
- At discharge continued normal amiodarone dose of 200mg daily.
Chronic Issues:
==========
#Hypertension - Stable during hospitalization with outpatient
meds continued.
#Macular degeneration - Stable. Further management as
outpatient.
#Hard of hearing - Stable. Further management as outpatient.
# Transitional Issues:
- Important to follow up with PCP ___ 2 weeks of discharge
- Patient needs assistance with meals due to weakness/
deconditioning, and PO intake should be encouraged
- Vancomycin started ___ late ___ - with goal for full 14
day course. Will provide prescription for remainder of course as
outpatient
- Consider further investigation of minimally invasive repairs
or palliation for severe hiatal hernia
- re-address goals of care
# Code Status: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO QAM
2. Spironolactone 25 mg PO 3X/WEEK (___)
3. Pantoprazole 40 mg PO Q12H
4. Vitamin D ___ UNIT PO BID
5. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500
mg)-800 unit oral daily
6. Multivitamins 1 TAB PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
Discharge Medications:
1. AMIODARONE 400mg PO QAM x 2 days (___) then Amiodarone
200 mg PO QAM
2. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
3. Multivitamins 1 TAB PO DAILY
4. Spironolactone 25 mg PO 3X/WEEK (___)
5. Vitamin D ___ UNIT PO BID
6. Pantoprazole 40 mg PO Q12H
7. Vancomycin Oral Liquid ___ mg PO/NG Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours
Disp #*32 Capsule Refills:*0
8. Acetaminophen 650 mg PO TID
9. Caltrate-600 + D Vit D3 (800) (calcium carbonate-vitamin D3)
600 mg(1,500mg) -800 unit oral daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Clostridium Difficile Colitis
Urinary Tract Infection
left wrist pseudogout
Secondary:
chronic diastoic Congestive Heart Failure
Atrial fibrillation with rapid ventricular response
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
You were admitted to ___ due to
severe diarrhea and weakness. During your admission it was found
that you have an infection called Clostridium Difficile (C.
Diff) which is a bacterium common in patients who have recently
been prescribed antibiotics. You were treated with a medication
called Vancomycin which improved your diarrhea. You were able to
eat and drink and pass regular bowel movements, and so you were
discharged to a rehab facility. After discharge it is important
to continue your Vancomycin course to ensure that your infection
fully resolves. While in the hospital you also completed your
full course of antibiotics for your urinary tract infection.
It has been a pleasure caring for you here at ___ and we wish
you all the best!
Kind regards,
Your ___ Team
Followup Instructions:
___
|
10302979-DS-6 | 10,302,979 | 25,610,512 | DS | 6 | 2200-06-04 00:00:00 | 2200-06-05 07:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ T2DM, CAD (s/p ___, HFpEF, Afib c/b SSS (s/p PPM, on
Coumadin), HTN, PVD, CKD with recent admission for mechanical
fall w/ left hallus toe
fracture and nail avulsion who is presenting with confusion and
fever and found to have complicated cystitis.
Of note, patient recently admitted to ___
___ for mechanical fall with left great toe fracture
and nail avulsion. Discharged on Keflex and completed a 10-day
course. No operative treatment was done for this injury and he
was placed in a surgical shoe. Due to the elongation of his L
hallux nail, his podiatrist deemed it appropriate to remove it
in order to prevent any further injuries. The left hallux nail
bed was exposed and the podiatrist believed that the wound was
in good condition.
While at rehab (___ of ___; ___
he's had intermittent somnolence and confusion. Was also
endorsing urinary symptoms with incontinence. Developed fever
to 102 so was referred to ___ ER.
While in the ER, labs notable for leukocytosis and bacteriuria.
Podiatry evaluate patient who felt that the toe was unlikely a
source of infection. Received IV unasyn in ER. Patient
transitioned to ceftriaxone for complicated cystitis on arrival
to the floor.
This morning, patient states that he is scared. He is unaware
of where he is or why he is in the hospital. Reports that he
has been feeling "unwell" recently but is unable to recount the
history. On review of symptoms, he endorses polyuria and
burning with urination. Also endorses fatigue and generalized
malaise. No foot pain but has underlying neuropathy. States
that his lower extremities are more edematous than normal. No
orthopnea
or PND. No cough.
Further history was obtained from the patient's daughter,
___, over the phone. Per ___, the patient has not
seemed himself over the last week. Usually very oriented but
over the last week while at rehab he has been more somnolent and
confused. Had also had episodes of urinary incontinence. Given
the fever, he was referred to the ___ ER.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative less otherwise noted in the HPI.
Past Medical History:
diabetes type II
CAD with MI at ___, s/p PCI with DES to pLAD in ___
(cardiac
cath showed collateralized total occlusion of the RCA and an 80%
proximal LAD lesion)
congestive heart failure - diastolic HFpEF
Afib on coumadin c/b sick sinus *s/p PPM ___ EnPulse)
hypertension
ankle sprain
hyperlipidemia
obesity
peripheral vascular disease
psoriasis
chronic kidney disease
urinary frequency
atrial fibrillation
neuropathy and weakness
sessile serrated adenoma
blister
S/p Rt carotid endarterectomoy in ___
Cataracts, left s/p removal
Social History:
___
Family History:
- Mother had diabetes. MI in her ___.
- Father had diabetes and emphysema. MI in his ___.
- Brother has CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS:98.2 PO 116 / 75 81 18 95 Ra
GENERAL: Pleasant, lying in bed comfortably, tearful and
anxious
CARDIAC: Regular rate and rhythm, holosystolic murmur RLSB,
rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, +suprapubic tenderness,
nondistended, no hepatomegaly, no splenomegaly
EXT: Warm, well perfused, 3+ pitting edema to shins, L hallux
nail bed is exposed, no erythema, no purulent drainage, no
exposed bone
NEURO: Alert, oriented to person only, CNs grossly intact,
moving all four extremities
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM:
GENERAL: Pleasant and overweight Caucasian gentleman, sitting up
in bed comfortably, no acute distress.
CARDIAC: RRR, holosystolic murmur best heard at the right upper
sternal border, no murmurs, gallops, or rubs
LUNG: CTAB
ABD: Normal bowel sounds. Abdomen is soft, nontender to
palpation, nondistended. No rebound or guarding.
EXT: Warm, well perfused, trace pitting edema to ankles
bilaterally, left hallux with dressing c/d/I. Patient still
with slightly swollen second and third digits on the right,
thumb and second digit on the left; erythema and tenderness
palpation of virtually resolved at this point.
NEURO: A&Ox3, CNs grossly intact, moving all four extremities.
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABORATORY STUDIES
=========================================
___ 08:44PM BLOOD WBC-19.8* RBC-3.39* Hgb-10.1* Hct-30.9*
MCV-91 MCH-29.8 MCHC-32.7 RDW-17.5* RDWSD-58.9* Plt ___
___ 08:44PM BLOOD Neuts-83.8* Lymphs-6.8* Monos-7.7
Eos-0.3* Baso-0.2 Im ___ AbsNeut-16.63* AbsLymp-1.34
AbsMono-1.53* AbsEos-0.05 AbsBaso-0.03
___ 08:44PM BLOOD Plt ___
___ 09:40AM BLOOD ___ PTT-37.4* ___
___ 08:44PM BLOOD Glucose-132* UreaN-49* Creat-1.7* Na-140
K-4.9 Cl-104 HCO3-21* AnGap-15
___ 09:40AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.2
___ 08:51PM BLOOD %HbA1c-6.6* eAG-143*
___ 09:40AM BLOOD CRP-289.9*
___ 08:50PM BLOOD Lactate-1.7
___ 08:51PM BLOOD %HbA1c-6.6* eAG-143*
___ 03:26AM BLOOD CRP-293.8*
___ 09:40AM BLOOD CRP-289.9*
DISCHARGE LABORATORY STUDIES
=========================================
___ 03:35AM BLOOD WBC-11.9* RBC-3.59* Hgb-10.3* Hct-32.1*
MCV-89 MCH-28.7 MCHC-32.1 RDW-16.9* RDWSD-54.8* Plt ___
___ 05:30AM BLOOD WBC-10.7* RBC-3.41* Hgb-9.9* Hct-30.6*
MCV-90 MCH-29.0 MCHC-32.4 RDW-17.0* RDWSD-55.7* Plt ___
___ 06:10AM BLOOD WBC-14.4* RBC-3.73* Hgb-10.6* Hct-32.9*
MCV-88 MCH-28.4 MCHC-32.2 RDW-16.9* RDWSD-54.7* Plt ___
___ 09:40AM BLOOD Neuts-86.0* Lymphs-4.5* Monos-7.2
Eos-0.4* Baso-0.2 Im ___ AbsNeut-21.99* AbsLymp-1.15*
AbsMono-1.85* AbsEos-0.09 AbsBaso-0.06
___ 03:35AM BLOOD ___ PTT-28.3 ___
___ 05:30AM BLOOD ___ PTT-28.4 ___
___ 03:35AM BLOOD Glucose-163* UreaN-80* Creat-1.6* Na-141
K-4.5 Cl-100 HCO3-28 AnGap-13
___ 05:30AM BLOOD Glucose-167* UreaN-82* Creat-1.6* Na-141
K-4.6 Cl-99 HCO3-27 AnGap-15
___ 04:00PM BLOOD Glucose-234* UreaN-79* Creat-2.2* Na-137
K-4.4 Cl-95* HCO3-26 AnGap-16
___ 03:35AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.4
IMAGING/REPORTS
=========================================
CXR:
Retrocardiac patchy opacity is likely atelectasis, though early
infection is not excluded in the correct clinical setting.
TOE XRAY
No definite radiographic evidence for osteomyelitis. Soft
tissue swelling
diffusely about the great toe without soft tissue gas. If there
is continued concern for osteomyelitis MRI with contrast would
be a more sensitive examination.
Radiology:
___ WRIST XR:
1. A 4 mm ossific density along the dorsal aspect of the left
carpus may represent sequelae of prior injury or a dystrophic
calcification. No evidence of acute fracture.
2. Multiple rounded and a single amorphous focus calcification
in the region of the right second metacarpal head are better
evaluated on the concurrent hand radiographs and appear
unchanged. Differential diagnosis remains the same.
3. Moderate osteoarthritis of the left thumb CMC, MCP, and IP
joints.
___ L HAND XR:
1. Multiple small rounded and a single amorphous calcific
density in proximity to the head of the right second metacarpal
appears similar to ___. No other similar foci are
seen. Differential remains the same.
2. Erosive changes with overhanging edges along the ulnar aspect
of the left small finger middle phalanx appears similar to ___. No other definite erosions are identified.
Differential remains same.
3.Scattered osteoarthritic changes.
4. Questionable soft tissue swelling along the ulnar aspect of
the distal left ulna.
___ B FINGERS XR:
1. Soft tissue swelling about both the right index finger left
small finger.
2. Erosion in the distal ulnar aspect of the middle phalanx of
the left small finger--the differential diagnosis includes a
gouty erosion versus osteomyelitis. No associated calcified
tophus identified. Compared with left hand radiographs from ___, this erosion is new.
3. No other erosions detected.
4. Osteoarthritis
of the left small finger and right index finger DIP joints.
Aside from mild non-specific periosteal new bone formation about
the proximal phalanx of the right index finger, no features
specific for psoriatic arthritis identified.
5. Multiple small loose bodies adjacent to the second metacarpal
joint, question loose bodies within the joint (Question synovial
osteochondromatosis, as there is no significant MCP joint
osteoarthritis) versus loose bodies in the surrounding soft
tissues. Though these are not definitely phleboliths, the
differential could include a vascular malformation.
6. Faint non-specific calcification radial to the second
metacarpal head without bone erosion is non-specific, but soft
tissue calcification due to gout is not entirely excluded.
MICROBIOLOGY
=========================================
___ 8:44 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed fecal flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL. PREDOMINATING
ORGANISM.
INTERPRET RESULTS WITH CAUTION.
Piperacillin/Tazobactam test result performed by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
Brief Hospital Course:
BRIEF SUMMARY
=============
___ w/ T2DM, CAD (s/p ___, HFpEF, Afib c/b SSS (s/p PPM, on
Coumadin), HTN, PVD, CKD with recent admission for mechanical
fall w/ left hallux toe fracture and nail avulsion who presented
to ___ with confusion and fever and found to have complicated
cystitis. Course complicated by gout.
ACTIVE ISSUES
=============
#) COMPLICATED CYSTITIS
Patient presented with confusion, dysuria, and fever and found
to have bacteriuria consistent with complicated cystitis. No CVA
tenderness to suggest pyelonephritis. Initially started on IV
CTX (___). Found to have pseudomonal UTI, so the patient was
transitioned to oral ciprofloxacin and completed a course of
7-day course (last day ___.
#) Acute POLYARTICULAR GOUT
Patient was noted to have painful red right index MCP and PIP
joints and left pinky DIP joint. Rheumatology performed bedside
aspirate of left ___ digit which revealedfrank chalky material,
positive for crystals. Given joint fluid consistent with crystal
arthropathy (gout) and patient was started on prednisone taper
with continued improvement in symptoms. On discharge, he was
continued on Prednisone taper and allopurinol 50mg daily, with
plan for rapid pred taper to try to limit potential delirium and
side effects from prednisone.
#) DELIRIUM
Has had waxing and waning mental status in the setting of
complicated cystitis. Thought to be secondary to delirium and
improved with treatment of UTI. Improved back to baseline by
hospital day 2.
#) LEFT HALLUX WOUND
Patient had recent mechanical fall with left hallux toe fracture
with nail avulsion. Evaluated by podiatry during admission.
Appears to be healing well without signs of infection.
# CHRONIC DIASTOLIC HEART FAILURE and # ACUTE KIDNEY INJURY on
CHRONIC KIDNEY DISEASE
Patient was noted to have ___ with Cr up to 2.2 along with
relative hypotension and decreased weight to 250 lbs, below his
previously estimated dry weight of 255lb. His home torsemide was
thus reduced from 60mg BID to 60mg once daily. His kidney
function improved with Cr 1.6 on discharge and he remained
euvolemic on exam on this reduced dose of diuretic. He will need
close outpatient follow up for volume exam given recent decrease
in his maintenance diuretic regimen. His home lisinopril was
briefly held in the setting of above, but was resumed prior to
discharge.
CHRONIC ISSUES
==============
#) ATRIAL FIBRILLATION: Initially with supratherapeutic INR,
then continued warfarin and metoprolol.
#) T2DM: ISS while inpatient
#) NEUROPATHY: held gabapentin in the setting of AMS. Resumed
prior to discharge.
TRANSITIONAL ISSUES
==================================
[ ] MEDICATION CHANGES:
- Added: Prednisone taper, allopurinol
--> Prednisone: Received 40 mg daily ___, 30 mg daily
___
--> Home prednisone taper: 30 mg daily ___, 20 mg daily
___, 10 mg ___, 5 mg ___ and every day following
- Changed: Torsemide (60 mg daily, was 60 mg BID)
[ ] FOLLOW UP LABS:
- Re-check uric acid in ___ weeks (___), with goal level
below 6.
- Patient should have INR checked on ___ and warfarin
adjusted accordingly. He follows ___ clinic.
- Please check A1C at follow up. Pt did require insulin during
hospitalization with steroid use for gout flare.
[ ] HEART FAILURE:
- Discharge weight: Weight on ___, 107.8 kg 237.65 lbs
- Discharge creatinine: 1.6
- Discharge diuretic: Torsemide 60mg daily
# CONTACT: ___ (___) ___
# CODE: Full, confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 5 mg PO 3X/WEEK (___)
2. Torsemide 60 mg PO BID
3. Lisinopril 5 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Aspirin 81 mg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Metoprolol Succinate XL 300 mg PO DAILY
9. Fleet Enema (Saline) 1 Enema PR ONCE
10. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
11. Bisacodyl 10 mg PR QHS:PRN constipation
12. Warfarin 7.5 mg PO 4X/WEEK (___)
13. Gabapentin 100 mg PO QAM
14. Gabapentin 200 mg PO QHS
Discharge Medications:
1. Allopurinol 50 mg PO DAILY
RX *allopurinol ___ mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*0
2. PredniSONE 40 mg PO DAILY Duration: 1 Dose
For ___.
This is dose # 1 of 4 tapered doses
RX *prednisone 10 mg 3 tablet(s) by mouth daily (see
instructions) Disp #*30 Tablet Refills:*0
3. PredniSONE 30 mg PO DAILY Duration: 3 Doses
___
This is dose # 2 of 4 tapered doses
Tapered dose - DOWN
4. PredniSONE 20 mg PO DAILY Duration: 3 Doses
___.
This is dose # 3 of 4 tapered doses
Tapered dose - DOWN
5. PredniSONE 10 mg PO DAILY Duration: 3 Doses
___.
This is dose # 4 of 4 tapered doses
Tapered dose - DOWN
6. PredniSONE 5 mg PO DAILY
Starting ___. Maintenance dose after steroid taper completes.
This is the maintenance dose to follow the last tapered dose
7. Torsemide 60 mg PO DAILY
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 80 mg PO QPM
11. Bisacodyl 10 mg PR QHS:PRN constipation
12. Gabapentin 200 mg PO QHS
13. Gabapentin 100 mg PO QAM
14. Lisinopril 5 mg PO DAILY
15. Metoprolol Succinate XL 300 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Vitamin D 400 UNIT PO DAILY
18. Warfarin 7.5 mg PO 4X/WEEK (___)
19. Warfarin 5 mg PO 3X/WEEK (___)
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
- complicated cystitis
- toxic metabolic encephalopathy
- Gout
SECONDARY:
- Heart failure with reduced ejection fraction
- Chronic kidney disease
- Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted
because of your fever and you were found to have a urinary tract
infection. You were treated with an antibiotic.
While in the hospital, you were also noted to have a lot of
swelling and pain in your hands. Our joint doctors
("rheumatologists") sampled your joint fluid using a needle and
saw evidence of a disease called "gout." They gave you a
medicine to calm down the swelling ("prednisone"), which you
will take in gradually decreasing doses, and a medicine to
prevent gout from developing again ("allopurinol"). Please
follow up with the Rheumatologists as scheduled below.
Finally, your blood pressure was slightly low after a few days
in the hospital. We decreased your water pill ("torsemide") to
prevent you from getting too dry. The new dose is 60 mg of
torsemide daily (it was twice per day before).
It is important for you to continue taking your medications as
prescribed and to follow up with your doctors ___ below for
your upcoming appointments).
Prednisone taper:
Take 30 mg daily ___, Take 20 mg daily ___, Take 10 mg
___, 5 mg ___ and every day following until you have your
rheumatology appointment.
We also started you on a new medicine called allopurinol to help
reduce future gout attacks.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10303040-DS-15 | 10,303,040 | 28,605,983 | DS | 15 | 2198-05-13 00:00:00 | 2198-05-13 18:42:00 |
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 ___ male with history of
metastatic lung adenocarcinoma to the brain s/p WBRT s/p 4
cycles
of ___ now on pemetrexed maintenance who presents
with left leg swelling and pain.
Patient reports pain in his left calf and swelling for the past
1
week. Pain with any active extension or flexion of his left
foot.
Patient reports an episode of syncope in the context of
shortness
of breath about 3 weeks ago. No recent syncope during the past
week but did feel dizzy which resolved spontaneously 4 days ago.
He notes intermittent chest pain. He has mild shortness of
breath. He also has had mild abdominal pain. Patient was
supposed
to go to ___ for his son's wedding but had to cancel the
trip
at the airport due to the pain in his leg. Per mother, patient
has had overall failure to thrive, general malaise, and is
requesting an admission that she does not feel he is managing
well at home.
On arrival to the ED, initial vitals were 98.1 89 124/70 16 99%
RA. Exam notable for left leg swelling, calf tenderness to
palpation, and positive ___ sign. Labs were notable for WBC
10.7, H/H 12.6/38.3, Plt 135, INR 1.2, Na 140, K 4.0, BUN/Cr
___. Left lower extremity ultrasound showed extensive
occlusive left lower extremity deep vein thrombosis. Head CT
showed overall stable brain mets without evidence of
intracranial
hemorrhage. CTA chest showed right segmental pulmonary emboli
and
increase in size of pulmonary metastases. Patient was not
started
on anticoagulation. Prior to transfer vitals were 98.5 82 112/61
16 93% RA.
On arrival to the floor, patient reports mild headache and ___
abdominal pain. He denies fevers/chills, night sweats, headache,
vision changes, weakness/numbness, cough, hemoptysis,
palpitations, nausea/vomiting, diarrhea, hematemesis,
hematochezia/melena, 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:
- ___: Developed fatigue and headaches which gradually became
worse. Also had occasional confusion.
- ___: Presented to OSH where head CT showed multiple
brain
masses and he was transferred to ___. He was seen by
neurosurgery and there was no role for surgical intervention.
- ___: Underwent biopsy of right sided lung nodule by ___.
Path showed adenocarcinoma.
- ___: WBRT
- ___: ___ C1D1
- ___: ___ C2D1
- ___: Treatment held due to ___ esophagitis and patient
admitted to hospital for poor PO intake.
- ___: ___ C3D1
- ___: ___ C4D1
- ___: pemetrexed maintenance C1
- ___: pemetrexed maintenance C2
- ___: CT torso with stable disease; pemetrexed maintenance
C3
- ___: Hold treatment given fatigue thought related to
chemotherapy.
PAST MEDICAL HISTORY:
- Lung Cancer, as above
- COPD
- HLD
- hernia
- Myofascial pain syndrome with shoulder and back pain, seen in
pain clinic
- Neck injury with L hand numbness after a fall down a flight of
stairs in ___
- s/p C3-5 cervical spine fusion in ___ at ___
- s/p right sided hernia repair x 2
Social History:
___
Family History:
Father passed away of lung cancer at age ___.
Mother is in her ___ in good health. Grandmother had "bone"
cancer and passed away in her ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 97.9, BP 113/73, HR 84, RR 18, O2 sat 88% RA.
GENERAL: Fatigue-appearing man, flat affect, in no distress,
lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, diffuse tenderness without rebound or guarding,
non-distended, positive bowel sounds.
EXT: Warm, well perfused, left leg swelling and tenderness ot
palpation.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAM:
VS: Temp 98.7, BP 112/72 , HR 80, RR 18, O2 sat 93 RA.
GENERAL: NAD
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, diffuse tenderness without rebound or guarding,
non-distended, positive bowel sounds.
EXT: Warm, well perfused, left leg swelling and tenderness ot
palpation.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
Pertinent Results:
Admission Labs:
===============
___ 10:30PM BLOOD WBC-10.7* RBC-4.20* Hgb-12.6* Hct-38.3*
MCV-91 MCH-30.0 MCHC-32.9 RDW-13.0 RDWSD-42.8 Plt ___
___ 10:30PM BLOOD Neuts-56.3 Lymphs-17.8* Monos-10.2
Eos-13.3* Baso-0.9 Im ___ AbsNeut-6.02 AbsLymp-1.90
AbsMono-1.09* AbsEos-1.42* AbsBaso-0.10*
___ 10:30PM BLOOD ___ PTT-28.7 ___
___ 10:30PM BLOOD Glucose-99 UreaN-11 Creat-0.6 Na-140
K-4.0 Cl-99 HCO3-26 AnGap-15
___ 10:30PM BLOOD ALT-89* AST-58* LD(LDH)-495* AlkPhos-183*
TotBili-0.3
___ 10:30PM BLOOD cTropnT-<0.01
___ 10:30PM BLOOD proBNP-53
___ 10:30PM BLOOD Albumin-4.2 Calcium-10.1 Phos-4.3 Mg-1.9
Discharge Labs:
===============
___ 07:55AM BLOOD WBC-9.5 RBC-4.41* Hgb-13.3* Hct-39.6*
MCV-90 MCH-30.2 MCHC-33.6 RDW-12.7 RDWSD-41.5 Plt ___
___ 07:55AM BLOOD ___ PTT-31.4 ___
___ 07:55AM BLOOD Glucose-88 UreaN-14 Creat-0.7 Na-140
K-3.8 Cl-98 HCO3-26 AnGap-16
___ 07:55AM BLOOD ALT-96* AST-49* AlkPhos-199* TotBili-0.3
___ 07:55AM BLOOD Calcium-10.1 Phos-3.7 Mg-2.0
Imaging:
========
___ CTA CHEST:
1. Right upper and lower lobe segmental pulmonary emboli. No
evidence of
right heart strain.
2. Interval worsening of right middle and lower lobe masses with
more proximal
obstruction of the right middle lobe bronchus resulting in
atelectasis and
post obstructive pneumonia.
3. Increased size of a precarinal lymph node. Stage T3
vertebral metastasis.
___ MR ___ & W/O CONT:
1. Diffuse bone metastasis throughout the thoracic and lumbar
spine is
identified.
2. No evidence of spinal cord compression. There is cortical
expansion of
tumor from the T10 vertebral body into the epidural space
without significant
spinal canal narrowing. No high-grade neural foraminal
narrowing.
3. Additional findings as described above.
___ MR ___ &W/O CONTR:
1. Diffuse bone metastasis throughout the thoracic and lumbar
spine is
identified.
2. No evidence of spinal cord compression. There is cortical
expansion of
tumor from the T10 vertebral body into the epidural space
without significant
spinal canal narrowing. No high-grade neural foraminal
narrowing.
3. Additional findings as described above.
___ SKELETAL SURVEY:
AP pelvis and femurs: No lytic or blastic lesions are
identified. A lesion in the right femoral neck seen on previous
CT scan from ___ is not visible on this x-ray
study. Clips are seen within the pelvis. Thoracic and lumbar
spine: Several sclerotic lesions are seen in the thoracic spine,
confirmatory of the MRI from the same day. There is also a
sclerotic lesion within the L5 vertebral body. This is also
seen to better advantage on the MRI examination. Degenerative
changes are evident. Postoperative changes are noted in the
cervical spine.
Humeri: No lytic or blastic lesions are identified.
Degenerative changes are evident involving the left glenohumeral
joint.
Lateral skull x-ray: No lytic or blastic lesions are identified.
The patient is edentulous.
Brief Hospital Course:
___ tobacco smoker with h/o COPD, chronic facila pain syndrome
and s/p neck vertebral fusion surgery s/p ___ trauma who
presented to OSH (___) with headaches, confusion and
personality changed of 3 weeks duration and had head CT which
demonstrated "Multiple prominent areas of parenchymal
hypodensity involving the gray and white matter in the right
frontoparietal right frontal, right temporal and left frontal
regions, suggesting vasogenic edema. Superimposed subacute
infarctions cannot be excluded. 2: There is also suggestion of
possible hyperdense mass lesion in the right temporoparietal
region, worrisome for neoplasm". Referred to ___ ED where he
was afebrile and hemodynamically stable but with sinus
bradycardia. MRI brain showed multiple enhancing intracranial
lesions involving both cerebral cortices highly concerning for
metastatic disease and c/b vasogenic edema and midline shift to
the left. Admitted to medicine where he was managed with PO
dexamethasoneand prophylactic po levetiracetam following IV
loads as well as home PO oxycodone and IV PRN hydromorphone for
pain control. Underwent CT chest which was notable for 5 lung
nodules ranging from 6 mm to 2.5 cm in diameter any one of which
could be a primary bronchogenic carcinoma, but the number could
suggests metastases from an extrathoracic primary malignancy. CT
abd/pelvis did not show obvious primary but did show omental fat
stranding and diffuse mild omental thickening, without masses,
but which likely represent metastatic disease. Underwent ___
guided biopsy of right pulmonary nodule on ___ which he
tolerated well. Cytology of brushing was negative for malignant
cells and biopsy results are pending at discharge. Patient was
reviewed by oncology who provided guidance about their plan for
ongoing post d/c follow-up and their contact details.
Problems Summary
- suspected Brain metastases per MRI
- right lung nodule per CT chest: likley primary lung cancer,
biopsy pending.
- omental stranding/thickening per CT abdomen: ? metastatic
disease
- right inguinal seroma at site of previous inguinal hernia
repair
- Sinus Bradycardia: ___ intracranial process/increased ICP? no
other signs of ___ reflex. Rate on previous ECG from ___
is 57
- hyperglycemia: no known history of DM. likely ___ to high-dose
steroids. Was put on conservative ISS but did not require
insulin doses.
- headaches - ___ to brain lesions
- cognitive impairment - ___ brain lesions. Per OT review during
this admission has "evident impairments in attention, memory,
and executive
function. At this time, recommend pt d/c home w/ direct
supervision for IADLs (medication management, cooking, community
integration).". Patient was ambulating independently throughout
admission and had no acute ___ needs.
- mild leukocytosis: ___ high dose steroids.
Chronic:
- h/o TOBACCO USE: on nicotine patches during this admission.
- chronic head aches
- HLD
Patient was discharged with the following plan:
- patient's wife to provide direct supervision for IADLs
(medication management, cooking, community integration).
- continue PO oxycodone 20mg Q6H:PRN home regimen + PO
hydromorphone PRN ___ records reviewed prior to discharge)
- continue PO dexamethasone 4 mg q 6 hours
- continue keppra 1g BID
- continue nicotine patches
- continue ensure enlive TID and MVI with minerals
- f/u with oncology who will follow-up on lung biopsy results
and coordinate further care as needed including engagement of
neuro-onc/rad-onc/neurosurgery as necessary.
- continue to address goals of care following with tissue biopsy
results and as part of the big-picture prognosis discussion once
diagnosis confirmed. Code status presumed full during this
admission and not discussed.
- consider outpatient cognitive neurology consult to further
assess cognition, per oncology and PCP discretion
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dexamethasone 2 mg PO DAILY
2. Diazepam 5 mg PO BID:PRN pain
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. FoLIC Acid 1 mg PO DAILY
5. LevETIRAcetam 1000 mg PO Q12H
6. Morphine SR (MS ___ 60 mg PO Q12H
7. Omeprazole 40 mg PO BID
8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
9. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
10. Senna 8.6 mg PO BID:PRN constipation
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
12. Tamsulosin 0.4 mg PO QHS
13. Vitamin D ___ UNIT PO DAILY
14. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain -
Moderate
15. Celecoxib 200 mg oral BID
16. MethylPHENIDATE (Ritalin) 10 mg PO BID
17. Mirtazapine 30 mg PO QHS
18. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Enoxaparin Sodium 60 mg SC Q12H
RX *enoxaparin 60 mg/0.6 mL 0.6 mL SC every twelve (12) hours
Disp #*60 Syringe Refills:*0
2. Morphine SR (MS ___ 60 mg PO Q8H
RX *morphine 60 mg 1 capsule(s) by mouth three times a day Disp
#*90 Capsule Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 30 mg 1 tablet(s) by mouth q4h PRN Disp #*70
Tablet Refills:*0
4. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
5. Dexamethasone 2 mg PO DAILY
6. Diazepam 5 mg PO BID:PRN pain
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. FoLIC Acid 1 mg PO DAILY
9. LevETIRAcetam 1000 mg PO Q12H
10. MethylPHENIDATE (Ritalin) 10 mg PO BID
11. Mirtazapine 30 mg PO QHS
12. Omeprazole 40 mg PO BID
13. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
14. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
15. Senna 8.6 mg PO BID:PRN constipation
16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
17. Tamsulosin 0.4 mg PO QHS
18. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Deep Vein Thrombosis
Pulmonary Embolism
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 ___ with leg swelling and shortness of
breath. You were found to have a blood clot in your left leg and
both lungs. You were started on a blood thinner called lovenox
to treat this and prevent future blood clots. Please continue to
take this.
Your pain regimen was also increased so that you can take up to
30mg of oxycodone every 4 hours as needed for pain. You will
also be taking the long-acting MS ___ three times a day
instead of twice a day. We have confirmed with your pharmacy
that these changes will not be too expensive, but please notify
your primary medical team immediately if you are having any
issues obtaining your medications. Lastly, you will need to stop
taking Celebrex (celecoxib) because it interacts with Lovenox.
Please follow up with all appointments as listed below.
It was a pleasure taking care of you,
Your ___ Oncology Team
Followup Instructions:
___
|
10303054-DS-18 | 10,303,054 | 29,172,819 | DS | 18 | 2184-03-10 00:00:00 | 2184-03-11 18:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ man with a family history of
polycystic ___ disease who presents with 10 days of
intermittent hematuria.
On ___ he passed what appeared to be blood clots while
urinating. He drank a lot of water and had no further episodes
until ___, when he had another two episodes, which also resolved
with hydration. He then did well until the morning of ___, when
he developed bloody urine again, with a total of 4 episodes. No
increase in frequency of urination, no dysuria. No fevers,
chills, abdominal pain, bowel symptoms, vomiting, or penile
discharge. No history of testicular torsion or pain, STDs, new
strenous activity. He is sexually active but no new partners.
Family history significant for PKD in mother, uncle, and
grandfather. Not on any medications, no new allergies.
He recently lost 50-60 lbs from exercise and diet.
Of note, patient was seen in ED in ___ with probable
nephrolithiasis. U/S at that point demonstrated multiple cysts
and
Cr was 1.8. Pt was treated conservatively for nephrolithiasis
and had
no follow up.
In the ED, initial vitals: 97.4 83 169/90 16 100% RA
Labs were significant for H/H 8.9/27.5, HC03 16, Cr/BUN 8.2/116,
and UA with >180 RBCs, 100 protein, and 23 WBCs.
CT abdomen/pelvis showed bilateral renal cysts, no
nephrolithiasis or hydronephrosis. Renal ultrasound showed
innumerable, mostly simple bilateral renal cysts, no definitive
calculi or hydronephrosis.
Vitals prior to transfer: 98.2 86 198/98 18 99% RA
Currently, he is eating and drinking well for the first time
today, with no nausea or vomiting. He denies any pain, headache,
or dizziness, and said he had a clear urine right before
transfer to the floor.
ROS:
+ per HPI
No fevers, chills, night sweats. No changes in vision or
hearing, no changes in balance. No cough, no shortness of
breath, no dyspnea on exertion. No chest pain or palpitations.
No nausea or vomiting. No diarrhea or constipation. No dysuria.
No hematochezia, no melena. No numbness or weakness, no focal
deficits.
Past Medical History:
presumed renal stone, ___
Testicular cyst
Broke his hand--had 3 screws placed
Adenoids removed
Social History:
___
Family History:
Mother, maternal ___, maternal grandfather with polycystic
___ disease
Mother had a ___ transplant at ___ yo, dx was at ___ yo.
Maternal uncle with transplant in his late ___
Brother with no known hx of ___ disease.
No berry aneurysms in family.
On father's side, history of leukemia and lung cancer.
Physical Exam:
ADMISSION EXAM:
VS: 97.9 72 169/70 18 100%RA
GEN: Alert, sitting up in chair, talking to his father, no acute
distress
HEENT: Moist mucus membranes, anicteric sclerae, no conjunctival
pallor
NECK: Supple without LAD
PULM: CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended.
BACK: no CVA tenderness
EXTREM: Warm, well-perfused, no edema
NEURO: Pupils 4mm and symmetric, reactive to light; extra-ocular
movements intact, face symmetric, gait normal.
DISCHARGE EXAM:
Vitals: 98.6 97.6 76 148/76 (148-169/70-79) 18 100%RA
General: alert, oriented, interactive, no acute distress
HEENT: Moist mucus membranes, anicteric sclerae, no conjunctival
pallor
PULM: CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, obese, non-tender, non-distended.
BACK: no CVA tenderness
EXTREM: Warm, well-perfused, no edema
NEURO: Pupils 4mm and symmetric, reactive to light; extra-ocular
movements intact, face symmetric, gait deferred.
Pertinent Results:
==============
PERTINENT LABS
==============
___ 10:11PM GLUCOSE-98 UREA N-114* CREAT-8.3* SODIUM-140
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-20* ANION GAP-19
___ 10:17PM freeCa-0.87*
___ 02:50PM ALBUMIN-4.4 CALCIUM-6.8* PHOSPHATE-6.6*
MAGNESIUM-1.6
___ 02:50PM OSMOLAL-324*
___ 02:50PM CRP-3.7
___ 02:50PM C3-121 C4-39
___ 02:50PM WBC-6.9 RBC-3.29*# HGB-8.9*# HCT-27.5*#
MCV-84 MCH-27.1 MCHC-32.4 RDW-13.4 RDWSD-41.1
___ 02:50PM NEUTS-63.4 ___ MONOS-8.9 EOS-2.6
BASOS-0.6 IM ___ AbsNeut-4.39 AbsLymp-1.67 AbsMono-0.62
AbsEos-0.18 AbsBaso-0.04
___ 02:15PM URINE HOURS-RANDOM CREAT-60 SODIUM-47
POTASSIUM-29 CHLORIDE-52 CALCIUM-0.7 PHOSPHATE-22.0
MAGNESIUM-2.3 TOTAL CO2-<5
___ 02:15PM URINE OSMOLAL-303
___ 01:00PM URINE COLOR-Red APPEAR-Hazy SP ___
___ 01:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
___ 01:00PM URINE RBC->182* WBC-23* BACTERIA-FEW
YEAST-NONE EPI-0
___ 07:53AM BLOOD WBC-6.3 RBC-3.32* Hgb-8.8* Hct-27.7*
MCV-83 MCH-26.5 MCHC-31.8* RDW-13.3 RDWSD-40.4 Plt ___
___ 07:53AM BLOOD ALT-17 AST-15 LD(LDH)-288* CK(CPK)-1594*
AlkPhos-58 TotBili-0.2
___ 07:53AM BLOOD calTIBC-263 VitB12-355 Hapto-241*
Ferritn-366 TRF-202
___ 07:53AM BLOOD TSH-1.6
___ 07:53AM BLOOD PTH-296*
===============
IMAGING
===============
CT Ab/Pel ___:
1. No acute CT findings in the abdomen or pelvis.
2. Trace tree in ___ nodularity in the left lower lobe,
nonspecific either
infectious or inflammatory.
3. Innumerable bilateral renal cysts seen keeping with
polycystic ___
disease. Some of the cysts are mildly complex with layering
debris and focal peripheral calcification. No nephrolithiasis
or hydronephrosis.
Renal U/S ___:
1. Innumerable, primarily simple, bilateral renal cysts,
consistent with
polycystic ___ disease.
2. No definitive renal calculi or hydronephrosis.
Brief Hospital Course:
___ is a ___ man with a family history of PKD in his
mother, uncle, and grandfather, who presented with hematuria and
___, consistent with ADPKD complicated by possible cyst rupture
or acute tubular necrosis.
# Acute-on-chronic ___ injury: Given family history, renal
cysts, elevated Cr, hematuria, and proteinuria, this is likely
cyst rupture or ATN in the setting of underlying ADPKD. There
were no signs of glomerulonephritis, renal stones, or bladder
pathology. Patient had numerous labs sent to determine if there
was another insult in addition to underlying polycystic kidneys
given the rapidity of progression of his disease (a few years).
In setting of exercise, weight loss and elevated CK to 1500, it
is possible that rhabdomyolysis was a contributing factor though
patient gave no report of other symptoms that would be
consistent with a history of rhabdo. He continued to maintain
good fluid intake with great urine output this admission and
reported no symptoms of fatigue, volume overload or uremia. He
was started on calcium carbonate 1250 mg TID, vitamin D 1000
units daily, sevelamer 800 mg TID. Creatinine remained elevated
to ~8. Two post void residual checks were ~42cc suggesting that
no element of obstruction was contributing to this process.
Patient would like to follow up with ___ Nephrology for
further care. He was instructed to get labs this coming week
and to go to ___ clinic with Dr. ___ on ___.
# Acidosis: Anion gap acidosis with concurrent non anion gap
acidosis
Likely ___ to renal failure. Urine tox screen was negative.
# Hypertension: likely ___ CKD. He was asymptomatic. We started
him on amlodipine 5mg on discharge.
# Anemia, Likely due CKD with low epo. Less likely blood loss
from hematuria. He was asymptomatic and did not require
transfusion.
TRANSITIONAL ISSUES
# We encouraged him to get his brother screened for ADPKD
# New medications: calcium carbonate 1250 mg TID, vitamin D 1000
units daily, sevelamer 800 mg TID, and amlodipine 5mg daily
# Patient to get labs next week to be sent for review to Dr.
___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Calcium Carbonate 1250 mg PO TID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth three times a day Disp #*90 Tablet Refills:*3
2. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate [___] 800 mg 1 tablet(s) by mouth
TID with meals Disp #*90 Tablet Refills:*3
3. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
4. Vitamin D 1000 UNIT PO DAILY
RX *cholecalciferol (vitamin D3) 1,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*3
5. Outpatient Lab Work
Please check Chem10, CBC, CK and send results to Attn: Dr.
___: ___ Fax ___. ICD9 code
___.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Autosomal dominant polycystic ___ disease, Type 1
Acute ___ injury
Chronic ___ disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came into the hospital for ~10 days of blood in your urine.
We did a number of tests on your urine and blood, and got both a
CT scan and an ultrasound of your kidneys. All of these tests
confirmed that you have autosomal dominant polycystic ___
disease, like your mother, uncle, and grandfather. We started
you on medications to supplement your calcium and vitamin D
levels, to reduce your phosphorus levels (sevelamer), and to
treat your blood pressure (amlodipine). You will need very close
follow-up with your ___ doctor going forward. We also
recommend that you encourage your brother to get screened for
this condition as soon as possible.
You will be discharged with a prescription to get your labs
checked next week. Please ensure that this is done next week.
You may go to any lab as the results should be forwarded to Dr.
___.
It was a pleasure to take care of you, and we wish you all the
best.
-Your ___ care team
Followup Instructions:
___
|
10303080-DS-18 | 10,303,080 | 29,055,641 | DS | 18 | 2170-05-09 00:00:00 | 2170-05-10 19:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril / IV Dye, Iodine Containing Contrast Media /
vancomycin
Attending: ___.
Chief Complaint:
Foot Ulcer
Major Surgical or Invasive Procedure:
Debridement of left foot first metatarsal and proximal phalanx
History of Present Illness:
Patietn seen and examined agree with house officer admission
note by Dr. ___ ___ with additions below
___ year old Male with Type 2 diabetes complicated by diabetic
retinopathy, diabetic neuropathy, and recurrent foot infections
who presents with worsening of an ulcer on his Left foot. In
___ he underwent left foot surgery on his ___ metatarsal head
with secondary closure of wound performed by Dr. ___. He
has had slow wound healing since that time, although without
fevers, frank discharge, pain or erythema. On the day prior to
admission he noticed his left foot was more swollen and
erythematous. He took some Keflex he had at home and went to
bed. The morning of admission it continued to look worse. He
reports no new drainage at the site, although he has yellow or
bloody drainage on his bandages daily. He denies any pain on his
foot, but noticed a malodorous smell around the area. He usualy
changes the bandages on his foot each day and applies betadine.
He currently is ambulating with crutches.
In the ED, his exam was notable for ulceration on the left foot.
Labs notable for WBC 9.6, neutrophils 79.8, and lactate 1.2 The
patient underwent an xray which showed no evidence of
osteomyelitis. The xray demonstrated: Post-surgical changes
involving the left first metatarsal head and a large plantar
soft tissue defect on the lateral view. He received zosyn and
vancomycin in the ED. He noticed soon after the vancomycin
infusion he began to feel very itchy and called the staff over.
He was found to have welts/hives(?) on his arms, so the
vancomycin infusion was stopped. He was seen by podiatry who
recommened IV antibiotics and daily wound dressing changes with
betadine.
Currently, the patient denies any pain from his foot or ulcer.
He reports minimal drainage from his ulcer/bandage site. He
denies fevers, chills, nightsweats, changes in energy or
appetite.
Past Medical History:
-Benign Hypertension
-Hyperlipidemia
-Type 2 Diabetes - retinopathy, neuropathy, and persistent
difficulties with foot ulcerations
-Anemia
-Obesity
-PVD
---Right BK POP-DP BPG and Rt ___ met head resection (___)
---I&D Rt ___ met head ulcer and balloon angioplasty of graft
(___)
---Left BK pop-pedal and left toe amputation (___)
---suspected occlusion of left graft, with plan for angiogram
Social History:
___
Family History:
Pt does not know history of mother or father.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VSS: 98.1, 168/63, 74, 18, 96%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE, 4cm erythematous incision on Left Foot, no eschar or
frank pus
NEURO: CAOx3, Motor ___ ___ Spread
DISCHARGE PHYSICAL EXAM:
VS - Tm/c 98.3 BP 146-172/57-64 HR 66 RR 16 99%RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, MMM, OP clear
NECK - supple
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - LLE with cast in place left foot to just below
left knee
SKIN - scattered seborhhic keratoses on back and cherry angiomas
on chest
NEURO - awake, A&Ox3
Pertinent Results:
ADMISSION LABS
___ 06:25AM BLOOD WBC-8.5 RBC-3.89* Hgb-10.3* Hct-30.3*
MCV-78* MCH-26.4* MCHC-33.8 RDW-16.4* Plt ___
___ 11:10AM BLOOD WBC-9.6 RBC-4.13* Hgb-10.7* Hct-32.4*
MCV-78* MCH-26.0* MCHC-33.1 RDW-16.6* Plt ___
___ 11:10AM BLOOD Neuts-79.8* Lymphs-14.0* Monos-3.3
Eos-2.5 Baso-0.3
___ 06:25AM BLOOD Glucose-199* UreaN-21* Creat-0.9# Na-140
K-3.3 Cl-98 HCO3-32 AnGap-13
___ 11:20AM BLOOD Lactate-1.2
DISCHARGE LABS
___ 05:23AM BLOOD WBC-10.4 RBC-3.92* Hgb-10.3* Hct-31.0*
MCV-79* MCH-26.3* MCHC-33.3 RDW-16.7* Plt ___
___ 05:23AM BLOOD Glucose-231* UreaN-27* Creat-1.0 Na-137
K-3.7 Cl-97 HCO3-34* AnGap-10
MICROBIOLOGY
___ 2:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:35 pm SWAB Source: left foot woud.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
STAPH AUREUS COAG +. RARE GROWTH. OF TWO COLONIAL
MORPHOLOGIES.
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----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 1:10 pm TISSUE LEFT ___ METATARSAL HEAD.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 350-2638N ___.
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # ___ ___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
IMAGING
FOOT AP,LAT & OBL LEFT Study Date of ___ 11:15 AM
IMPRESSION:
1. Post-surgical changes involving the left first metatarsal
head. Although post-operative radiographs since the last
debridement are not available, indistinct bony borders,
fragmentation, and focal demineralization are concerning for
osteomyelitis. A large plantar soft tissue defect is depicted
on the lateral view.
2. Linear opacity overlying the third toe proximal phalanx,
likely a foreign body within the soft tissues, unchanged
compared to the prior study from ___.
MRI LEFT FOOT ___:
IMPRESSION: Osteomyelitis of the first metatarsal as well as
the base of the first proximal phalanx. Inflammation of the
soft tissues surrounding the amputated metatarsal head as
described above, with associated skin ulcer along the plantar
aspect- of the foot. No drainable fluid collections to suggest
abscess.
Brief Hospital Course:
___ year old gentleman with h/o of type 2 diabetes complicated by
diabetic retinopathy, neuropathy, and persistent foot infections
presenting with acute worsening of an ulcer on his L foot, found
to have osteomyelitis of ___ metatarsal and ___ proximal
phalanx.
ACTIVE ISSUES
1. Osteomyelitis: The patient was started on empiric
antibiotics for cellulitis and suspected osteomyelitis upon
admission. He received 1 dose each of linezolid and cefepime,
and then was started on ampicillin-sulbactam on ___. The
foot ulcer was cultured and grew Group B streptococcus as well
as coagulase positive, methicillin-sensitive staphylcococcus
aureus. An MRI of the foot was performed which showed
osteomyelitis, and the patient was taken to the OR for
debridement and deep tissue culture by the Podiatry service on
___. Infectious diseases was consulted for antibiotic
management and agreed with coverage by ampicillin-sulbactam
pending final cultures. Deep tissue cultures revealed the same
organisms as above, and the patient was switched to nafcillin 2g
q4h per ID recommendations for a total course of 6 weeks. A
PICC line was placed, and the patient was discharged. He
remained afebrile and without signs of systemic infection
throughout the admission. Blood cultures remained negative.
Baseline ESR and CRP were drawn to be followed for improvement
as an outpatient. The patient will follow up with Podiatry in 1
week after admission and with ID in the ___ clinic in 2 weeks.
2. Type 2 Diabetes: The patient's diabetes is uncontrolled with
complications, including diabetic retinopathy and neuropathy.
He was initially started on his home regimen of Lantus 43 units
qhs and Humalog 8 units QAC, but due to uncontrolled blood
glucose levels (elevated to high 300s at times throughout
admission), his Lantus was titrated up to 50 units qhs and
Humalog was titrated to 20 units qac with SSI. The
hyperglycemia was likely caused, in part, by his acute
infection. He was discharged on this new insulin regimen and
will follow up with his primary physician for further
adjustments.
3. Rash: The patient was found to have multiple erthematous
papules covalesecing into plaques on the gluteal fold.
Differential diagnosis includes inverse psorias vs eczema. He
was empirically treated with topical Clobetasol Propionate 0.05%
Ointment. He was scheduled for a follow up appointment with
Dermatology as an outpatient.
CHRONIC ISSUES
1. Chronic Diastolic Congestive heart failure: the patient's
last echocardiogram ___ showed the left atrium was
moderately dilated, with mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). The patient was continued on his home carvedilol 25
mg BID and torsemide 20 mg BID. CHF was stable throughout the
admission.
2. Coronary artery disease: Stable during admission. Home
aspirin 81 mg and atorvastatin 80 mg were continued.
3. Hypertension: Stable during admission. Home torsemide 20 mg
BID was continued.
TRANSITIONAL ISSUES
1. The patient has a PICC line placed in his left arm and will
receive IV nafcillin q4h for 6 weeks. He received teaching from
___ prior to discharge. The PICC should be removed upon
completion of antibiotic course. He will follow up with ID in
the ___ clinic in 2 weeks for management.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. Torsemide 20 mg PO BID
6. Potassium Chloride (Powder) 10 mEq PO DAILY
Hold for K >4.8
7. Lantus *NF* (insulin glargine) 43 units Subcutaneous qhs
8. NovoLOG *NF* (insulin aspart) SSI Subcutaneous daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Carvedilol 25 mg PO BID
4. Ferrous Sulfate 325 mg PO DAILY
5. Torsemide 20 mg PO BID
6. Potassium Chloride (Powder) 10 mEq PO DAILY
Hold for K >4.8
7. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
apply to gluteal fold
RX *clobetasol 0.05 % 1 application twice a day Disp #*1 Tube
Refills:*0
8. Glargine 50 Units Bedtime
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
Humalog 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
RX *heparin lock flush 10 unit/mL 2mL Line flush Disp #*100 Unit
Refills:*0
10. NovoLOG *NF* (insulin aspart) ___ UNITS SUBCUTANEOUS DAILY
according to sliding scale as above
11. Lantus *NF* (insulin glargine) 50 units SUBCUTANEOUS QHS
12. Nafcillin 2 g IV Q4H Duration: 6 Weeks
RX *nafcillin in D2.4W 2 gram/100 mL 2 grams every 4 hours Disp
#*504 Gram Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Osteomyelitis
Secondary: Diabetes mellitus, Congestive heart failure,
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance with crutches
Discharge Instructions:
It was a pleasure to participate in your care at ___. You
were admitted to the hospital because of your left foot ulcer.
You were treated with antibiotics. A biopsy of your bone was
performed by the podiatry service and a portion of infected bone
was removed. Cultures were obtained from the deep tissues
during surgery. Your wound continued to improve and was closed
with sutures. A PICC line was placed so that you can receive IV
antibiotics outside of the hospital. You remained stable and
were discharged home.
You will be treated with the IV antibiotic nafcillin through
your PICC line for 6 weeks. A visiting nurse ___ show you how
to set up the infusion. You will follow up with the Infectious
Disease department as well as Podiatry for care of the ulcer.
Followup Instructions:
___
|
10303080-DS-22 | 10,303,080 | 23,544,559 | DS | 22 | 2176-02-29 00:00:00 | 2176-02-29 17:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril / IV Dye, Iodine Containing Contrast Media /
vancomycin / Nafcillin
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
R groin HD line ___
R IJ Temp HD Line placement ___
Kidney biopsy ___
Tunneled dialysis placement ___
History of Present Illness:
___ w/ a history of DMII, CHF, CAD, PVD, anemia, foot ulcers,
BPH presenting with worsening shortness of breath found to be in
renal failure and hyperkalemia, admitted for emergent HD.
He was recently seen by PCP ___ ___, when he had polyarthralgia
felt to be from gout. He had Cr checked at that time, which was
normal at 1.1. Therefore, allopurinol started. Additionally, he
was started on nabumetone, an NSAID. Three days later, his wife
tested positive for the flu, and so he reached out to his PCP
for ___ prescription given that there is a newborn in the
house.
Since that time, he has felt well until the past ___ days, when
he reports chills, cough, productive sputum, and loose stools.
Additionally, he has noticed ___ days of dyspnea with exertion,
orthopnea, lower extremity swelling, and 20 pound weight gain.
His dry weight is 275 lbs, and he reports being close to 300
lbs. He also reports decreased PO intake and anuria for 48
hours. No chest pain, palpitations, lightheadedness, nausea,
vomiting, or myalgias. He called his PCP's and cardiologist's
offices, who referred him to the ED.
Past Medical History:
DIABETES TYPE II
DIABETIC NEUROPATHY
DIABETIC NEPHROPATHY
CORONARY ARTERY DISEASE
ANEMIA
CONGESTIVE HEART FAILURE
HYPERLIPIDEMIA
HYPERTENSION
OBESITY
ONYCHOMYCOSIS
PERIPHERAL VASCULAR DISEASE
DIABETIC RETINOPATHY
Social History:
___
Family History:
His mother died in her ___s. HIs father died at about ___ of an
aneurysm. He had type II diabetes. He has a brother and sister,
both of whom have type II diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP to mandible while sitting upright
LUNGS: Decreased at the bases bilaterally
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Distended, soft, non-tender, no rebound tenderness or
guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, 2+ edema to the thighs
SKIN: No rash
NEURO: No gross motor or coordination abnormalities
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: NAD, A/Ox3.
HEENT: NC/AT, anicteric sclera, neck supple, unable to
appreciate
JVD.
RESPIRATORY: CTABL.
CARDIAC: Distant, S1S2 w/o m/r/g.
ABDOMEN: Soft, NT, ND, +BS.
GU: Foley in place, scant brown urine with visible sediment
draining.
EXTREMITIES: Warm, 1+ edema to knees, bilateral foot ulceration
w/ dressing clean.
Pertinent Results:
ADMISSION LABS
==============
___ 03:06PM BLOOD WBC-13.3* RBC-3.16* Hgb-8.0* Hct-25.7*
MCV-81* MCH-25.3* MCHC-31.1* RDW-15.7* RDWSD-46.9* Plt ___
___ 03:06PM BLOOD Neuts-87.1* Lymphs-6.1* Monos-5.9
Eos-0.1* Baso-0.2 Im ___ AbsNeut-11.60* AbsLymp-0.81*
AbsMono-0.79 AbsEos-0.01* AbsBaso-0.02
___ 05:52AM BLOOD ___ PTT-26.6 ___
___ 03:06PM BLOOD Glucose-310* UreaN-106* Creat-6.0*#
Na-130* K-7.5* Cl-91* HCO3-17* AnGap-22*
___ 05:52AM BLOOD ALT-9 AST-8 AlkPhos-93 TotBili-0.8
___ 03:06PM BLOOD ___
___ 03:06PM BLOOD cTropnT-0.04*
___ 10:14PM BLOOD Calcium-8.2* Phos-7.9* Mg-2.8*
___ 10:14PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 06:52PM BLOOD ___ pO2-22* pCO2-44 pH-7.36
calTCO2-26 Base XS--1
___ 03:12PM BLOOD Lactate-2.1* K-7.3*
___ 06:12AM BLOOD freeCa-1.07*
MICROBIOLOGY
============
__________________________________________________________
___ 4:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 3:40 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:06 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
STUDIES
=======
Renal US ___ IMPRESSION:
1. Echogenic renal cortices consistent with medical renal
disease.
2. No hydronephrosis or nephrolithiasis.
3. Small bilateral pleural effusions.
CXR ___ IMPRESSION:
Moderate pulmonary edema. Superimposed consolidation of the
left lung base is difficult to exclude.
TTE ___
The left atrial volume index is mildly increased. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with hypokinesis
of the inferolateral wall. The remaining segments contract
normally (LVEF = 50-55 %).Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with mild regional systolic dysfunction.
Temp IJ Line Placement ___
Successful placement of a right internal jugular approach double
lumen
temporary dialysis catheter. The line is read to use.
CXR ___
In comparison with the study of ___, there has been
placement a a
large-bore IJ catheter that extends to the mid to lower SVC. No
evidence of post procedure pneumothorax. Again there is
enlargement of the cardiomediastinal silhouette with moderate
pulmonary vascular congestion and small bilateral pleural
effusions with compressive basilar atelectasis bilaterally. In
the appropriate clinical setting, it would be difficult to
unequivocally exclude superimposed aspiration/pneumonia,
especially in the absence of a lateral view.
DISCHARGE LABS
==============
___ 07:45AM BLOOD WBC-9.9 RBC-2.97* Hgb-7.7* Hct-25.1*
MCV-85 MCH-25.9* MCHC-30.7* RDW-17.2* RDWSD-52.9* Plt ___
___ 07:45AM BLOOD Glucose-172* UreaN-27* Creat-4.4*# Na-139
K-4.4 Cl-96 HCO3-28 AnGap-15
___ 05:35AM BLOOD ALT-7 AST-7 LD(LDH)-164 AlkPhos-90
TotBili-0.4
___ 07:45AM BLOOD Calcium-8.4 Phos-4.8* Mg-2.2
Brief Hospital Course:
SUMMARY FOR ADMISSION:
=======================
Mr. ___ is a ___ with dCHF, CAD, PVD, IDDM, anemia, foot
ulcers and BPH who presented with worsening DOE, found to be in
new acute renal failure complicated by hyperkalemia.
ISSUES:
=======
# Acute renal failure:
The patient initially presented with new acute renal failure,
with prior known baseline Cr of 1.1. Patient had a right femoral
line placed and was urgently started on hemodialysis given
volume overloaded and electrolyte abnormalities including
hyperkalemia in the ICU. Nephrology was consulted and an
extensive work-up was unrevealing except for a marginally low C3
level @ 53. The patient did report on admission that he had
suffered a gout flare prior to admission and was taking
nabumetone prior to presentation. He was also accidentally
taking more NSAIDs than prescribed because he had switched his
medications and had gotten confused. Still, he was not taking
excessive NSAIDs. However, given no known etiology of his renal
disease, the working theory was NSAID nephropathy. He
experienced no renal recovery and became near anuric
(~100cc/day). He ultimately underwent renal biopsy ___ which
unfortunately was a poor sample and ultimately given limited
cortical material precluded a definitive diagnosis (see report
in d/c summary). A repeat biopsy was discussed but decided
against given that it was very unlikely that it would change
treatment. A tunneled line was placed and the patient will
continue dialysis as an outpatient with the ultimate hope of
renal recovery. He will start dialysis ___ at ___
___ dialysis (confirmed).
# Acute on Chronic HFpEF:
Patient has a known history of HFpEF and was on torsemide at
home. He presented to the hospital with acute on chronic
diastolic heart failure exacerbation the setting of new renal
failure with a BNP > 11K. TTE showed mild symmetric left
ventricular hypertrophy with mild regional systolic dysfunction.
Torsemide was held given renal function and further fluid status
was managed w/ HD w/ resolution of dyspnea.
# Hypertension:
The patient is on carvedilol and losartan at home and these were
held on admission given degree of renal failure. He was thus
started on labetalol for BP control but had stably elevated
pressures so was isosorbide dinitrate + hydralazine. This
regimen was titrated for a goal of < 130-140 and we will
continue this upon discharge. We will continue to hold losartan
for renal protection in hopes of renal recovery. We will also
continue to hold carvedilol as it is BID dosing and all of his
BP medications will now be TID (labetalol as well as
hydralazine-isosorbid). He will have further titration per
outpatient PCP/nephrologist.
# Anemia:
Patient presented with acute-on-chronic anemia of unclear
etiology. He had no active bleeding. Hemolysis labs were
negative. Iron studies were consistent with iron deficiency so
he was initiated on iron replacement therapy. Also initiated EPO
w/ HD.
-TI: Repeat colonoscopy (had 1 in ___ w/ recommendation for
repeat ___.
# IDDM:
___ diabetes was consulted and actively managed the patient's
regimen. He will transition his diabetes care from his PCP to
___ upon discharge. He was provided with glucometer, test
strips and lancets upon discharge; please see medication list
for insulin regimen.
# CAD:
Continued ASA + clopidogrel. ASA was held in the pre-biopsy &
post-biopsy period but was resumed ___ and will be resumed upon
discharge.
# Polyarticular gout:
Continued on allopurinol w/ renal dosing. ___ he complained of
multiple painful joints thought to be representative of an acute
gout flare. He was given a course of prednisone ___ w/
resolution of symptoms.
# Glaucoma:
-Continue home eye drops.
TRANSITIONAL ISSUES:
====================
# ESRD:
[] Initiated ___ HD with R tunneled HD line. Should he not
demonstrate renal recovery, would plan for further access per
outpatient nephrology team.
# HTN:
[] Carvedilol and losartan held on d/c given hope for renal
recovery and TID dosing for labetalol and hydralazine-isosorbide
dinitrate for ease of dosing. Further titration per PCP and
nephrologist.
# Anemia:
[] Iron studies most consistent w/ iron-deficiency anemia.
Started iron supplementation. Also receiving EPO w/ HD. Please
re-check periodically.
[] Please check CBC at next PCP ___.
# IDDM:
[] Will follow w/ ___. Discharge regimen: 34U glargine QAM,
10U novalog @ breakfast, 8U novalog @ lunch, 6U novalog @
dinner, w/ sliding scale.
#CODE: FULL CODE
#CONTACT: ___
> 30 minutes was spent on discharge planning and coordination
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. Torsemide 40 mg PO DAILY
3. Torsemide 20 mg PO QPM
4. Allopurinol ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Carvedilol 25 mg PO BID
7. Atorvastatin 80 mg PO QPM
8. Nabumetone 750 mg PO BID
9. Finasteride 5 mg PO DAILY
10. Glargine 72 Units Bedtime
Discharge Medications:
1. BiDil (isosorbide-hydralazine) ___ mg oral Q8H
Take 2 pills every 8 hours.
RX *isosorbide-hydralazine [BiDil] 20 mg-37.5 mg 2 tablet(s) by
mouth three times a day Disp #*180 Tablet Refills:*3
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE TID
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
4. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*3
5. FreeStyle Lancets (lancets) 28 gauge miscellaneous W/ MEALS
& BEFORE BED
RX *lancets [FreeStyle Lancets] 28 gauge Check finger sticks
with meals and at bedtime. Check finger sticks with meals and at
bedtime Disp #*100 Each Refills:*0
6. FreeStyle Lite Meter (blood-glucose meter) 1 miscellaneous
W/ MEALS
RX *blood-glucose meter [FreeStyle Lite Meter] Check finger
sticks with meals and at bedtime Check finger sticks with meals
and at bedtime Disp #*1 Kit Refills:*0
7. FreeStyle Lite Strips (blood sugar diagnostic) 120
miscellaneous W/ MEALS & AT BEDTIME
RX *blood sugar diagnostic [FreeStyle Lite Strips] Check finger
sticks with meals and at bedtime Check finger sticks with meals
and at bedtime Disp #*100 Strip Refills:*0
8. Labetalol 600 mg PO TID
RX *labetalol 300 mg 2 tablet(s) by mouth three times a day Disp
#*180 Tablet Refills:*3
9. sevelamer CARBONATE 1600 mg PO TID W/MEALS
RX *sevelamer carbonate 800 mg 2 tablet(s) by mouth three times
a day Disp #*180 Tablet Refills:*3
10. travoprost 0.004 % ophthalmic (eye) QHS
11. Allopurinol ___ mg PO EVERY OTHER DAY
12. Glargine 34 Units Breakfast
Novalog 10 Units Breakfast
Novalog 8 Units Lunch
Novalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
13. Aspirin 81 mg PO DAILY
14. Atorvastatin 80 mg PO QPM
15. Finasteride 5 mg PO DAILY
16. HELD- Carvedilol 25 mg PO BID This medication was held. ___
not restart Carvedilol until instructed by your physician.
17. HELD- Losartan Potassium 25 mg PO DAILY This medication was
held. ___ not restart Losartan Potassium until instructed by your
physician.
18. HELD- Torsemide 40 mg PO DAILY This medication was held. ___
not restart Torsemide until instructed.
19. HELD- Torsemide 20 mg PO QPM This medication was held. ___
not restart Torsemide until instructed.
20.Rolling Walker
Diagnosis: osteoarthritis ICD 715.9x
Prognosis: Good
Length of Need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
=================
Acute kidney injury/acute renal failure
Hyperkalemia
Pulmonary edema
Acute on chronic diastolic heart failure
Urinary tract infection
Polyarticular gout flare
Secondary Diagnoses
===================
Coronary artery disease
Diabetes mellitus, type II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you in the hospital!
WHY WERE YOU ADMITTED?
-You came to the hospital because you had difficulty breathing.
WHAT HAPPENED WHEN YOU WERE HERE?
-You were found to have kidney failure and were started on
hemodialysis urgently in the intensive care unit to ___ the work
of your kidneys.
-We did a kidney biopsy. The results were still not totally
clear on why your kidneys failed. You talked with the kidney
doctors about repeating a biopsy but we ultimately decided to
not ___ this because this will not change the management of your
disease.
-You got dialysis every few days to ___ the work of your kidneys.
-You were followed by the diabetes doctors to ___ control your
blood sugars.
WHAT SHOULD YOU ___ YOU GO HOME?
-Please continue taking all of your medications as prescribed.
-Keep all of your appointments as scheduled.
-You should weigh yourself every morning at the same time
wearing the same thing. If you gain more than ___ pounds in 1
day, this may mean that you are collecting too much fluid on
your body. If this happens, you should call your doctor.
-___ stick to a low potassium diet (see the handouts we've
given you). Also stick to less than 1.5-2 liters of fluid per
day. Doing these things will help your kidneys not become too
stressed.
-___ medical attention if you have new or concerning symptoms
or you develop.
We wish you the very best!
Your ___ Care Team
Followup Instructions:
___
|
10303080-DS-23 | 10,303,080 | 27,887,382 | DS | 23 | 2176-07-04 00:00:00 | 2176-07-04 20:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril / IV Dye, Iodine Containing Contrast Media /
vancomycin / Nafcillin
Attending: ___
Chief Complaint:
shortness of breath, lower extremity edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx CKD recently off HD,
T2DM, CAD, ?___, HTN who was referred to ED from his PCP's
office with dyspnea and worsening pedal edema.
Of note the patient was admitted to ___ ___ for ESRD +
hyperkalemia and was initiated on HD. He was then maintained on
HD until about 3 weeks ago when he was informed by his
outpatient
nephrologist, Dr. ___ because "he was making more urine
on his own, and his numbers were improving" he would no longer
need dialysis. For the past week, he reports increasing ___ edema
and about a 20 lb weight gain. He also reports gradually
worsening fatigue and leg pain/SOB upon exertion (with the leg
pain limiting his ability to exert himself moreso than the SOB).
He also reports sleeping on 4 pillows at home which has been
stable for some time. He has a LLE wound (followed by podiatry)
that he says has also been weeping for the last few days since
In the ED, initial VS were: 97.2 79 116/42 20 99% RA
Labs showed:
-H/H 8.2/26.5, WBC 9.6, plt 213
-Na 139, K 5.6, Cl 104, HCO3 22, BUN 40, Cr 1.7
-Ca 9.0,
-Trop 0.02
-proBNP: ___
-___: 13.8 PTT: 27.3 INR: 1.3
Imaging showed:
CXR: Relatively low lung volumes. Pleural effusions. Moderate
pulmonary edema.
Patient received: 40 mg IV lasix
On arrival to the floor, patient endorses the history above. He
says he feels like he has gradually been putting on weight since
being taken of home and notes that he thinks his dose of Lasix
"isn't enough" even though he notes peeing "a good amount"
daily.
He has otherwise been in his USOH and denied any HA, blurred
vision, CP, abdominal pain, n/v/d, constipation, or urinary
symptoms.
Past Medical History:
DIABETES TYPE II
DIABETIC NEUROPATHY
DIABETIC NEPHROPATHY
CORONARY ARTERY DISEASE
ANEMIA
CONGESTIVE HEART FAILURE
HYPERLIPIDEMIA
HYPERTENSION
OBESITY
ONYCHOMYCOSIS
PERIPHERAL VASCULAR DISEASE
DIABETIC RETINOPATHY
Social History:
___
Family History:
His mother died in her ___. HIs father died at about ___ of an
aneurysm. He had type II diabetes. He has a brother and sister,
both of whom have type II diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: 98.1 177 / 43 69 92 Ra
GENERAL: Elderly M sitting comfortably in bed, obese
HEENT: NCAT, MMM
NECK: Supple, JVP to angle of mandible w/ pressure on RUQ
CV: RRR, no m/r/g
PULM: Crackles to mid-lung fields bilaterally, diminished breath
sounds at bases
GI: Obese, soft, NT/ND, BS+
EXTREMITIES: Pitting edema up thighs and w/ some pre-sacral
edema
NEURO: AAOx3, grossly intact
DERM: LLE w/ dressing in place over ___ toe w/ some serous
drainage
DISCHARGE PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ 1155)
Temp: 98.5 (Tm 100.0), BP: 134/52 (124-152/52-69), HR: 65
(64-68), RR: 18 (___), O2 sat: 94% (94-96), O2 delivery: Ra,
Wt: 259.92 lb/117.9 kg
I/Os: Fluid Balance (last updated ___ @ 531)
Last 8 hours Total cumulative -625ml
IN: Total 0ml
OUT: Total 625ml, Urine Amt 625ml
Last 24 hours Total cumulative -735ml
IN: Total 540ml, PO Amt 540ml
OUT: Total 1275ml, Urine Amt 1275ml
GENERAL: NAD, sitting up in bed.
NECK: JVP not visualized sitting upright.
CV: RRR, no m/r/g.
PULM: Slightly diminished breath sounds at the bases, no wheezes
rales or ronchi.
EXTREMITIES: trace edema to mid-shin RLE, 1+ pitting edema to
mid-shin LLE.
NEURO: AAOx3, moving all 4 extremities spontaneously and
purposefully.
Pertinent Results:
ADMISSION LABS:
==============
___ 07:05PM BLOOD WBC-9.6 RBC-3.21* Hgb-8.2* Hct-26.5*
MCV-83 MCH-25.5* MCHC-30.9* RDW-17.5* RDWSD-52.6* Plt ___
___ 07:05PM BLOOD Neuts-81.0* Lymphs-11.5* Monos-5.0
Eos-2.0 Baso-0.1 Im ___ AbsNeut-7.78* AbsLymp-1.10*
AbsMono-0.48 AbsEos-0.19 AbsBaso-0.01
___ 07:05PM BLOOD ___ PTT-27.3 ___
___ 07:05PM BLOOD Glucose-200* UreaN-40* Creat-1.7* Na-139
K-5.6* Cl-104 HCO3-22 AnGap-13
___ 07:05PM BLOOD Calcium-9.0 Phos-4.0 Mg-1.9
___ 07:05PM BLOOD proBNP-8487*
___ 07:05PM BLOOD cTropnT-0.02*
___ 03:05AM BLOOD CK-MB-3 cTropnT-0.02*
PERTINENT LABS/MICRO/IMAGING:
============================
___ 08:00AM BLOOD %HbA1c-8.3* eAG-192*
___ CXR:
Relatively low lung volumes. Pleural effusions. Moderate
pulmonary edema.
___ Doppler LLE:
No evidence of deep venous thrombosis in the left lower
extremity veins.
DISCHARGE LABS:
===============
___ 06:55AM BLOOD WBC-9.1 RBC-2.93* Hgb-7.6* Hct-23.4*
MCV-80* MCH-25.9* MCHC-32.5 RDW-18.4* RDWSD-53.4* Plt ___
___ 06:55AM BLOOD Glucose-46* UreaN-52* Creat-1.9* Na-144
K-4.1 Cl-101 HCO3-27 AnGap-16
___ 06:55AM BLOOD Calcium-8.7 Phos-4.6* Mg-1.8
Brief Hospital Course:
PATIENT SUMMARY:
================
Mr. ___ is a ___ year-old male with a PMHx of CKD recently
off HD, T2DM, CAD, HFpEF, and HTN who presents with acute on
chronic HFpEF and hypertensive urgency with SBP to 200 on
admission. He was diuresed with boluses of IV lasix and when
euvolemic was transitioned to PO torsemide. He was started on
amlodipine and hydralazine for better BP control. His course was
complicated by uncontrolled blood sugars into the 300s, for
which ___ was consulted and his insulin regimen was
optimized.
ACUTE ISSUES:
=============
#Acute on Chronic HFpEF:
Patient with a history of HFpEF with last TTE ___
demonstrating mild regional systolic dysfunction but preserved
EF and no evidence of diastolic dysfunction. He had been on HD
until about 3 weeks prior to admission when his nephrologist
took him off HD due to improvement in renal function (initial
indication was acute renal failure, hospitalized here ___. Since then he has been on 40mg PO lasix daily with
reported good adherence. He patient presented with worsening
dyspnea and lower extremity edema, appeared volume overloaded on
exam with elevated JVP, lung sounds diminished at the bases, and
pitting edema. BNP was elevated to 8000 and trops 0.02->0.02.
CXR showed pleural effusions and moderate pulmonary edema.
Trigger uncertain, but likely a combination of elevated BP
(patient was not consistently taking labetalol at home) vs.
inadequate diuretic dose vs. worsening renal function (though Cr
stable here and making good urine). He diuresed well to boluses
of IV lasix, and once euvolemic was transitioned to PO torsemide
40mg daily with Cr remaining stable throughout. He was continued
on his home labetalol 600mg TID, and was started on amlodipine
10mg and hydralazine 25mg TID for further blood pressure
management.
#HTN:
Patient with SBP 200 and asymptomatic on admission but had not
received home labetalol. However, per his wife and later
confirmed by him, he was not consistently taking his labetalol
at home. In the hospital, he was continued on his home labetalol
600mg TID and also started on amlodipine 10mg daily and
hydralazine 25mg TID with better blood pressure control with SBP
120s-140s.
#CKD Stage 3B:
The patient was on HD following acute renal failure
(hospitalized here ___, but recovered his renal
function and HD was stopped about 3 weeks prior to admission. Cr
on admission was 1.7 and remained fairly stable (peak was 2.0)
with aggressive diuresis.
#T2DM:
A1c here 8.3% from 8.1% in ___ (however likely inaccurate
given anemia/CKD). At home he is on Lantus 34u and Novolog 10u
breakfast, 8u lunch, 6u dinner and Novolog ISS. Here, he
remained on Lantus and was transitioned to Humalog and his
insulin regimen was optimized with ___ Diabetes following.
Upon discharge, his regimen consisted of: Lantus 34u at bedtime,
Novolog 12u with all meals.
#LLE edema > RLE:
The patient's LLE edema was noted to be greater than his RLE
edema, and in that setting a left lower extremity doppler was
checked ___ which showed no evidence of DVT.
#Bacterial conjunctivitis R eye, resolved:
Patient reported discharge, crusting, and pruritis of right eye
for the week prior to admission. He received polymyxin
B/trimethoprim drops for 5 days (___) with resolution of
symptoms.
#Dermatitis:
Patient reported a pruritic rash in the gluteal folds, appeared
erythematous and maculopapular on exam, likely secondary to
irritation/friction. Received sarna lotion with much
improvement.
CHRONIC ISSUES:
===============
#Normocytic anemia:
Hgb remained stable in 8 range, which appears to be his
baseline. No signs of active bleeding. Continue daily iron
supplementation. Ensure age appropriate colon cancer screening
as an outpatient. Last colonoscopy ___ and given adenomatous
polyps recommend ___ year follow up (___).
#Chronic LLE wound:
Likely diabetic ulcer, s/p recent debridement by podiatry
outpatient. Clinically stable. Has f/u with podiatry on ___.
#Acute polyarticular gout:
Continued home allopurinol.
#BPH:
Continued home finasteride.
#CAD:
Continue ASA 81 mg daily and atorvastatin 80 mg daily.
#Glaucoma:
Continue brimonidine tartrate 0.15% 1gtt left eye TID,
dorzolamide-timolol 1gg left eye BID, and travatan z 0.004% 1gtt
left eye QHS.
TRANSITIONAL ISSUES:
===================
DISCHARGE WEIGHT: 117.9 kg (259.92 lb)
DISCHARGE Cr: 1.9
[] Given patient re-accumulated fluid pretty rapidly after
stopping HD, must continue to monitor weight closely and may
need to uptitrate diuretic further (with careful attention to
renal function).
[] Ensure adequate blood pressure control. Can discuss with
nephrologist about possibly starting ACEI and downtitrating
hydralazine or labetalol as both are TID meds.
[] Patient should follow-up with ___ re: diabetes management.
[] Colonoscopy due ___, especially given level of anemia.
#CODE: Full (presumed)
#CONTACT: ___ (wife/HCP) - ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 600 mg PO TID
2. Allopurinol ___ mg PO EVERY OTHER DAY
3. Atorvastatin 80 mg PO QPM
4. Furosemide 40 mg PO DAILY
5. Glargine 34 Units Bedtime
Novolog 10 Units Breakfast
Novolog 8 Units Lunch
Novolog 6 Units Dinner
Insulin SC Sliding Scale using Novolog Insulin
6. Aspirin 81 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. ___ (B complex-vitamin C-folic acid) 0.8 mg oral DAILY
10. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
11. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
12. Travatan Z (travoprost) 0.004 % ophthalmic (eye) QHS
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
2. HydrALAZINE 25 mg PO TID
RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*2
3. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*2
4. Glargine 34 Units Bedtime
Novolog 12 Units Breakfast
Novolog 12 Units Lunch
Novolog 12 Units Dinner
5. Allopurinol ___ mg PO EVERY OTHER DAY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
9. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
10. Ferrous Sulfate 325 mg PO DAILY
11. Finasteride 5 mg PO DAILY
12. Labetalol 600 mg PO TID
13. ___ (B complex-vitamin C-folic acid) 0.8 mg oral
DAILY
14. Travatan Z (travoprost) 0.004 % ophthalmic (eye) QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Acute on chronic heart failure with preserved ejection fraction
-Hypertension
SECONDARY:
-Diabetes mellitus, type 2
-Chronic kidney disease, stage 3B
-Bacterial conjunctivitis
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 ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you were feeling
increasingly short of breath and noted increased swelling in
your legs.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-You were given medication through your IV to help get rid of
the excess fluid in your body. You were then started on a new,
stronger oral medication to keep the fluid off (called
Torsemide).
-You were started on new medications to better control your
blood pressure, as this will also help keep the fluid off.
-You were seen by the diabetes specialists as your sugars were
often running high in the 200s-300s, and your insulin regimen
changed
-You completed a course of antibiotic eye drops for the
bacterial conjunctivitis (eye infection) in your right eye.
-You noticed that your left leg looked more swollen than your
right, so an ultrasound of your left leg was done and showed no
clots in the left leg.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
-Continue to take all of your medications as prescribed.
-Please attend all ___ clinic appointments.
-Please weigh yourself every morning, and call your heart doctor
___ if you gain more than 3 lbs in a day or
5 lbs in a week.
-Continue to routinely check your blood sugars at home. An
appointment is being set up with ___. If you
are not contacted within a few business days, please call ___ to set up an appointment.
-Please call your primary care doctor Dr. ___ ___ to
make an appointment within the next ___ weeks.
-If you continue to have skin irritation, you can use
over-the-counter Sarna lotion. This is what was used in the
hospital.
We wish you all the best,
Your ___ Care Team
Followup Instructions:
___
|
10303080-DS-27 | 10,303,080 | 26,712,428 | DS | 27 | 2176-11-16 00:00:00 | 2176-11-16 19:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril / IV Dye, Iodine Containing Contrast Media /
vancomycin / Nafcillin / Bumex
Attending: ___.
Chief Complaint:
dyspnea, weight gain, ___ edema
Major Surgical or Invasive Procedure:
___ EMR of 3cm duodenal adenoma - 2 clips placed
___ Temp HD line placement
___ R thoracentesis
___ L thoracentesis
History of Present Illness:
Mr. ___ is a ___ y.o. male patient with HFpEF (EF
57%
___, CAD, HTN, PVD (s/p b/l femoral bypass ___, IDDM c/b
neuropathy + L plantar foot ulcer, and Stage 3 CKD with recent
admission ___ for CHF exacerbation who presented to ED
on
___ for dyspnea, reported weight gain, lower extremity edema
and was subsequently admitted to Inpatient HF Service on ___
for acute decompensated HFrEF and ___ on Stage 3 CKD.
Over the past ___ days, he reports worsening dyspnea (not on
home
O2), lower extremity swelling, poor appetite, fatigue, and
weight
gain of ~8 lbs (232 > 240 lbs). On ___, he took metolazone
2.5mg as directed by Cardiology. On ___, he began taking
metolazone 5mg + KCl 30mEq x1 per Dr ___ on
___ in conjunction with his torsemide to address his weight
gain. Despite taking diuretics, he reported decreased urination.
Usually he voids ___ he continued voiding as much, but
noticed he was making ~5cc urine with each void.
Notably, he was recently admitted and prior to this on
___ for ADHFpEF (Diuresed with IV boluses 160mg bid,
Lasix gtt@10mg/hr > d/c weight: 259lbs on PO Torsemide 80mg qd).
Discharge weight was 106.9 kg (235.67 lb) (dry weight thought
to
be ~133 lbs) and discharge Cr was 2.7.
Additionally, he reports ___ loose stools over the past few
days.
Grandkids have been sick, but no recent GI illnesses or travel
history. Reports brown stools recently, though had melena while
on Eliquis (started at last hospitalization for Afib). EGD at
that time was notable for multiple gastric polyps (2-5mm) in
fundus and body of stomach and ___ + bleeding 4cm duodenal
adenoma. He is scheduled to have repeat endoscopy with removal
of
duodenal adenoma in ___.
ED Course:
===============
In the ED initial vitals were: T 97.1, HR 52, BP 96/23, HR 22,
SpO2 96% RA. Exam was notable for: 2+ ___ b/l. Guiaic + brown
stool on rectal exam.
Labs notable for:
1. CBC: WBC 6.1, Hgb 7.0, Plt 211.
2. BMP: Cr 4.4 (last Cr 2.5 on ___.
3. LFTs: AP elevated 137, otherwise nml.
4. ___: 19051
5. Lactate: 0.7
Studies notable for:
EKG ___ (my read): HR 56 (Sinus brady), nml axis, ___
degree
block (PR 266msec), LBBB though w/ positive V1 deflection(QRS:
125msec).
___ CXR: Worsening moderate bilateral pleural effusions with
associated compressive atelectasis. No focal consolidation in
remaining visualized lungs. No frank pulmonary edema.
Patient was given: Nothing.
Vitals on transfer: 97.4, HR 52, BP 132/48, RR 20, SpO2 94% 2L
NC
Past Medical History:
CORONARY ARTERY DISEASE
ANEMIA
CONGESTIVE HEART FAILURE, DIASTOLIC
HYPERLIPIDEMIA
HYPERTENSION
DIABETES TYPE II
DIABETIC NEUROPATHY
DIABETIC NEPHROPATHY
DIABETIC RETINOPATHY
OBESITY
PERIPHERAL VASCULAR DISEASE
Social History:
___
Family History:
His mother died in her ___. HIs father died at about ___ of an
aneurysm. He had type II diabetes. He has a brother and sister,
both of whom have type II diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 97.4, 121/66, HR 61, RR 20, ___ NCL
GENERAL: Mildly uncomfortable, on 2L NC.
HEENT: NCAT.
NECK: Supple. JVP of 15cm H2O (at mandible)
CARDIAC: Normal S1, S2. No murmurs, rubs, or gallops.
LUNGS: 2L NC. Decreased bibasilar breath sounds.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. ___ ___ up to knees b/l
(worse
on L > R, pt reports this is chronic). L foot bandaged (ulcer on
plantar aspect of L. foot)
SKIN: Chronic venous stasis changes with b/l longtidunal
surgical
scars along
the medial aspect of the calves (s/p fem-pop bypass x2)
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data
Temp: 98.2 (Tm 99.0), BP: 123/64 (105-153/58-73), HR: 72
(72-86), RR: 18 (___), O2 sat: 93% (93-96), O2 delivery: Ra,
Wt: 208.33 lb/94.5 kg
Fluid Balance
Last 24 hours Total cumulative 130ml
IN: Total 430ml, PO Amt 430ml
OUT: Total 300ml, Urine Amt 300ml, L Chest tube 0ml
GENERAL: NAD.
HEENT: JVD 8cm H20
CARDIAC: Normal rate, regular rhythm. No m/r/g
LUNGS: Decreased breath sounds R base.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: 1+ non-pitting ___ edema b/l to knees, WWP. L
forearm
edematous with ecchymosis.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:36PM BLOOD WBC-6.1 RBC-2.62* Hgb-7.0* Hct-22.1*
MCV-84 MCH-26.7 MCHC-31.7* RDW-17.0* RDWSD-51.8* Plt ___
___ 04:36PM BLOOD Neuts-81.3* Lymphs-8.8* Monos-7.4 Eos-1.8
Baso-0.2 Im ___ AbsNeut-4.92 AbsLymp-0.53* AbsMono-0.45
AbsEos-0.11 AbsBaso-0.01
___ 04:36PM BLOOD Plt ___
___ 04:36PM BLOOD Glucose-181* UreaN-117* Creat-4.4*#
Na-136 K-4.0 Cl-98 HCO3-22 AnGap-16
___ 04:36PM BLOOD estGFR-Using this
___ 04:36PM BLOOD ALT-27 AST-29 AlkPhos-137* TotBili-0.6
___ 04:36PM BLOOD Lipase-32
___ 04:36PM BLOOD CK-MB-3 cTropnT-0.04* ___
___ 04:36PM BLOOD Albumin-3.7 Calcium-9.1 Phos-6.5* Mg-2.5
___ 07:10PM BLOOD Lactate-0.7
INTERVAL LABS:
==============
___ 03:18AM BLOOD calTIBC-269 Ferritn-183 TRF-207
___ 04:08PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 03:35PM BLOOD C3-116 C4-15
___ 04:08PM BLOOD HIV Ab-NEG
___ 04:08PM BLOOD HCV Ab-NEG
DISCHARGE LABS:
===============
___ 06:28AM BLOOD WBC-10.7* RBC-3.61* Hgb-9.8* Hct-30.3*
MCV-84 MCH-27.1 MCHC-32.3 RDW-16.4* RDWSD-50.5* Plt ___
___ 06:28AM BLOOD ___ PTT-27.7 ___
___ 06:28AM BLOOD Glucose-341* UreaN-41* Creat-2.4* Na-133*
K-4.1 Cl-94* HCO3-27 AnGap-12
___ 06:28AM BLOOD Calcium-8.2* Phos-2.0* Mg-2.0
MICROBIOLOGY:
=============
L pleural fluid
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
R pleural fluid
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
___: S. aureus Negative; MRSA Negative.
STUDIES/IMAGING:
================
CXR ___:
Worsening moderate bilateral pleural effusions with associated
compressive
atelectasis. No focal consolidation in remaining visualized
lungs. No frank pulmonary edema.
pMIBI ___:
1. Fixed, medium sized, moderate severity perfusion defect.
2. Increased left ventricular cavity size. Mid and basal
inferior hypokinesis with preserved systolic function.
EUS ___:
Normal mucosa in esophagus, erythema in the stomach compatible
with gastritis, 3cm polyp in second part of the duodenum. EUS
with no evidence of invasive disease. Successful EMR and
clipping.
GI pathology ___:
Adenoma, low-grade with focal high-grade dysplasia, with focal
erosion.
-No adenomatous epithelium seen at the inked, cauterized tissue
margin.
VENOUS DUP UPPER EXT BILATERAL Study Date of ___
Patent right cephalic vein from the antecubital fossa distally,
and basilic vein from the antecubital fossa proximally with
measurements as above. Patent left cephalic vein with
measurements as above. Patent basilic vein proximal to the
antecubital fossa with mild wall thickening in the mid arm.
Calcification of the bilateral radial arteries with normal peak
systolic velocities. Minimal calcification of the bilateral
brachial arteries.
UNILAT UP EXT VEINS US LEFT Study Date of ___
No evidence of deep vein thrombosis in the left upper extremity.
There is
edema in the soft tissues of the upper left arm.
CT CHEST W/O CONTRAST Study Date of ___
1. Status post placement of a catheter in the right pleural
space. New
moderate right hydropneumothorax.
2. Moderate left pleural effusion.
3. Few ground-glass opacities and atelectasis in the right lower
lobe that
could be related to focal aspiration or pulmonary edema.
Brief Hospital Course:
Mr. ___ is a ___ y.o. male patient with HFpEF (EF
57% ___, CAD, HTN, PVD, IDDM c/b L plantar foot ulcer, and
Stage 3 CKD with recent admission ___ for CHF
exacerbation who presented to ED on ___ for dyspnea, reported
weight gain, lower extremity edema and was subsequently admitted
to Inpatient HF Service on ___ for acute decompensated HFrEF
and ___ on Stage 3 CKD. Hospital course was complicated by
persistent volume overload and dyspnea requiring initiation of
hemodialysis.
===============
ACTIVE ISSUES:
===============
# Acute Decompensated HFpEF
Presented with acute on chronic dyspnea and weight gain - last
discharge weight: 106.9 kg (235.67lbs) (___). Presented
with dyspnea on exertion, weight gain, and lower extremity
swelling c/w ADHFpEF. Unclear etiology for this admission,
though suspect fluid overload may be ___ ___ on CKD (Cr 4.4 at
admission (___), compared to Cr 2.5 on ___. Trop peaked
@0.04 on ___, CKMB 3. BNP: 19051 (13113 at last admission).
___ pMIBI: Fixed medium sized moderate severity perfusion
defect. Cath was not performed given ___. Actively diuresed with
Bumex gtt, though was discontinued due to diffuse myalgias and
instead given Lasix + started HD for volume removal.
On ___, pt was triggered for dyspnea and hypoxemia, and was
sent to the CCU for BiPAP. In the CCU he was continued on a
Lasix drip and was continued with daily HD. Lasix drip was
discontinued on ___ due to inadequate response. His
afterload regimen was titrated to the following: labetalol 600
TID was discontinued and he was started on metoprolol succinate
50mg daily; hydralazine was held; amlodipine 10 mg daily was
continued.
# Acute on chronic Anemia
# ___ esophagus
# Duodenal Mass
Hgb 7.0 at admission ___ in past year). Likely mixed with AoCD
___ CKD and iron deficiency based on prior iron studies. ___
EGD notable for multiple gastric polyps (2-5mm) in fundus and
body of stomach and ___ + bleeding 4cm duodenal adenoma.
s/p EGD ___ with removal of duodenal adenoma. s/p 1U pRBC on ___
for Hgb 6.8, 1U pRBC on ___. GI followed closely given concern
for reported melena 48 hours after EGD/duodenal adenoma removal
and low Hgb ~7. Hep gtt (for Afib) was briefly paused for 24
hours after EGD due to concern for ongoing bleeding, but was
restarted given stable H/H and hemodynamic stability. Otherwise,
continued on Protonix bid, and received ferrlecit 125mg x 8
doses (per Renal - ___. On arrival to the CCU patient's
hemoglobin was noted to be downtrending in the setting of
melanic stool. He remained hemodynamically stable but required 2
transfusion (___). His heparin drip (started for Afib)
was held and repeat EGD was performed on ___ which showed clot
at site where adenoma was removed, no active bleeding. Epi was
injected and clips were placed. Patient's hemoglobin stabilized
and he had no further episodes of melena.
# pAF (CHADS2VASC 6).
Diagnosed at last admission (___) and spontaneously
converted to NSR. Started Eliquis 5mg bid at last admission;
however, this was c/b GI bleed (melena). Per GI recs, hep gtt
was started 48 hours after duodenal adenoma removal on ___ (see
below). Hep gtt was briefly held due to concern for ongoing GI
bleeding, then restarted, but held again when he developed
further transfusion requirements in the CCU as described above.
Once patient's hemoglobin stabilized, he was started on warfarin
without a bridge due to recent GI bleeding. For rate control, he
was transitioned from home labetalol 600mg tid to metoprolol
succinate 50mg daily.
# Hypertension
Initaially continued home labetalol 600 mg TID, amlodipine 10 mg
daily, hydralazine to 50 mg TID. In the CCU labetalol was
discontinued and hydralazine held due to low blood pressures. In
place of labetalol he was started on metoprolol as above.
# ___ on Stage III CKD
p/w Cr 4.4 at admission (___), compared to Cr 2.5 on ___.
Suspected cardiorenal at this time, though may have pre-renal
component as well based on reported h/o poor intake and diarrhea
___ BMs in the past few days prior to admission). Baseline
creatinine has fluctuated significantly in the last year iso of
multiple heart failure exacerbations. Recent low was 1.9 in
___. Given persistent volume overload/dyspnea despite
aggressive diuresis, HD was initiated on ___. PPD was
placed/read (no induration) and hepatitis serologies were
obtained; Hep B booster was administered. Discharged on
Sevelamer 800mg TID. Patient did not have adequate recovery of
his renal function during this admission. A tunneled dialysis
catheter was placed and he will be continuing dialysis as an
outpatient on a TuThSat schedule.
# IDDM
Has a h/o poorly controlled blood sugars. At his last admission,
FSBG up to 300s for which ___ was c/s. Triggered on morning
of ___ for AMS ___ hypoglycemia (evening prior, pt had
FSBG>500). ___ was consulted. Final recs were as follows:
lantus 15U qAM, lantus 10U qPM, Humalog 6U with meals.
#Pleural effusions
Patient had bilateral pleural effusions leading to shortness of
breath and hypoxia, though to be secondary to CHF and volume
overload. He underwent R thoracentesis on ___ and L
thoracentesis on ___ after which he no long had a supplemental
oxygen requirement. He will follow up with interventional
pulmonology to monitor for re-accumulation.
# Urinary retention
Started Flomax 0.4mg qhs
===============
RESOLVED ISSUES:
===============
# Diffuse joint pain
Reported diffuse joint pain shortly after starting Bumex gtt
which was subsequently stopped in favor of Lasix gtt due to his
pain. Resolved off Bumex.
# Diarrhea
At admission, reported ___ per day for the past few days prior
to admission. Resolved.
===============
CHRONIC ISSUES:
===============
# Left diabetic medial plantar foot ulcer
Left foot has ~1.5cm ulcer on medial plantar surface of left
foot. Followed by outpatient Podiatry. Seen by Inpatient Wound
Care who agreed with outpatient Wound Care ___ recs (___): NSW
to left foot wound, pat dry and
apply Aquacel AG to wound bed and covered by 3x3 silicone
bordered foam 3 x weekly. Apply removable felted foam. Dressing
changes every other day.
# CAD
# PVD s/p femoral bypass x2
Continued home ASA 81mg qd + Atorvastatin 80mg qhs.
# Gout
Continued allopurinol ___ qod
TRANSITIONAL ISSUES
===================
- EGD pathology (___) showing low grade dysplasia with focal
high-grade dysplasia, recommend repeat EGD in 6 months for
surveillance.
- continue hepatitis B vaccination series (s/p first dose
___
- consider cMRI to further evaluate possible AR
- 10 cm intramuscular lipoma in the right posterior chest wall.
Given its size, a dedicated MRI could be considered.
- IP follow up / further management of large pleural effusion /
chest tube
- follow up pleural fluid cytology results
- Blood sugars remained above goal prior to discharge. Continue
close glucose monitoring and insulin titration.
[]DISCHARGE WEIGHT: 208 lbs.
[]DISCHARGE CR: 2.4
[]DISCHARGE Hgb: 9.8
# LANGUAGE: ___
# CODE STATUS: Full Code (confirmed with pt on ___
# HCP: Mairetta ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. HydrALAZINE 50 mg PO TID
10. Pantoprazole 40 mg PO Q12H
11. Travoprost 0.004 % Ophth Soln (*NF*) 0.004 % Other QPM
12. Labetalol 600 mg PO TID
13. Torsemide 80 mg PO BID
14. Ferrous Sulfate 325 mg PO DAILY
15. Glargine 21 Units Breakfast
Glargine 21 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
16. Metolazone Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate [Toprol XL] 50 mg 1 tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*1
2. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth Daily Disp #*30 Capsule Refills:*3
3. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate 800 mg 1 tablet(s) by mouth Three times
a day, with meals Disp #*90 Tablet Refills:*3
4. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth At bedtime Disp #*30
Capsule Refills:*3
5. Warfarin 6 mg PO DAILY16
RX *warfarin [Coumadin] 2 mg 3 tablet(s) by mouth Daily Disp
#*90 Tablet Refills:*0
6. Glargine 15 Units Breakfast
Glargine 10 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
7. Allopurinol ___ mg PO EVERY OTHER DAY
8. amLODIPine 10 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 80 mg PO QPM
11. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
12. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
13. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
14. Ferrous Sulfate 325 mg PO DAILY
15. Fluticasone Propionate NASAL 1 SPRY NU BID
16. Pantoprazole 40 mg PO Q12H
17. Travoprost 0.004 % Ophth Soln (*NF*) 0.004 % Other QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute on chronic diastolic heart failure
Acute kidney injury
Atrial fibrillation
Bilateral pleural effusions
Acute on chronic anemia
Hypertension
Insulin dependent diabetes mellitus
Coronary artery disease
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WAS I ADMITTED?
==================
You were admitted to the hospital because you were feeling short
of breath, had worsening lower leg swelling, and increased
weight gain despite taking medications to remove the additional
fluid off your body.
WHAT HAPPENED WHILE I WAS HOSPITALIZED?
===================================
- We gave you IV medications to remove fluid from your lungs and
body.
- We started you on dialysis to remove the fluid, since you were
not getting rid of the fluid on IV medications alone.
- You had the fluid around your lungs drained.
- You were improved significantly and were ready to leave the
hospital.
WHAT SHOULD I DO AFTER LEAVING THE HOSPITAL?
========================================
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Your weight at discharge is 208 lbs. Please weigh yourself
today at home and use this as your new baseline weight.
- Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs in one day or 5
lbs in three days.
We wish you the best!
- Your ___ Healthcare Team
Followup Instructions:
___
|
10303080-DS-28 | 10,303,080 | 23,202,397 | DS | 28 | 2176-11-26 00:00:00 | 2176-12-01 13:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril / IV Dye, Iodine Containing Contrast Media /
vancomycin / Nafcillin / Bumex
Attending: ___.
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
Mr ___ is a ___ y/o M with PMH significant for duodenal
adenoma (s/p recent resection), AF (on Coumadin), HFpEF (EF 57%
___, CAD, HTN, PVD (s/p b/l femoral bypass ___, IDDM and
Stage 3 CKD (on hemodialysis), presents as a transfer for GI
bleed.
Patient was at dialysis ___, where he was noted to have 6
episodes of melanotic stools. He was subsequently taken to OSH,
and was noted to have an additional large volume melanotic
stool. He was also found to be hypotensive, and was given 1 unit
of blood and transferred to ___. On evaluation at the ___ ED,
he denied full ROS, and was immediately admitted to the MICU for
further monitoring. He was noted to be coagulopathic with an
elevated INR, so his warfarin was reversed with IV vitamin K and
Kcentra. He was also noted to be hyperkalemic and give insulin
and dextrose.
Of note, during the patient's recent admission from
___ he had endovascular resection of a 4 cm duodenal
adenoma. Patient had a repeat EGD 2 weeks ago notable for
resection site with clot with no active bleeding. Endoclips were
successfully applied with 3 endoclips placed.
Past Medical History:
CORONARY ARTERY DISEASE
ANEMIA
CONGESTIVE HEART FAILURE, DIASTOLIC
HYPERLIPIDEMIA
HYPERTENSION
DIABETES TYPE II
DIABETIC NEUROPATHY
DIABETIC NEPHROPATHY
DIABETIC RETINOPATHY
OBESITY
PERIPHERAL VASCULAR DISEASE
Social History:
___
Family History:
His mother died in her ___. HIs father died at about ___ of an
aneurysm. He had type II diabetes. He has a brother and sister,
both of whom have type II diabetes.
Physical Exam:
ADMISSION
=========
VITALS: Reviewed in MetaVision.
GEN: No acute distress
HEENT: Conjunctiva clear, PERRL, MMM
NECK: No JVD noted
LUNGS: CTAB, slightly decreased in bases
HEART: RRR, nl S1, S2. No m/r/g.
ABD: NT/ND, normal bowel sounds.
EXTREMITIES: 1+ ___ edema b/l. WWP.
SKIN: No rashes.
NEURO: AOx3.
DISCHARGE
=========
Vital Signs: ___ 0719 Temp: 98.6 PO BP: 116/73 R Lying HR:
90 RR: 18 O2 sat: 94% O2 delivery: Ra FSBG: 222
General: AOX3. Lying in bed in NAD.
HEENT: MMM, EOMI, PERRL, neck supple
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
Ext: ___ edema 1+ pitting to shins bilaterally
Neuro: Face grossly symmetric. Moving all limbs with purpose
against gravity. Not dysarthric.
Pertinent Results:
Admission Labs:
___ 02:00AM BLOOD WBC-12.4* RBC-2.26* Hgb-6.1* Hct-19.4*
MCV-86 MCH-27.0 MCHC-31.4* RDW-15.8* RDWSD-49.1* Plt ___
___ 02:00AM BLOOD ___ PTT-30.0 ___
___ 02:00AM BLOOD Glucose-390* UreaN-37* Creat-1.3*# Na-138
K-6.4* Cl-101 HCO3-29 AnGap-8*
Discharge Labs:
___ 05:25AM BLOOD WBC-8.2 RBC-2.47* Hgb-7.0* Hct-22.1*
MCV-90 MCH-28.3 MCHC-31.7* RDW-16.4* RDWSD-51.6* Plt ___
___ 05:25AM BLOOD ___ PTT-25.3 ___
___ 05:25AM BLOOD Glucose-175* UreaN-39* Creat-1.1 Na-141
K-5.5* Cl-107 HCO3-24 AnGap-10
___ 05:25AM BLOOD Phos-3.2 Mg-1.6
Studies:
___ CXR
In comparison with the study of ___, the left chest tube
has been
removed and there is no evidence of appreciable pneumothorax.
Right IJ
catheter again extends to the right atrium. No evidence of acute
focal pneumonia.
___ EGD
1. Mucosa suggestive of ___ in Esophagus
2. Solid food in fundus, multiple polyps but without a clear
source of bleeding.
3. Duodenal bulb normal. At junction of bulb and ___ part of
duodenum prior EMR scar identified with 2 previously placed
clips and scant oozing. A single clip was placed with a gush of
arterial bleeding. Epinephrine was injected and two more clips
placed with hemostasis.
Brief Hospital Course:
SUMMARY
=======
Mr ___ is a ___ y/o M with PMH significant for duodenal
adenoma (s/p recent resection), AF (on Coumadin), HFpEF (EF 57%
___, CAD, HTN, PVD (s/p b/l femoral bypass ___, IDDM and
Stage 3 CKD (on hemodialysis), presents as a transfer for GI
bleed. He was hypotensive on admission and received a total of
4U of PRBCs and underwent emergent EGD with clipping on ___
with successful hemostasis, although the GI team mentioned that
further endoscopic hemostasis would be difficult and that repeat
bleeding would have to be treated with ___ embolization. After
the procedure his diet was advanced and he tolerated PO well
without bleeding and was called out to the floor.
ACTIVE ISSUES
=============
# Upper GI bleed
# Acute Blood Loss Anemia
# Coagulopathy
Of note, patient had resection of 4 cm duodenal adenoma on ___,
with recurrent melena, and repeat EGD on ___ with more clips
placed at adenoma resection site. He received 4 units of PRBCs
and had an EGD with clipping performed on ___. No additional
evidence of bleeding after clipping and the Hgb remained stable.
# Non-valvular Atrial Fibrillation
CHADSVASC of 6. After discussion with the patient about the
risks and benefit of anticoagulation with now two episodes of
life-threatening GI bleeding, the patient decided to hold
anticoagulation until he follows up with his PCP. He understands
that by not restarting anticoagulation sooner, he has a higher
risk of stroke. HAS-BLED score calculated to 4 pertaining to
bleeding risk of 8.9%.
# CKD on HD
Patient had recently been started on dialysis on ___ for volume
control iso of failed oral diuretic regimen during most recent
admission. Dialysis team followed patient. During admission,
patient had noted improvement in UOP and subsequent drop in Cr,
consistent with recovery from acute tubular necrosis. Patient's
outpatient nephorologist, Dr. ___, was contacted and it was
decided to hold further HD pending outpatient follow-up. Ca and
phos were at acceptable levels, he was discharged on Vit D 1000
QD. His tunneled HD line was removed prior to discharge.
# HFpEF
Discharged on ___ from heart failure service with a dry weight
of 208. He had been receiving HD for volume control. Discharge
weight was 100.61 kg (221.8 lb). He appeared euvolemic on
discharge. He was discharged on torsemide.
# DM II
Briefly on an insulin drip in the MICU for blood sugars up to
500, ___ consulted and he was maintained on long acting and
insulin sliding scale at modified doses while NPO. His discharge
regimen was lantus 15U BID and Humalog 10U pre-meal TID.
CHRONIC ISSUES
==============
# HTN
Home antihypertensives were initially held iso GI bleed. They
were restarted prior to discharge which he tolerated.
# Urinary Retention
Home tamsulosin was held iso GI bleed. It was restarted prior to
discharge which he tolerated.
# CAD
# PVD s/p femoral bypass x2
ASA was initially held but restarted prior to discharge.
Atorvastatin was continued.
# Gout
Continued home allopurinol ___ qod.
TRANSITIONAL ISSUES
===================
#CODE STATUS: Full Code
#CONTACT: ___ (wife) ___
Discharge weight 100.61 kg (221.8 lb), discharge creatinine 1.1
on ___
[ ] Warfarin is being held due to ___ GI bleed because of strong
patient preference (Patient with preference for restarting in 2
weeks, risks discussed in detail). Patient's ASA was restarted
once he was stabilized inpatient.
[ ] Patient started on Torsemide 20mg daily on discharge in
discussion with inpatient renal team in setting of mild
hyperkalemia. Recommend evaluation for continued need in the
future.
[ ] Repeat CBC and BMP labs at first outpatient PCP ___
[ ] Right tunneled HD line removed prior to discharge. Please
evaluate site for proper healing.
[ ] Prior to admission patient was on HD which was stopped of
improving UOP and downtrending Cr without HD. Please continue to
re-evaluate if indications for RRT re-emerge.
[ ] Blood sugars were labile and elevated during hospitalization
with SBPs in 170s at times, recommend monitoring and further
titration of anti-hypertensives
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
8. Ferrous Sulfate 325 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. Pantoprazole 40 mg PO Q12H
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Nephrocaps 1 CAP PO DAILY
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
14. Tamsulosin 0.4 mg PO QHS
15. Travoprost 0.004 % Ophth Soln (*NF*) 0.004 % Other QPM
16. Warfarin 6 mg PO DAILY16
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. Glargine 15 Units Breakfast
Glargine 15 Units Bedtime
Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 15 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Allopurinol ___ mg PO EVERY OTHER DAY
4. amLODIPine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
9. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
10. Ferrous Sulfate 325 mg PO DAILY
11. Fluticasone Propionate NASAL 1 SPRY NU BID
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Nephrocaps 1 CAP PO DAILY
14. Pantoprazole 40 mg PO Q12H
15. sevelamer CARBONATE 800 mg PO TID W/MEALS
16. Tamsulosin 0.4 mg PO QHS
17. Travoprost 0.004 % Ophth Soln (*NF*) 0.004 % Other QPM
18. HELD- Warfarin 6 mg PO DAILY16 This medication was held. Do
not restart Warfarin until you discuss with your PCP and
cardiologist
___ Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS:
===================
Upper GI Bleed
Acute blood loss anemia
SECONDARY DIAGNOSES:
====================
CKD stage III
Atrial Fibrillation
HFpEF
Type II Diabetes
Hypertension
Urinary Retention
Coronary Artery Disease
Peripheral Vascular Disease s/p femoral bypass X2
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You were found to have a GI bleed
What did you receive in the hospital?
- You required blood transfusions and were initially monitored
in the ICU
- The GI doctors performed ___ and put 3 clips in to stop
the bleeding
- The Kidney doctors ___ and recommend no further
dialysis due to your kidney recovery and recommended that
further dialysis need be evaluated by your outpatient kidney
doctor.
- Your blood sugars were very elevated, ___ (diabetes team)
was consulted and adjusted your insulin scale
What should you do once you leave the hospital?
- Please follow-up with all your appointments
- Please take your medications as prescribed
- Please closely monitor your weights daily. If you gain >3 lbs,
call your nephrologist, Dr. ___ further instructions
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
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