Datasets:

dischargesum
/

discharge

Dataset card Data Studio Files Files and versions Community

Split (3)

train · 68.8k rows

note_id stringlengths 13 15	subject_id int64 10M 20M	hadm_id int64 20M 30M	note_type stringclasses 1 value	note_seq int64 2 133	charttime stringlengths 19 19	storetime stringlengths 19 19	text stringlengths 1.56k 52.7k
10303080-DS-29	10,303,080	23,693,744	DS	29	2176-12-28 00:00:00	2176-12-31 16:43:00	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 Major Surgical or Invasive Procedure: EGD (___) History of Present Illness: Mr. ___ is a ___ y.o. male patient with HFpEF (EF 57% ___, CAD, HTN, PVD (s/p b/l femoral bypass ___, A fib (not on A/C), IDDM c/b neuropathy + L plantar foot ulcer, Stage 3 CKD with recent admission on ___ for CHF exacerbation, and duodenal adenoma s/p resection, who presented to ED with progressive dyspnea on exertion. The patient was in his USOH until 1 week prior to admission. He noticed that he began developing a 10 lbs weight gain (dry weight 100.61kg) and b/l ___ edema. His symptoms progressed and he felt acutely dyspneic on the day of admission, at approximately 1800.At baseline, the patient states that he can walk 1 block. Now, he can only walk 50 ft. He does not use home O2. He also endorsed 4 pillow orthopnea. He denies any PND, chest pain or pressure, palpitatios, abdominal pain, n/v. He notes that he went out to a restaurant and ate a salty meal (chicken). He denies any sick contacts, travel history, and no further bleeding per rectum. He presented to OSH where he was found to be volume overloaded. He was placed on BiPAP with IV Lasix. It is unclear if he had UOP, however his respiratory status improved and he was weaned to 6L NC. He was transferred to ___ for further management. Of note, the patient was recently admitted to ___ on ___ for ADHFpEF, requiring IV diuresis with Lasix gtt and HD, due to a lack of response. HD was stopped at the time of discharge with no formal plan to resume, given that his renal function improved remarkably. In the ED, - Initial vitals: T 98.6 HR 89 BP 130/67 RR 18 SPO2 93% 6L NC - Exam notable for: Con: in no acute distress HEENT: NCAT. no icterus. Resp: Breathing comfortably on 6 L nasal cannula. No incr WOB, Crackles at left lung base CV: RRR. Abd: Soft, Nontender, Nondistended. MSK: Lower extremities with ___ pitting edema bilaterally. Moves all extremities to command. Skin: No rash, Warm and dry. Neuro: AOx3, speech fluent, no obvious facial asymmetry, moves all 4 ext to command. Psych: Normal mentation - Labs notable for: CBC: WBC 13.7 Hb 7.6 Plt 332 INR: 1.3 CHEM7: K 4.3 BUN/Cr 40/1.5 VBG: pH 7.36 pCO2 48pO2 42 - Imaging notable for: +CXR PA/LAT 1. Interval increase in bilateral lower lobe opacities, which likely represent worsening moderate-sized pleural effusions. 2. Mild pulmonary interstitial edema. - Pt given: n/a - Vitals prior to transfer: Upon arrival to the floor, the patient endorses the above story. He has significant dyspnea at rest and orthopnea. He states his ___ edema has improved. He denies any cp. Otherwise, he has no acute complaints. REVIEW OF SYSTEMS: A 10-point ROS was taken and is negative except otherwise stated in the HPI. 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 ======================= VITALS: 98.3PO 163 / 75 R Lying 99 18 98 6L General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP elevated to ear lobe, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: diffuse crackles in posterior lobes, no wheezes, rales, rhonchi Abdomen: mild distension, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, 2+ pitting edema to calves b/l Skin: Warm, dry, no rashes or notable lesions. Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally. DISCHARGE PHYSICAL EXAM ======================= VS: ___ 0723 Temp: 98.3 PO BP: 129/57 L Sitting HR: 78 RR: 20 O2 sat: 95% O2 delivery: RA Fluid Balance (last updated ___ @ 811) Last 8 hours Total cumulative -375ml IN: Total 300ml, PO Amt 300ml OUT: Total 675ml, Urine Amt 675ml Last 24 hours Total cumulative 220ml IN: Total 1545ml, PO Amt 1545ml OUT: Total 1325ml, Urine Amt 1325ml WEIGHT: 97.89 kg (98.7 kg) General: Alert, oriented, no acute distress NECK: JVP 8-9 cm CV: RRR. Normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB. No wheezes/rales/rhonchi. Abdomen: +BS. Soft, mild distension, non-tender to palpation. Ext: Warm, LLE>RLE, no edema of RLE, tense LLE that is his baseline. Pertinent Results: ADMISSION LABS ============== ___ 02:30AM BLOOD WBC-13.7* RBC-2.80* Hgb-7.6* Hct-25.1* MCV-90 MCH-27.1 MCHC-30.3* RDW-17.2* RDWSD-55.5* Plt ___ ___ 02:30AM BLOOD Neuts-85.7* Lymphs-7.0* Monos-6.3 Eos-0.2* Baso-0.1 Im ___ AbsNeut-11.70* AbsLymp-0.96* AbsMono-0.86* AbsEos-0.03* AbsBaso-0.02 ___ 02:30AM BLOOD ___ PTT-28.4 ___ ___ 02:30AM BLOOD Plt ___ ___ 06:50AM BLOOD ___ ___ 02:30AM BLOOD Glucose-299* UreaN-40* Creat-1.5* Na-136 K-4.3 Cl-101 HCO3-23 AnGap-12 ___ 02:30AM BLOOD CK(CPK)-53 ___ 06:50AM BLOOD ALT-10 AST-17 CK(CPK)-51 AlkPhos-109 TotBili-0.8 ___ 02:30AM BLOOD CK-MB-3 cTropnT-0.08* ___ ___ 06:50AM BLOOD CK-MB-4 cTropnT-0.16* ___ ___ 02:45PM BLOOD CK-MB-3 cTropnT-0.24* ___ 02:30AM BLOOD Calcium-8.6 Phos-4.2 Mg-1.8 ___ 04:19AM BLOOD %HbA1c-6.2* eAG-131* DISCHARGE LABS =============== ___ 07:33AM BLOOD WBC-9.9 RBC-3.03* Hgb-8.2* Hct-26.4* MCV-87 MCH-27.1 MCHC-31.1* RDW-15.9* RDWSD-50.9* Plt ___ ___ 07:33AM BLOOD Glucose-166* UreaN-70* Creat-1.8* Na-141 K-3.9 Cl-93* HCO3-32 AnGap-16 ___ 07:33AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.3 IMAGING ========= CXR (___) -------------- IMPRESSION: There are small to moderate bilateral pleural effusions. A dense right middle lobe opacity is suspicious for pneumonia. There is mild to moderate pulmonary edema, increased since prior. No discrete pneumothorax is identified. Evaluation of the cardiac silhouette is limited given the adjacent parenchymal opacities. EGD (___) ------------- - Normal mucosa of entire esophagus. - Multiple fundic gland appearing polyps in fundus. - Small non-bleeding red spots in proximal duodenum but no bleeding. TTE (___) ------------- CONCLUSION: CONCLUSION: The left atrial volume index is SEVERELY increased. The right atrium is mildly enlarged. The estimated right atrial pressure is >15mmHg. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is mild regional left ventricular systolic dysfunction with focal inferior akinesis (see schematic) and preserved/normal contractility of the remaining segments. Quantitative biplane left ventricular ejection fraction is 49 %. There is no resting left ventricular outflow tract gradient. Mildly dilated right ventricular cavity with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal 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 an eccentric, inferolaterally directed jet of moderate [2+] mitral regurgitation. Due to the Coanda effect, the severity of mitral regurgitation could be UNDERestimated. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Mild aortic stenosis. Moderate mitral regurgitation. Moderate pulmonary hypertension. Compared with the prior TTE (images not available for review) of ___, the findings are similar. MICROBIOLOGY ============= __________________________________________________________ ___ 2:40 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 2:50 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. Brief Hospital Course: SUMMARY ======== Mr. ___ is a ___ y.o. male patient with HFpEF (EF 57% ___, CAD, HTN, PVD (s/p b/l femoral bypass ___, A fib (not on A/C due to significant GI bleeding on A/C), IDDM c/b neuropathy + L plantar foot ulcer, Stage 3 CKD with recent admission on ___ for CHF exacerbation, and duodenal adenoma s/p resection, who presented to ED with progressive dyspnea on exertion consistent with acute on chronic HFpEF exacerbation. ================ ACUTE PROBLEMS ================ #Shortness of breath #Acute on Chronic HFpEF (EF 57%)NYHA IV Stage C #Bilateral pleural effusion Thought to be due to underdosing of outpatient diuretic after last hospital admission (discharged on Torsemide 20 mg BID) as well as dietary indiscretion (had KFC prior to admission). The patient presented with acute on chronic dyspnea and was 10 kg over dry weight. He also required 6L NC O2. Patient was actively diuresed with continued uptitration of his blood pressure medications, keeping in mind that patient has a history of angioedema with lisinopril. Interventional pulmonology was consulted for potential thoracenteses of pleural effusions, and they deferred due to patient improvement with diuresis. Patient was eventually weaned off of oxygen and was discharged on room air. Patient underwent TTE prior to discharge which showed inferior WMA that was stable from prior. His heart failure regimen on discharge was: DIURESIS: Torsemide 80 mg QD AFTERLOAD: Amlodipine 10 mg QD Hydralazine 50 mg TID NHBK: Carvedilol 25 mg BID - Discharge weight: 97.89 kg (215.81 lb) - Discharge Cr: 1.8 ___ on CKD: Baseline Cr 1.1. Presented with Cr of 1.6. Likely due to venous congestion from HF exacerbation. Had been recently discontinued off of HD during last hospitalization in ___. He was actively diuresed as above. Discharge Cr: 1.8 #NSTEMI Likely Type 2 NSTEMI due to wall stress and increased oxygen demand from volume overload. He was continued on aspirin, atorvastatin. He was switched from metoprolol to Carvedilol for better blood pressure control #Hypoproliferative Normocytic Anemia #Duodenal Adenoma #h/o UGIB ___ Esophagus Baseline Hb ___. Patient required 2 u pRBCs during his hospitalization. He had a few episodes of melena and had guaiac positive stools. Reticulocyte count low, and iron studies indicated anemia of chronic inflammation. Patient underwent EGD on ___ which showed no sources of bleeding. He was continued on pantoprazole. GI was consulted and stated that if his Hgb remained stable and he had no more episodes of melena or GI bleeding, then they would plan on setting up an outpatient colonoscopy and capsule study. ======================== CHRONIC/STABLE PROBLEMS ======================== #Paroxysmal A fib: CHADS2VASC 6. Recently diagnosed in ___. Started on Eliquis, though c/b GI bleeding. Transitioned to warfarin for A/C, however had another severe GIB. The patient has decided to hold off on further anticoagulation. HASBLED 4. He remained off of coagulation during his hospital stay. He was switched from metoprolol to Carvedilol for ongoing rate control and better blood pressure control as above. #HTN: - Continued home amlodipine 10 mg QD - Started hydralazine 50 mg TID - Started Carvedilol 25 mg BID #DM2, on insulin - His insulin regimen on discharge: - Lantus 15 u QHS - Standing Humalog 15 u at mealtimes #Urinary Retention: - Continued home Finasteride 5 mg PO DAILY #CAD #PVD s/p femoral bypass x2 - Continued home ASA 81mg qd - Continued home Atorvastatin 80mg qhs. #Gout - Continued allopurinol ___ qod ==================== TRANSITIONAL ISSUES ==================== [ ] HFpEF - Please continue to titrate his Torsemide regimen as appropriate. [ ] HTN - Patient was started on hydralazine and Carvedilol during this admission. Consider addition of ___ (of note, patient has history of angioedema with lisinopril) or continued uptitration of his hydralazine. [ ] GI bleed - Patient should continue to be worked up for his GI bleed with colonoscopy and capsule study in outpatient setting. [ ] ___ - Please repeat chemistry panel to ensure Cr is back to patient's baseline and start spironolactone if able. [ ] DM: Please monitor blood glucose as an outpatient and uptitrate or downtitrate insulin as needed. [ ] AF: CHADS2VASC 6, please start AC after GIB work-up =============== CORE MEASURES =============== #CODE: Full (confirmed) #CONTACT: ___, ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Finasteride 5 mg PO DAILY 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 3. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 4. Allopurinol ___ mg PO EVERY OTHER DAY 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID 7. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 8. Atorvastatin 80 mg PO QPM 9. Torsemide 20 mg PO BID 10. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN Pain - Mild 11. Pantoprazole 40 mg PO Q12H 12. Aspirin 81 mg PO DAILY 13. Vitamin D ___ UNIT PO 1X/WEEK (___) 14. Glargine 15 Units Bedtime Humalog 15 Units Breakfast Humalog 15 Units Lunch Humalog 15 Units Dinner Insulin SC Sliding Scale using HUM Insulin 15. amLODIPine 10 mg PO DAILY Discharge Medications: 1. CARVedilol 25 mg PO BID RX carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 2. HydrALAZINE 50 mg PO Q8H RX hydralazine 50 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 3. Torsemide 80 mg PO DAILY RX torsemide 20 mg 4 tablet(s) by mouth once a day Disp #120 Tablet Refills:*0 4. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 5. Allopurinol ___ mg PO EVERY OTHER DAY 6. amLODIPine 10 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 10. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 11. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID 12. Finasteride 5 mg PO DAILY 13. Glargine 15 Units Bedtime Humalog 15 Units Breakfast Humalog 15 Units Lunch Humalog 15 Units Dinner Insulin SC Sliding Scale using HUM Insulin 14. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN Pain - Mild 15. Pantoprazole 40 mg PO Q12H 16. Vitamin D ___ UNIT PO 1X/WEEK (___) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS =================== Acute on chronic heart failure with preserved ejection fraction SECONDARY DIAGNOSES ==================== GI bleed Atrial fibrillation 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 participating in your care. Please read through the following information. WHY WAS I ADMITTED TO 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. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - You were given a diuretic medication through the IV to help get the fluid out. You improved considerably and were ready to leave the hospital. - You underwent an EGD, which is a procedure that involves placing a tube with a camera at the end to look at your esophagus, stomach, and part of your small intestine; this did not show any source of bleeding. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed. - Please keep all of your appointments. - Weigh yourself every morning. Your weight on discharge is 97.89 kg (215.81 lb). Please call Dr. ___ office at ___ if your weight goes up more than 3 lbs. - Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs, abdominal distention, or shortness of breath at night. You can call our ___ Heartline at ___ at any time (24 hours a day, 7 days a week) to speak to a nurse practitioner or cardiologist about your symptoms and concerns. We wish you the best! -Your ___ Care Team Followup Instructions: ___
10303081-DS-16	10,303,081	28,854,743	DS	16	2134-09-18 00:00:00	2134-10-05 19:07:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Coconut / Oxycodone Attending: ___ Chief Complaint: Chest pain, nausea, vomiting, diarrhea Major Surgical or Invasive Procedure: - None. History of Present Illness: ___ F w HTN, HLD, PVD, R paramedian pontine ischemic stroke ___, & recent admisison for temporal arteritis work-up presents with chest pain. Pt reports chest pain x 35 minutes that started while she was going to the bathroom & having diarrhea. The pain was sharp, substernal & radiated to her back & L arm. It was associated with SOB. The pain was relieved on administration of oxygen by EMS. Of note, the patient has had 3 days of n/v/diarrhea but denies abdominal pain, fevers. Her daughter has had the same symptoms. . Pt was recently admitted to ___ for headache associated with vision changes. A temporal biopsy was performed & the pt was started on 60 mg prednisone QD. . In the ED, initial VS: 98.1 74 149/93 20 97/RA CXR negative, CTA negative, trop 0.01, EKG unchanged from prior. Lytes: K 3.0 Bicarb 10 Creat 1.4 WBC 16 with 82% N, HCT 37, PLT 272 Got 2 L IVF, Gave 40 mEq K . On the floor, pt reported feeling comfortable, no chest pain. Reports that she used to have chest pain many years ago, but nothing since then. No exertional chest pain or DOE. . REVIEW OF SYSTEM: Denies fevers, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, SOB, abdominal pain, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - CVA: Ischemic R paramedial pontinue ___ - HLD - PVD - HTN - C5-C6 disc surgery with rods placed ___ - ? Giant Cell Arteritis ___, undergoing work-up Social History: ___ Family History: - Mother: DM, 3 strokes - Father: Unknown Physical ___: ADMISSION PHYSICAL EXAM: 97.4 134/96 62 16 100/RA GEN: Well-appearing in NAD HEENT: Tenderness of palpation of L temple radiating out the distribution of trigeminal nerve, L neck, decreased sensation in that area NECK: Supple, no thyromegaly, no JVD, no bruits COR: +S1S2, RRR, no m/g/r PULM: CTAB, no c/w/r. ___: Hyperactive BS in 4Q. Soft, NTND EXT: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO: Strength ___ on L, ___ on right. Sensation intact throughout. DISCHARGE PHYSICAL EXAM: No change. Pertinent Results: ADMISSION LABS & STUDIES: ___ 03:00AM BLOOD WBC-15.6* RBC-4.41 Hgb-12.4 Hct-37.4 MCV-85 MCH-28.1 MCHC-33.1 RDW-13.8 Plt ___ ___ 03:00AM BLOOD Neuts-82.2* Lymphs-13.7* Monos-3.4 Eos-0.6 Baso-0.2 ___ 03:00AM BLOOD Glucose-117* UreaN-37* Creat-1.4* Na-144 K-3.0* Cl-109* HCO3-19* AnGap-19 ___ 09:25PM BLOOD CK(CPK)-71 ___ 03:00AM BLOOD cTropnT-<0.01 ___ 03:00AM BLOOD Phos-3.5 Mg-2.3 ___ 03:00AM BLOOD GreenHd-HOLD CTA CHEST (___): IMPRESSION: 1. No acute aortic dissection or pulmonary embolism is detected. 2. No abnormality identified to explain the patient's pain. DISCHARGE LABS & STUDIES: ___ 07:30AM BLOOD WBC-18.1* RBC-3.65* Hgb-10.3* Hct-30.8* MCV-84 MCH-28.1 MCHC-33.3 RDW-14.4 Plt ___ ___ 06:00AM BLOOD Glucose-73 UreaN-16 Creat-1.0 Na-140 K-3.7 Cl-109* HCO3-23 AnGap-12 STRESS MIBI: IMPRESSION: No ischemic ECG changes. No anginal type symptoms. Appropriate hemodynamic response to Persantine. 1. Normal myocardial perfusion. 2. Normal left ventricular cavity size and systolic function. Brief Hospital Course: REASON FOR HOSPITALIZATION: ___ F w PVD, HLD, HTN, CVA ___, recent admission for temporal arteritis work-up presents with chest pain, nausea, vomiting, diarrhea. ACUTE DIAGNOSES: # Gastroenteritis: This was most likely due to a viral gastroenteritis. The patient's daughter, who lives with her mother, had similar symptoms. The patient was treated with IVF and anti-emetics. Her diet was slowly advanced and she was symptom-free at the time of discharge. Given the patient's recent hospitalization, C. Diff was sent and was negative. # Chest Pain: The patient's chest pain was atypical for unstable angina, but given her significant risk factors (HTN, smoking history, HTN, recent CVA) a stress MIBI was obtained, which was normal. Her EKG was not concerning for ischemic changes; her cardiac enzymes remained negative. The patient's pain improved on administration of antacid/reflux medications. Aspirin was continued. # ? Temporal Arteritis: Results of temporal artery biopsy still pending. Pt was continued on prednisone, famotidine. CHRONIC DIAGNOSES: # HTN: Pt was continued on lisinopril. HCTZ was reinitiated on discharge. # HLD: Continued statin. # Depression: Continued celexa. TRANSITIONAL ISSUES: # Follow Up: The patient will follow up with rheumatology for the results of her temporal artery biopsy. # Code Status: Full code. Medications on Admission: Rosuvastatin 20 mg QD Citalopram 30 mg QD Hydrochlorothiazide 25 mg QD Famotidine 20 mg QHS Aspirin 81 mg QD Valacyclovir 100 mg BID for 7 days Lisinopril 10 mg QD Trazodone 25 mg QHS PRN insomnia Prednisone 60 mg QD Calcium + Vitamin D Discharge Medications: 1. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 2 weeks: to finish ___. 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 8. Medication Calcium + Vitamin D daily 9. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 2 days. 10. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for insomnia. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Viral gastroenteritis SECONDARY DIAGNOSIS: - Atypical chest pain - s/p ischemic CVA, R paramedial pontine ___ - HLD - PVD - HTN - possible Giant Cell Arteritis ___, s/p temporal artery biopsy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, you were admitted to the medicine service at ___ ___ from ___ to ___ for chest pain and vomiting. You had a nuclear stress test which showed normal heart function, and no evidence of blockages. This is obviously good news. Your chest pain was most likely related to the nausea and vomiting you were having as a result of a viral illness. Your recent biopsy result returned normal. Please discuss these results with rheumatologist on ___. MEDICATION INSTRUCTIONS: - Medications ADDED: None. - Medications STOPPED: None. - Medications CHANGED: None. Followup Instructions: ___
10303334-DS-16	10,303,334	27,881,004	DS	16	2134-11-11 00:00:00	2134-11-11 15:18:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___ Chief Complaint: abdominal pain for ___ weeks Major Surgical or Invasive Procedure: ERCP with sphincterotomy History of Present Illness: HMED INITIAL NOTE PCP: Name: ___ ___: ___ ASSOCIATES Address: ___ Phone: ___ Fax: ___ CC: abdominal pain for ___ weeks HPI: Ms. ___ is a ___ year old F with a PMH of tetralogy of fallot repair as an infant who presents with ___ weeks of waxing/waning epigastric and right upper quadrant pain that radiates to her back. She has never had this pain before. She was otherwise healthy without any symptoms prior to the onset of this pain. The pain is not specifically induced by food. She denies f/c. She denies diarrhea or bloody/black stool. She denies CP or SOB. Currently her pain is minimal as it waxes and wanes. She denies any radiation currently. She is not on any new medications. She denies pain with urination. ROS: Pertinent positives and negatives as noted in the HPI. All other 10 point systems were reviewed and are negative. Past Medical History: Tetralogy of Fallot repair in infancy Social History: ___ Family History: Mother - cholecystectomy for gallstones Physical Exam: ADMISSION PHYSICAL EXAM: GENERAL: Alert and in no apparent distress EYES: + mildly icteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, diffuse systolic and diastolic murmur noted with sternal surgical scar noted RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, + epigastric TTP without rebound. Mild voluntary guarding to deep palpation of ___ sign. 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 PHYSICAL EXAM: GENERAL: Alert and in no apparent distress EYES: no scleral icterus, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, diffuse systolic and diastolic murmur noted with sternal surgical scar noted RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, + epigastric TTP without rebound. Mild voluntary guarding to deep palpation of ___ sign. 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, not jaundiced NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS: ___ 03:53AM ___ COMMENTS-GREEN TOP ___ 03:53AM LACTATE-1.3 ___ 03:00AM GLUCOSE-78 UREA N-9 CREAT-0.7 SODIUM-142 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-22 ANION GAP-18 ___ 03:00AM estGFR-Using this ___ 03:00AM ALT(SGPT)-391* AST(SGOT)-172* ALK PHOS-172* TOT BILI-3.1* ___ 03:00AM LIPASE-42 ___ 03:00AM ALBUMIN-4.6 ___ 03:00AM WBC-7.1 RBC-4.39 HGB-13.5 HCT-40.6 MCV-93 MCH-30.8 MCHC-33.3 RDW-13.2 RDWSD-45.1 ___ 03:00AM NEUTS-74.9* LYMPHS-15.8* MONOS-7.5 EOS-1.0 BASOS-0.4 IM ___ AbsNeut-5.33 AbsLymp-1.12* AbsMono-0.53 AbsEos-0.07 AbsBaso-0.03 ___ 03:00AM PLT COUNT-185 ___ 03:00AM ___ PTT-31.8 ___ Outside hospital Atrius labs notable for: Labs ___: T bili 1.0, D bili 0.4, ALT 129, AST 254, AP 98 Labs ___: T bili 3.0 D bili 1.5 ALT 462 AST 241 AP 149 HIV/HBV/HCV negative Repeat labs here are notable again for elevated transaminases, T bili 3.1, WBC 7.1. WBC 7.1/HB 13.5/Plt 185 Na 142/K 4.0/Cl 102/HCO2 22/BUN 9/Cr 0.7 ALT 391/AST 172/Alk P ___ Total bilirubin 3.1 RUQ U/S: IMPRESSION: 1. Cholelithiasis with borderline gallbladder wall thickening and small volume RIGHT upper quadrant fluid. Although ___ sign was negative, findings are concerning for cholecystitis 2. Limited visualization of the extrahepatic biliary duct demonstrating dilation up to 14 mm without obstructing stone/mass. No pancreatic duct dilation. Findings may be related to presence of gallstones, but obstructing process in the nonvisualized portion of the duct is possible. Depending on treatment for the above, MRCP without and with contrast may be obtained for further evaluation. IMPRESSION: 1. Cholelithiasis with borderline gallbladder wall thickening and small volume RIGHT upper quadrant fluid. Although ___ sign was negative, findings are concerning for cholecystitis 2. Limited visualization of the extrahepatic biliary duct demonstrating dilation up to 14 mm without obstructing stone/mass. No pancreatic duct dilation. Findings may be related to presence of gallstones, but obstructing process in the nonvisualized portion of the duct is possible. Depending on treatment for the above, MRCP without and with contrast may be obtained for further evaluation ERCP: Impression: The scout film was normal. The major papilla appeared normal. The bile duct was successfully cannulated using a Rx sphincterotome preloaded with a 0.035in guidewire. Contrast was injected and there was brisk flow through the ducts. Contrast extended to the entire biliary tree. Contrast injection showed a single 1cm subtle stricture/narrowing at the lower third CBD. There was mild post-obstructive dilation of the CBD, CHD and right and left main hepatic ducts. No filling defects were seen. These findings may be compatible with inflammation from passed stone vs. autoimmune pancreatitis. A biliary sphincterotomy was successfully performed with the sphincterotome. There was no post-sphincterotomy bleeding. A cytology brush was then inserted to obtain specimen from the CBD stricture which was sent for cytology. Subsequently, a ___ x 7cm biliary strait plastic stent (Cotton ___ was successfully placed across the stricture using a preloaded OASIS stent introducer kit. Excellent bile and contrast drainage was seen endoscopically and fluoroscopically. MRCP ___: read pending DISCHARGE LABS: ___ 07:35AM BLOOD WBC-4.8 RBC-4.52 Hgb-13.8 Hct-41.0 MCV-91 MCH-30.5 MCHC-33.7 RDW-13.0 RDWSD-43.1 Plt ___ ___ 07:35AM BLOOD Glucose-82 UreaN-10 Creat-0.8 Na-142 K-4.7 Cl-105 HCO3-28 AnGap-9* ___ 07:35AM BLOOD ALT-179* AST-49* AlkPhos-119* TotBili-1.1 ___ 07:35AM BLOOD Albumin-4.3 Calcium-9.2 Mg-2.0 ___ 07:45AM BLOOD IgG-1112 Brief Hospital Course: Ms. ___ is a ___ year old F with a PMH of tetralogy of fallot repair as an infant who presents with ___ weeks of waxing/waning epigastric and right upper quadrant pain found to have CBD stricture c/w passed stone or autoimmune pancreatitis. #CBD stricture #Possible choledocholithiasis S/p ERCP with sphincterotomy and biopsies of CBD taken. Post-procedural LFT's improved and pt is w/out recurrence of abdominal pain. CBD stricture c/w possible passed stone vs. autoimmune pancreatitis. Total IgG and IgG4 sent and are pending on discharge. Pt also underwent MRCP to evaluate for autoimmune pancreatitis. The read on this is pending but per Advanced Endoscopy team, not likely to change management at the current time and they would favor waiting for ___ pancreatitis to be completed prior to scheduling ccy. Pt given number of Surgery clinic to call for f/u. # Tetrology of Fallot repair: Followed by Dr. ___ at ___. Stable Billing: greater than 30 minutes spent on discharge counseling and coordination of care Medications on Admission: TUMS prn Ibuprofen prn Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every 12 hours Disp #4 Tablet Refills:*0 2. Calcium Carbonate 500 mg PO QID:PRN heartburn Discharge Disposition: Home Discharge Diagnosis: Bile obstruction/CBD stricture Cholelithiasis 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 obstruction in your bile tract. You had an ERCP procedure which showed a "stricture" in your bile duct. You also had gallstones. An MRI was performed, the results of this are still pending on discharge but will likely not change management in the short term so we will call you with these results. Please call the Acute Care Surgery Clinic at ___ to schedule an appointment in ___ weeks for follow-up. Please also call the advanced endoscopy fellow on-call ___/ pager ___ if you experience any recurrent abdominal pain, nausea/vomiting, jaundice, or if you have any fevers/chills. It was a pleasure taking care of you at ___ ___. Followup Instructions: ___
10303361-DS-11	10,303,361	25,112,963	DS	11	2187-03-23 00:00:00	2187-03-23 17:41:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: intubation History of Present Illness: ___ year old female with HTN, CHF, afib not on coumadin, s/p ___, with recent fall ___ transferred from OSH to ___ with type 2 dens fracture of the C2 vertebral body with posterior subluxation of C1 presenting from rehab with hyponatremia Na 120 from ___. She recieved 1 LNS prior to transfer. She endorses feeling generally weak and a little confused, but denies CP, SOB, diarrhea, vomiting, decreased PO intake. No recent med changes. Per granddaughter, almost no PO intake for last few days due to no appetite, increasing confusion at rehab center. . In ER: (Triage Vitals:97.9, 18, 78, 122/72 ) Meds Given: none Fluids given: 400 cc / hour Radiology Studies: head CT consults called: none . PAIN SCALE: ___ but increases in her neck with movement. She cannot quantify how much. + anorexia and decreased appetite without increased abdominal pain. Denies fevers/chills/cp/n/v/d. She does not report saddle anesthesia incontinence of bowel or bladder. She also denies back pain. All other ROS negative except as above. NKDA Past Medical History: AFib (not on coumadin) GERD sCHF (EF 40%) Hypothyroid s/p Pacemaker HTN High Cholesterol S/p ORIF of R hip Social History: ___ Family History: Patient was altered and unable to provide history. Physical Exam: Exam on admission: VS: T98.4, P96, BP126/102, R24, 97 on@2L NC General: AOx0, initially able to follow simple commands, loudly breathing w/ prominent sternal/abdominal retractions HEENT: PERRLA, dry MM, Rigid C-Collar in place CV: AFib on telemetry, unable to assess heart sounds over rhonchorous breath sounds LUNGS: Inspiratory rhonchi, radiating b/l in chest, seemingly transmitted from upper airway, breathing through nose w/ clenched mouth and substantial abdominal/sternal retractions ABD: Soft, unable to assess tenderness, unable to auscultate bowel sounds given rhonchi, not distended EXT: warm, well perfused, no cyanosis/clubbing/edema SKIN: Warm, Dry, NEURO: Initially able to follow simple commands (stick out tongue, open mouth, squeeze hands) but later unable to do so, AOxO, normal tone in extremities Pertinent Results: ___ 06:35PM PLT COUNT-290 ___ 06:35PM NEUTS-82.2* LYMPHS-9.8* MONOS-7.5 EOS-0.3 BASOS-0.2 ___ 06:35PM WBC-11.9* RBC-3.27* HGB-9.6* HCT-29.2* MCV-89 MCH-29.3 MCHC-32.8 RDW-14.3 ___ 06:35PM OSMOLAL-255* ___ 06:35PM CALCIUM-8.7 PHOSPHATE-3.0 MAGNESIUM-1.7 ___ 06:35PM estGFR-Using this ___ 06:35PM GLUCOSE-98 UREA N-19 CREAT-0.6 SODIUM-121* POTASSIUM-4.7 CHLORIDE-83* TOTAL CO2-31 ANION GAP-12 ___ 10:17PM NA+-121* ___ 10:17PM ___ COMMENTS-GREEN TOP MICRO: Urine culture: negative Blood culture: pending Sputum culture: no microorganisms on gram stain REPORTS: CXR (___): 1. Severe compression of lower thoracic vertebral body/vertebral body at the thoracolumbar junction of indeterminate age, given lack of priors for comparison. 2. Tortuous aorta. No definite focal consolidation. CT HEAD WO CONTRAST (___): No acute intracranial abnormality. CXR (___): IMPRESSION: The ET tube tip of the recently intubated patient is approximately 2 cm above the carinal. Pacemaker leads are in unchanged location. Cardiomediastinal silhouette is unchanged. There is no substantial change in mild vascular congestion, bilateral pleural effusions. There is no appreciable pneumothorax demonstrated CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS (___): No large vessel obstruction, dissection, or aneurysm greater than 3 mm. Multifocal atherosclerotic calcifications within the bilateral carotid arteries without evidence of flow-limiting stenosis. . CT neck ___: IMPRESSION: 1. Worsening distraction of the previously noted dens fracture 2. There is a possible epidural hematoma would recommend further evaluation with MRI . CXR ___: IMPRESSION: As compared to the previous radiograph, the patient has been extubated. The lung volumes have decreased. However, except for a moderate left atelectasis, caused by an elevated hemidiaphragm, no other atelectatic changes are noted. Moderate cardiomegaly without pulmonary edema persists. Unchanged position of the left pectoral pacemaker and the pacemaker wires Brief Hospital Course: ___, AFib (not on coumadin), sCHF (40%), HTN, pacemaker who is s/p recent mechanical fall (striking face/neck) resulting in C2 type II dens vertebral body fracture w/ posterior subluxation of C1 who was managed conservatively w/ C-Collar at rehab, but was returned to ___ for hyponatremia. #AMS On the first day of admission, the pt became acutely confused. Ddx included worsening hyponatremia, narcotic administration, or aspiration event. At the time she was also breathing with very coarse rhonchorous sounds. Seizure unlikely as no typical symptomatology or exam findings and no personal history. Stroke possible given hx of AFib without anticoagulation. Alternatively, could be ___ subluxation causing compression of adjacent brain parenchyma, however imaging was negative for any worsening of her spinal injury. Lastly, tetanus was a concern given hx of head trauma, open wound above eye, and trismus and concern for upper airway constriction. The patient was intubated for airway protection. However, mental status rapidly improved with improvement in her sodium. She was subsequently extubated with clearing of her mental status and no further signs of trismus. #Hypercarbic respiratory failure/Respiratory Status Initially with hypercarbic respiratory failure on presentation to the ICU, so was intubated with improvement in respiratory status soon thereafter. She was successfully extubated on ___, without further signs of trismus and with clearing mental status per above #Aspiration PNA Given respiratory failure in the setting of altered mental status, there was concern for possible aspiration event and/or pneumonia. Given recent stay in rehab and >48hrs here, started treating for HCAP with Vanc/Cefepime. However, no infiltrate was seen on CXR and respiratory status rapidly improved. Speech and swallow eval showed no overt aspiration. Antibiotics were ultimately d/c'ed. Speech and swallow therapy evaluated the patient and recommended soft solids with thin liquids. #Hyponatremia Pt presented w/ Na of 121, with ULytes suggestive of SIADH, but her previous caregivers felt that she looked hypovolemic so treated w/ IVF to little effect. On day of admission to ICU, pt Na was 119. SIADH possibly ___ meds (Paxil), or pain from trauma. Paxil was held. Given possible pulm edema ___ IVF, and ULytes suggestive of SIADH, began fluid restriction to 1L/day and began hypertonic saline infusion of 20cc/hour over 4 hours. Sodium corrected to 125. Hypertonic saline was stopped, and maintenance IV fluids (D5W with K 40 mEq) were started. By 6PM, sodium increased to 131, and later to 136, with stabilization around 135 with D5W. IV fluids were subsequently stopped and pt was maintained on PO fluid restriction. Sodium remained stable. #Recent C2 Fracture Pt had been seen in ED recently for C2 fracture and placed in hard cervical collar. Repeat imaging was performed during admission which showed worsened displacement of her fracture with possible epidural hematoma. Spine was consulted and recommended that she would likely need surgical fusion as this type of fracture would likely be unable to heal. For now, recommend continue C-collar and to follow up Dr. ___ ___ weeks after discharge to discuss further options. #sCHF Pt is w/out evidence of gross fluid overload, but appears to have some slight pulmonary edema on CXR. She is known to have sCHF with EF of 40% and is not on lasix as outpatient. Lisinopril and amiloride were held, as the patient was being fluid-restricted. They were held on discharge and can be restarted prn. #AFib Pt has known hx of AFib but is not on A/C for unclear reasons. On admission to ___, EKG w/ LBBB, no concerning findings for ischemia, and initial trop negative. However, pt had ? episode of Vtach to 120's on monitor while in CT scanner, did not lose pulse, and had resolved before pads could be applied and was temporarily paced by pacemaker. Troponins were negative x2. Amiodarone was continued and the patient was maintained on continuous telemetry. #Hypothyroid Stable, levothyroxine was continued. . #eye laceration with sutures-Can likely have sutures removed shortly after transfer to rehab. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Bisacodyl 10 mg PR HS:PRN constipation 3. Lactulose 30 mL PO DAILY:PRN constipation 4. Lorazepam 0.5 mg PO HS:PRN insomnia 5. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain 6. Senna 17.2 mg PO HS:PRN constipation 7. Polyethylene Glycol 17 g PO DAILY 8. Quinapril 5 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Heparin 5000 UNIT SC TID 11. Levothyroxine Sodium 100 mcg PO DAILY 12. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H 13. Paroxetine 10 mg PO DAILY 14. Amiloride HCl 5 mg PO DAILY 15. Amiodarone 200 mg PO DAILY 16. Atorvastatin 10 mg PO DAILY 17. Docusate Sodium 100 mg PO BID 18. Fluticasone Propionate NASAL 1 SPRY NU BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Amiodarone 200 mg PO DAILY 3. Atorvastatin 10 mg PO DAILY 4. Bisacodyl 10 mg PR HS:PRN constipation 5. Docusate Sodium 100 mg PO BID 6. Fluticasone Propionate NASAL 1 SPRY NU BID 7. Heparin 5000 UNIT SC TID 8. Levothyroxine Sodium 100 mcg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Polyethylene Glycol 17 g PO DAILY 11. Senna 17.2 mg PO HS:PRN constipation 12. Lactulose 30 mL PO DAILY:PRN constipation 13. Lorazepam 0.5 mg PO HS:PRN insomnia Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Hyponatremia Hypercarbic Respiratory Failure C2 Fracture 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 presented to the hospital with low sodium levels. This caused confusion and breathing problems, ultimately requiring transfer to the ICU and a breathing tube. After your fluid intake was limited, your sodium improved. You will need to continue to restrict your free water to 1L daily. You also had a CT scan during your admission which showed some worsening of your recent spine fracture. The spine surgeons were consulted and recommended that you continue to wear your neck collar at all times. You will need to see Dr. ___ in ___ weeks for follow up reevaluation. . You were briefly on antibiotic therapy for a possible pneumonia. However, these were discontinued prior to discharge as it was not felt that you had a true pneumonia. Followup Instructions: ___
10303398-DS-14	10,303,398	25,161,837	DS	14	2154-02-15 00:00:00	2154-02-15 13:38:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache and blurry vision Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old male with a history of aortic dissection at ___ treated medically per patient report presenting from a psych facility on a ___ for evaluation of hypertension. Patient reports that his blood pressure has been uncontrolled for the past 4 days. His blood pressures typically systolics of 170s but has recently been in the 190s. He reports that his psych facility had changed his clonidine to an unknown medication and since then his blood pressure was poorly controlled. He endorses intermittent sharp pain in his chest and abdomen for years and headaches with blurred vision. He reports having his headache with blurred vision today. He denies any nausea, vomiting or dyspnea. Past Medical History: PMH: Hypertension Obesity OSA Aortic type B dissection. Bipolar disorder PSH: Gunshot wound to Left leg Social History: ___ Family History: HTN: father, mother, and brother Physical ___: Vital signs: Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No right carotid bruit, No left carotid bruit. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, no masses, no tenderness to palpation Extremities: No skin changes. Pulses: R: P/P/P/P L: P/P/P/P Pertinent Results: ADMISSION LABS ___ 01:30PM BLOOD WBC-4.6 RBC-4.77 Hgb-12.9* Hct-37.9* MCV-80* MCH-27.0 MCHC-34.0 RDW-12.9 RDWSD-36.7 Plt ___ ___ 01:30PM BLOOD Glucose-116* UreaN-15 Creat-1.1 Na-139 K-5.1 Cl-102 HCO3-24 AnGap-18 ___ 02:11AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.1 DISCHARGE LABS ___ 08:10AM BLOOD WBC-4.3 RBC-4.89 Hgb-13.2* Hct-39.3* MCV-80* MCH-27.0 MCHC-33.6 RDW-12.7 RDWSD-36.5 Plt ___ ___ 08:10AM BLOOD Glucose-99 UreaN-16 Creat-1.3* Na-131* K-4.4 Cl-94* HCO3-25 AnGap-16 ___ 08:10AM BLOOD Calcium-9.6 Phos-3.9 Mg-2.2 IMAGING ___ CTA chest/abdomen: 1. Type B aortic dissection extending from just distal to the left subclavian artery to the proximal aspect left common iliac artery with aneurysmal dilatation of the descending aorta up to 7 cm. No evidence of rupture. 2. Mild cardiomegaly. ___ Transthoracic echocardiogram: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild global left ventricular hypokinesis (LVEF = 40-45 %). Right ventricular chamber size is normal with borderline normal free wall function. The ascending aorta and aortic arch are mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Dilated thoracic aorta. Mild symmetric left ventricular hypertrophy with normal cavity size and mild global hypokinesis. No valvular pathology or pathologic flow identified. ___ Chest xray: Enlargement of the left mediastinal contour in keeping with the known type B aortic dissection. Clear lungs. Brief Hospital Course: Mr. ___ is a ___ year old male with uncontrolled hypertension and a chronic type B aortic dissection who was admitted to the ___ on ___ from ___ on ___. Patient was admitted to the CVICU for tight blood pressure control and monitoring. Cardiology was consulted for blood pressure control. He was on an esmolol drip until hospital day 3, when he was finally weaned off of it and had adequate blood pressure control with an oral regimen. He was thus transferred to the floor on ___. Once on the floor, the patient's oral blood pressure medication regimen was optimized. Psychiatry was also asked to re-evaluate the patient and deemed that he would benefit from continued inpatient psychiatric treatment. The BEST team also evaluated the patient and were able to find him a bed at ___, where Dr. ___ agreed to accept the patient. He was deemed ready for discharge on ___, and was given the appropriate discharge and follow-up instructions. He was scheduled to follow up with vascular surgery for operative planning for his Type B dissection as well as cardiology for pre-operative evaluation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clozapine 2 mg PO TID 2. Latuda (lurasidone) 40 mg oral QHS 3. OXcarbazepine 600 mg PO BID 4. Omeprazole 20 mg PO DAILY 5. amLODIPine 10 mg PO DAILY 6. Atorvastatin 10 mg PO QPM 7. Metoprolol Succinate XL 50 mg PO BID 8. CloNIDine 0.3 mg PO TID 9. Lisinopril 10 mg PO DAILY 10. Mylanta 30 mL oral Q6H:PRN 11. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 12. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate 13. DiphenhydrAMINE 50 mg PO Q6H:PRN allergies 14. OLANZapine 5 mg PO Q6H 15. ChlorproMAZINE 50 mg PO Q12H:PRN agitation Discharge Medications: 1. ClonazePAM 2 mg PO TID 2. HydrALAZINE 25 mg PO Q6H RX hydralazine 25 mg 1 tablet(s) by mouth every six (6) hours Disp #120 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 4. amLODIPine 10 mg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. ChlorproMAZINE 50 mg PO Q12H:PRN agitation 7. CloNIDine 0.3 mg PO TID 8. DiphenhydrAMINE 50 mg PO Q6H:PRN allergies 9. Latuda (lurasidone) 40 mg oral QHS 10. Lisinopril 10 mg PO DAILY 11. Metoprolol Succinate XL 50 mg PO BID 12. Mylanta 30 mL oral Q6H:PRN 13. OLANZapine 5 mg PO Q6H 14. Omeprazole 20 mg PO DAILY 15. OXcarbazepine 600 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Type B aortic dissection 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 very high blood pressure and imaging which showed a chronic type B aortic dissection. Your blood pressure is now controlled on oral medications, and you are ready to be discharged. You will be scheduled for elective open repair of your aortic dissection at your discretion. CALL THE OFFICE FOR : ___ A sudden increase in back or abdominal pain A sudden change in the ability to move or use your leg or the ability to feel your leg Temperature greater than 101.5F for 24 hours Chest pain Any other signs or symptoms that are concerning to you Followup Instructions: ___
10303503-DS-23	10,303,503	24,766,136	DS	23	2147-12-31 00:00:00	2148-01-07 23:53:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim / Penicillins Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo female history of UC and ___ s/p OLT presenting to the ED with diffuse abdominal pain that started around 7 AM this morning when she woke up. The patient reports the pain as being constant and predominantly in the LUQ and LLQ. It does not radiate. The pain is currently a ___. She has associated nausea but no vomiting. Last bowel movement was yesterday but reports having been constipated. No bloody bowel movement. No vaginal bleeding, dysuria, hematuria. She has not had her menses in ___ years, but no relationship to her menstrual cycle that she can tell. Patient had a recent liver biopsy on ___. She reports fever and chills on ___ but didnt not come in for labs until ___. She was started on cell cept secondary to mild rejection at that time. She reports nausea since starting this medication, but this has improved with spliting the doses up to 500mg qAM, 500mg at noon, and 1000mg qhs. . ___ reports not taking her Oxycontin as scheduled at home. In addition, she reports taking double doses of her dilaudid and not taking it according to her schedule. She was able to tolerate a ___ sandwhich, an apple, and a nutragrain bar without issue. . In the ED, initial VS were Pain 10 99.1 100 105/57 18 100% RA. Exam revealed diffuse abdominal tenderness but more significant in the left lower quadrant, no rebound or guarding; guaiac-negative brown stool. Labs were significant for hyperkalemia. EKG: sinus rhythm, no changes associated with hyperK. She was given dilaudid 1mg IV x2 and her pain improved. She also received 2L IVF, calcium gluconate, insulin, dextrose for hyperkalemia. CT abd/pelvis was negative for any acute process but did revealed left paracolic gutter fluid. Potassium was 5.1 prior to transfer to the floor. Most Recent Vitals: 97.2 TA, 96/60, 85, 99%RA. . Currently, she does not report abdominal pain and is able to get up and walk over to the thermostat to turn down the heat in the room. . REVIEW OF SYSTEMS: +headache, urinary urgency, decreased UOP -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: - S/p OLT ___ primary sclerosing cholangitis in - Ulcerative colitis (last ___ ___ - erythema in the cecum, ascending colon and mid-transverse colon. Normal mucosa in the sigmoid colon and rectum. - Gastroesophageal reflux disease - Herpes simplex viral infection - Chronic neck pain - Asthma - Migraine headaches - Iron deficiency anemia Social History: ___ Family History: Mother who died of cervical cancer young in ___. Father - healthy brother- healthy Uncle with ulcerative colitis Physical Exam: ADMISSION PHYSICAL EXAM: VS - 96.6 94/57 88 16 100% on RA 109lbs GENERAL - well-appearing female in NAD, comfortable, falling asleep during the interview and exam, quick to text on her phone but slow to roll over for lung exam HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits, well healed right lateral neck incision LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, systolic murmur, nl S1-S2 ABDOMEN - +BS, soft, well healed midline and perpendicular right horizonatl scar, nondistended, tender over LUQ and LLQ, no rebound/guarding, no fluid wave EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - multiple healed excoriations on limbs LYMPH - no cervical or inguinal LAD NEURO - falling asleep but A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, steady gait, no asterixis DISCHARGE PHYSICAL EXAM: VS - 98, 80-90/40-50, 80s, 16 100% on RA GENERAL - well-appearing female in NAD, comfortable, HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits, well healed right lateral neck incision LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, systolic murmur, nl S1-S2 ABDOMEN - +BS, soft, well healed midline and perpendicular right horizonatl scar, nondistended, tender over LUQ and LLQ, no rebound/guarding, no fluid wave EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - multiple healed excoriations on limbs LYMPH - no cervical or inguinal LAD NEURO - falling asleep but A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, steady gait, no asterixis Pertinent Results: LABS ON ADMISSION: ___ 03:45PM BLOOD WBC-2.6* RBC-3.18* Hgb-9.7* Hct-28.0* MCV-88 MCH-30.5 MCHC-34.7 RDW-15.1 Plt ___ ___ 03:45PM BLOOD Neuts-63.8 ___ Monos-4.1 Eos-11.9* Baso-0.4 ___ 03:45PM BLOOD ___ PTT-37.2* ___ ___ 03:45PM BLOOD Glucose-103* UreaN-24* Creat-1.3* Na-134 K-7.5* Cl-104 HCO3-26 AnGap-12 ___ 03:45PM BLOOD ALT-26 AST-88* AlkPhos-295* TotBili-0.5 ___ 05:05AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.6 ___ 03:45PM BLOOD tacroFK-14.9 ___ 03:52PM BLOOD Lactate-0.9 K-5.7* MYCOPHENOLIC ACID Test Name Flag Results Units Reference Value --------- ---- ------- ----- --------------- Mycophenolic Acid, S Mycophenolic Acid 1.4 mcg/mL 1.0 - 3.5 MPA Glucuronide H 123 mcg/mL 35 - 100 PERTINENT LABS: ___ 05:05AM BLOOD ___ ___ 05:05AM BLOOD Glucose-87 UreaN-22* Creat-1.2* Na-140 K-5.2* Cl-109* HCO3-27 AnGap-9 ___ 05:45AM BLOOD ALT-20 AST-19 AlkPhos-275* TotBili-0.4 ___ 05:05AM BLOOD ALT-19 AST-20 AlkPhos-265* TotBili-0.4 ___ 05:05AM BLOOD tacroFK-9.8 MICROBIOLOGY: ___ 3:45 pm BLOOD CULTURE Blood Culture, Routine (Pending): RADIOLOGY: CT ABD & PELVIS WITH CONTRAST Study Date of ___ 7:40 ___ Final Report INDICATION: History of liver transplant, ulcerative colitis, and splenomegaly, with significant diffuse abdominal pain, particularly at the left lower quadrant. COMPARISON: CTs available from ___ through ___ and MRCP from ___. TECHNIQUE: MDCT-acquired 5-mm axial images of the abdomen and pelvis were obtained following the uneventful administration of oral and 130 ml of Optiray intravenous contrast. Coronal and sagittal reformations were performed at 5-mm slice thickness. ABDOMEN: Included views of the lung bases demonstrate mild dependent atelectasis. There is no pericardial or pleural effusion. The heart size is normal. The patient is status post liver transplant. No focal intrahepatic lesions or intrahepatic bile duct dilation is present. The portal and hepatic veins are widely patent. A small amount of pneumobilia is present.. The gallbladder is surgically absent. Again seen are extensive splenic and paraesophageal varices (2:6, 24) and moderate splenomegaly. The pancreas, adrenal glands, kidneys, stomach, and intra-abdominal loops of small and large bowel are within normal limits. There is moderate degree of colonic fecal loading. Trace fluid along the left paracolic gutter (2:52) is new since the ___ examination. No neighboring bowel wall thickening is seen. There is no mesenteric or retroperitoneal lymphadenopathy, and no free air. PELVIS: There is a trace amount of intrapelvic free fluid (2:74), within physiological limits. Intrapelvic loops of small and large bowel appear normal. The appendix is normal (2:54). There is no intrapelvic lymphadenopathy. The urinary bladder and uterus are normal. No adnexal masses are detected. OSSEOUS STRUCTURES: There is no acute fracture. No concerning blastic or lytic lesions are identified. IMPRESSION: 1. No acute intra-abdominal or intrapelvic process detected. 2. Trace free fluid in the left paracolic gutter. No abnormal findings are seen in the adjacent loops of small and large bowel. 3. Unchanged splenomegaly and massive splenic and paraesophageal varices. 4. Status post liver transplant. No intra- or extra-hepatic bile duct dilation. Small foci of air near the left portal vein takeoff are smaller. CHEST (PA & LAT) Study Date of ___ 8:55 ___ IMPRESSION: No evidence of acute disease. Non-specific air-fluid levels in the epigastrium. Brief Hospital Course: ___ yo female history of UC, PSC s/p OLT, and chronic left upper quadrant abdominal pain presents with nausea and left sided abdominal pain. . # Abdominal pain: CT on admission showed fecal loading, pain most likely related to constipation from heavy opiate use at home. The pt doubled her home dose of PO Dilaudid and stopped taking her home laxatives. We decreased her Dilaudid dose back to her home regimen and restarted senna, docusate sodium and polyethylene glycol. The pt multiple bowel movement and her pain resolved. She was encouraged to take her home pain medications at the doses prescribed and to continue to take laxative medications on a daily basis. . # Primary Sclerosing Cholangitis s/p Liver Transplant: We continued her home regimen of Mycophenolate Mofetil and Tacrolimus. We checked levels of both medications and they were at out therapeutic range goals. She also was continued on inhaled Pentamidine for PCP ___. . # Ulcerative Cholitis: The patient denied any bloody bowel movements and actually was complaining of abdominal discomfort from constipation. We continued Mesalamine. . #Transitional:Follow up appointments were made for her with the liver ___. She was instructed to continue to have her blood drawn regularly on ___ and ___. The results will continue to be faxed to the ___ follow up. Medications on Admission: -albuterol sulfate 90 mcg HFA Aerosol Inh 2 puffs(s) prn prior to pentamidine -desogestrel-ethinyl estradiol 0.15 mg-0.03 mg Tablet daily -ergocalciferol 50,000 unit Capsule by mouth Q week on ___ X 12 wks -nr hydromorphone 4 mg Tablet by mouth 4 hours -nr lorazepam 1 mg Tablet by mouth one to two times a day -mesalamine [Asacol HD] 800 mg Tablet, 3 Tablet(s) bid -mycophenolate mofetil 500 mg Tablet by mouth qid Mylan generic brand preferred. -ondansetron 4 mg Tablet, Rapid Dissolve po bid-tid prn nausea -nr oxycodone [OxyContin] 30 mg Tablet ER 12 hr bid -pentamidine [Nebupent] 300 mg Recon Soln inh qmonth -tacrolimus 1 mg Capsule 3 Capsule(s) by mouth twice a day -ursodiol 300 mg Capsule 3 Capsule(s) by mouth a day -nr zolpidem 5 mg Tablet PO qhs prn -calcium carbonate-vitamin D3 500 mg calcium (1,250 mg)-400 unit 2 qhs Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: ___ puffs Inhalation prior to pentamidine. 2. desogestrel-ethinyl estradiol 0.15-30 mg-mcg Tablet Sig: One (1) Tablet PO once a day. 3. hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety/insomnia. 5. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Six (6) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 6. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 7. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 8. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 9. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 10. oxycodone 10 mg Tablet Extended Release 12 hr Sig: Three (3) Tablet Extended Release 12 hr PO Q12H (every 12 hours). 11. pentamidine 300 mg Recon Soln Sig: One (1) Inhalation once a month. 12. ursodiol 300 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 13. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 14. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit Tablet Sig: Two (2) Tablet PO at bedtime. 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:6 16. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:6 17. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) PO once a day. Disp:30 17g Refills:6 Discharge Disposition: Home Discharge Diagnosis: Abdominal pain / Constipation liver transplant ulcerative colitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, It was a pleasure taking care of you at ___ ___. You were admitted to the hospital with abdominal pain. A CT scan of your abdomen showed that you were significantly constipated. This degree of constipation was most likely causing your abdominal pain. The opiate medications that you currently are taking can lead to constipation. It is very important that you continue to take stool softeners on a daily basis. Please make sure to continue to get your blood work done on ___ and ___. The following changes have been made to your medications: START: Docusate Sodium 100mg by mouth twice per day Senna 1 tablet by mouth twice per day Polyethylene Glycol 17g by mouth once per day Please see below for follow-up appointments that have been made on your behalf. Followup Instructions: ___
10303503-DS-25	10,303,503	25,589,249	DS	25	2148-10-15 00:00:00	2148-10-19 14:32:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim / Penicillins Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ with history of ulcerative colitis complicated by primary sclerosing cholangitis and cirrhosis requiring liver transplant in ___ in ___ who presents with abdominal pain. Patient reports that she was in her usual state of health until 3 days ago when she developed general malaise and abdominal pain. She reports that pain was located in RUQ and initially felt like constipation. She took some magnesium citrate and had a BM however did it not relieve her pain. She describes her pain has squeezing in nature and radiating to right flank and shoulder. She denies fevers, urinary symptoms, or ETOH use however endorsed chills (which occurs at baseline). She denies nausea, vomiting, and diarrhea. Given her ongoing pain she presented to the ED for evaluation. Of note patient has had several admissions in the past for similar complaints of abdominal pain. In most cases, the etiology is unknown and sometimes attributed to MSK related. The patients reports that her prior pain was in the LUQ and her RUQ and flank pain are new. In the ED, initial vs were 98.3 115 106/68 20 98%. Exam was significant for a tender abdomen. Of note because of pain, patient was not very cooperative with exam. Received dilaudid 1mg IV x4, toradol 15mg x 1, lorazepam 2mg x 1, zofran 4mg x 1, and cipro/flagyl. She also received a total of 2LNS. Labs were otherwise unremarkable except an alk phos of 258 and Cr 1.2 (baseline 0.9-1.0). RUQ ultrasound was otherwise unremarkable. While in ED, patient began to feel better and diet was advanced to clear liquids. Transfer VS 97.9 87 99/60 16 100%. On arrival to the floor, VS were 98.3 125/81 105 20 100%RA. Patient was continuing to complain of significant abdominal pain, very tearful, asking for the same pain meds as given in the ED. Past Medical History: - S/p OLT ___ primary sclerosing cholangitis - Ulcerative colitis (last ___ ___ - Gastroesophageal reflux disease - Herpes simplex viral infection - Chronic neck pain - Asthma - Migraine headaches - Iron deficiency anemia Social History: ___ Family History: Mother who died of cervical cancer young in ___. Father - healthy brother- healthy Uncle with ulcerative colitis Physical Exam: Admission Exam: VS: 98.3 125/81 105 20 100%RA GEN: awake, alert, tearful, crying HEENT: OP clear, no LAD PULM: CTAB, but pt vocalizing during exam CV: RRR no m/r/g ABD: +BS, soft, diffusely tender to palpation, but pt reacting to even light touch, no rebound, voluntary guarding EXT: WWP, no edema Discharge Exam: GEN: awake, alert, anxious PULM: CTAB, but pt vocalizing during exam CV: RRR no m/r/g ABD: +BS, soft, diffusely tender to palpation, but pt reacting to even light touch, no rebound, voluntary guarding EXT: WWP, no edema Pertinent Results: Admission Labs: ___ 09:40AM BLOOD WBC-3.3* RBC-4.24 Hgb-12.5 Hct-35.4* MCV-84 MCH-29.4 MCHC-35.2* RDW-13.1 Plt ___ ___ 09:40AM BLOOD Neuts-59.2 ___ Monos-4.9 Eos-12.5* Baso-0.2 ___ 09:40AM BLOOD ___ PTT-37.6* ___ ___ 09:40AM BLOOD Glucose-105* UreaN-17 Creat-1.2* Na-141 K-4.8 Cl-104 HCO3-25 AnGap-17 ___ 09:40AM BLOOD ALT-39 AST-27 AlkPhos-258* TotBili-0.9 ___ 09:40AM BLOOD Albumin-4.0 ___ 08:32AM BLOOD Albumin-3.4* Calcium-8.8 Phos-3.6 Mg-2.0 ___ 09:52AM BLOOD Lactate-1.3 Additional labs: ___ 06:00AM BLOOD IgA-175 ___ 06:00AM BLOOD tTG-IgA-10 ___ 06:00AM BLOOD tacroFK-7.0 ___ 08:32AM BLOOD tacroFK-7.2 HELICOBACTER PYLORI ANTIBODY TEST (Final ___: NEGATIVE BY EIA. (Reference Range-Negative). Urine: ___ 09:45AM URINE Color-Yellow Appear-Clear Sp ___ ___ 09:45AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-8* pH-6.0 Leuks-NEG ___ 09:45AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-2 ___ 09:45AM URINE CastHy-7* ___ 09:45AM URINE Mucous-RARE Discharge Labs: ___ 06:00AM BLOOD WBC-2.7* RBC-3.72* Hgb-10.8* Hct-31.1* MCV-84 MCH-29.1 MCHC-34.8 RDW-13.1 Plt ___ ___ 06:00AM BLOOD Glucose-93 UreaN-12 Creat-1.0 Na-138 K-5.2* Cl-106 HCO3-25 AnGap-12 ___ 08:32AM BLOOD ALT-34 AST-21 AlkPhos-229* TotBili-0.9 ___ 06:00AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0 Micro: ___ Blood cultures x 2 - PENDING (no growth to date) ___ Urine cultures x 2 - FINAL no growth Imaging: ___ Liver/Gallbladder U/S: IMPRESSION: 1. Normal-appearing liver, with patent hepatic vasculature and appropriate directional flow. 2. Unchanged splenomegaly with lobulated splenic contour likely related to prior infarcts which were better evaluated on the prior CT. EKG ___: Sinus rhythm. Probably normal tracing for age. Since the previous tracing of ___ probably no significant change. CXR ___: FINDINGS: PA and lateral views of the chest were obtained. The lungs are well expanded and clear. The cardiomediastinal silhouette is unremarkable. Brief Hospital Course: ___ with history of ulcerative colitis complicated by PSC and cirrhosis requiring OTL in ___ in ___ who presents with abdominal pain. Active issues: # Abdominal Pain: Patient with chronic abdominal pain of unclear etiology. No acute process was revealed by work-up during this admission. RUQ ultrasound was reassuring as well as mostly normal labs. Alk phos mildly elevated which is concerning for biliary process however it is at her baseline. Common processes include viral gastroenteriis v. gastritis v. PUD v. dyspepsia. Patient tolerated regular diet well. We started the patient on bentyl and uptitrated her PPI. We maintained her home narcotic regimen. Close follow-up appointments were scheduled with the patient's PCP and transplant service physician. # Acute kidney injury: Cr 1.2 at admission. Baseline Cr 0.9-1.0. Likely in setting of poor PO intake. Received fluid in ED, tolerated regular diet and Cr returned to baseline. Chronic issues: # S/P Liver Transplant: Stable. Continued home medications # Leukopenia/thrombocytopenia: At baseline Transitional issues: -Patient with continued chronic abdominal pain of uncertain etiology. -Patient lost some insurance coverage as was planning to start a job in the beginning of ___. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Apri NF (desogestrel-ethinyl estradiol) 0.15-30 mg-mcg Oral daily 2. FoLIC Acid 1 mg PO DAILY 3. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain 4. HydrOXYzine 25 mg PO QID 5. imiquimod NF 5 % Topical 3x/week 6. Lorazepam 1 mg PO BID:PRN anxiety 7. Mesalamine ___ 2400 mg PO BID 8. Mycophenolate Mofetil 500 mg PO BID 9. Omeprazole 20 mg PO DAILY 10. Tacrolimus 4 mg PO Q12H 11. Ondansetron 4 mg PO BID-TID:PRN nausea 12. Oxycodone SR (OxyconTIN) 30 mg PO Q12H 13. Ursodiol 300 mg PO TID 14. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 15. Calcarb 600 With Vitamin D NF (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit Oral 2 tablets BID 16. Docusate Sodium 100 mg PO BID 17. Claritin-D 12 Hour NF (loratadine-pseudoephedrine) ___ mg Oral daily Discharge Medications: 1. Apri NF (desogestrel-ethinyl estradiol) 0.15-30 mg-mcg Oral daily 2. Docusate Sodium 100 mg PO BID 3. FoLIC Acid 1 mg PO DAILY 4. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain 5. Lorazepam 1 mg PO BID:PRN anxiety 6. Mesalamine ___ 2400 mg PO BID 7. Mycophenolate Mofetil 500 mg PO BID 8. Omeprazole 40 mg PO DAILY RX omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #30 Capsule Refills:0 RX omeprazole 40 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 9. Ondansetron 4 mg PO BID-TID:PRN nausea 10. Oxycodone SR (OxyconTIN) 30 mg PO Q12H 11. Tacrolimus 4 mg PO Q12H 12. Ursodiol 300 mg PO TID 13. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 14. Calcarb 600 With Vitamin D NF (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit Oral 2 tablets BID 15. Claritin-D 12 Hour NF (loratadine-pseudoephedrine) ___ mg Oral daily 16. HydrOXYzine 25 mg PO QID 17. imiquimod NF 5 % Topical 3x/week 18. DiCYCLOmine 20 mg PO TID 1 hour prior to meals RX dicyclomine 20 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 RX dicyclomine 20 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY Abdominal pain SECONDARY status-post liver transplant Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleausre taking care of you at ___. You were admitted with abdominal pain. You were evaluated by medical doctors. ___ tests did not show sign of infection or other liver problem. You were stable and ready for discharge. Followup Instructions: ___
10303503-DS-27	10,303,503	29,241,832	DS	27	2149-11-03 00:00:00	2149-11-05 13:58:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim / Penicillins Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: Liver biopsy (___) History of Present Illness: ___ yo F with PMH of ulcerative colitis and PSC s/p OLT in ___ who presents with fever. This week, patient was in her usual health when she went to Liver Clinic for routine labs and was found to have elevated LFTs. Repeat labs later in the week were also elevated and RUQ US was performed which was unremarkable. Patient was asymptomatic except for chronic LUQ pain and recurrent migraines. Was called by Liver Clinic this morning to arrange for liver biopsy on ___ and advised that she should seek immediate medical evaluation if she develops any alarming symptoms such as fever. This afternoon, she awoke with a migraine and fever of 102 at home. Came to the ED for evaluation. Other than the migraine, she reports worsening abdominal pain, mostly in LUQ. She describes it as crampy, ___, and localized. She denies any increased abdominal distention, diarrhea, or constipation. Had a normalbowel movement day before, with no melena or hematochezia. She denies any nausea, except for one episode last night when felt hot and drank a large quantity of water quickly, resulting in nausea and one episode of NBNB emesis. She reports decreased PO intake over last day, but she had normal appetite prior. She reports increased pruritus but denies any new skin lesions. She reports a headache that is similar to her recurrent migraines. It is associated with photophobia but no phonophobia. She has some chronic neck soreness but denies any neck stiffness. She denies lightheaded or blurry vision. She denies any increased congestion (has baseline rhinorrhea). Denies chest pain, cough, SOB, dysuria, and hematuria. Denies recent medication changes. No sick contacts. No flu shot. She complains only of fatigue and malaise. In the ED, initial vital signs were 98.8, 125, 103/63, 16, 100% RA. She remained afebrile, but reported headache and abdominal pain. Patient was given Zofran, Fioricet, IV Dilaudid, and 1 L of IVF. Liver US with Dopplers was performed and showed no thrombosis of biliary dilation. Past Medical History: - PSC s/p OLT in ___ - Ulcerative colitis (last colonoscopy ___ - GERD - Iron deficiency anemia - HSV infection - Chronic neck pain - Asthma - Migraine headaches Social History: ___ Family History: Mother died of cervical cancer in ___. Uncle with ulcerative colitis. Physical Exam: ADMISSION EXAM VS: 98, 98, 99/59, 20, 100% RA General: AAOx3, NAD, sitting in bed with iPad HEENT: Sclera anicteric, PERRLA, EOMI, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD, no nuchal rigidity CV: RRR, nl S1/S2, no MRG Lungs: CTAB, no wheezes/rales/rhonchi Abdomen: Soft, LUQ tenderness, ___, no rebound/guarding, normoactive bowel sounds GU: Deferred Ext: Warm, ___, no cyanosis/clubbing/edema Neuro: CN ___ grossly intact Skin: No jaundice, no concerning lesions DISCHARGE EXAM VS: 97.8, 96, 143/65, 20, 98% RA General: Sleepy HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, no LAD CV: RRR, nl S1/S2, no MRG Lungs: CTAB, no wheezes/rales/rhonchi Abdomen: Soft, LUQ tenderness to light palpation not auscultation, ___, no rebound/guarding, normoactive bowel sounds GU: Deferred Ext: Warm, ___, no cyanosis/clubbing/edema Neuro: CN ___ grossly intact Skin: No jaundice, no concerning lesions Pertinent Results: ADMISSION LABS ___ 05:55PM BLOOD ___ ___ Plt ___ ___ 05:55PM BLOOD ___ ___ ___ 09:30AM BLOOD ___ ___ ___ 05:55PM BLOOD ___ ___ ___ 05:55PM BLOOD ___ ___ ___ 05:55PM BLOOD ___ ___ 05:55PM BLOOD ___ ___ 06:07PM BLOOD ___ ___ 09:30PM URINE ___ Sp ___ ___ 09:30PM URINE ___ ___ ___ ___ 09:30PM URINE ___ DISCHARGE LABS ___ 10:40AM BLOOD ___ ___ Plt ___ ___ 10:40AM BLOOD ___ ___ ___ 10:40AM BLOOD ___ ___ ___ 10:40AM BLOOD ___ ___ 10:40AM BLOOD ___ ___ 10:40AM BLOOD ___ MICROBIOLOGY: All blood, urine, and stool cultures NEGATIVE or PENDING on day of discharge. IMAGING MRCP (___): ___ transplant. No suspicious enhancement. No intrahepatic duct dilatation or peribiliary enhancement. Study slightly limited by motion however hepatic arteries appear patent. The intrahepatic portal veins have increased in caliber compared to study of ___. No evidence of thrombosis and this likely relates to underlying portal hypertension. The paraesophageal and splenic varices are slightly more prominent. Unchanged gastric fundal varices. Unchanged splenomegaly with areas of splenic infarction. Trace fluid adjacent to the spleen. No significant ascites. Pancreas, kidneys and adrenal unremarkable. Abdominal Doppler US (___): Normal biliary system. Liver parenchyma looks normal. All hepatic vessels are within normal limits. Massive splenomegaly, a chronic finding. CXR (___): No significant interval change. Abdominal US (___): Patent hepatic vasculature. Unremarkable appearance of the transplanted liver with no biliary dilatation. Splenomegaly. Brief Hospital Course: ___ yo F with PMH of ulcerative colitis and primary sclerosing cholangitis s/p OLT in ___ who presents with fever. ACTIVE ISSUES # Cholangitis: Patient presented with fever. In the setting of elevated LFTs this was most concerning for cholangitis. Patient covered broadly with meropenem and linezolid given history of VRE abscess. RUQ US on admission did not show any biliary dilation. Subsequent MRCP was not suggestive of cholangitis. Antibiotics were discontinued given clinical stability. Liver biopsy on day prior to discharge consistent with cholangitis due to recurrence of primary sclerosing cholangitis. Because of this meropenem was restarted. This was switched to ciprofloxacin and Flagyl the next day so that patient could be discharged on a PO regimen. She will complete a 2 week course of antibiotics as an outpatient. # Elevated LFTs: Obstructive pattern. Elevation was discovered prior to onset of symptoms. Liver biopsy was remarkable for recurrent PSC. Managed as above. # Pruritus: Due to elevated bilirubin. Managed with ursodiol and hydroxizine. CHRONIC ISSUES # Liver transplant: Continued home tacrolimus. Levels were acceptable. # Ulcerative colitis: Denied any symptoms of flare. Last colonoscopy in ___ was normal with the exception of few inflammatory polyps. Continued mesalamine. # Migraines: Initially continued Fioricet but this was subsequently held and then discontinued on discharge per Transplant Pharmacy. Patient should be referred to headache specialist as outpatient. # Chronic abdominal pain: Continued home dicyclomine. Patient was initially given IV Dilaudid as needed for pain. Due to multiple drug seeking behaviors including demanding medications be pushed, this was infused in 50 mL NS over 15 minutes. Patient subsequently taken off IV pain medications. Her pain was ___ on discharge home. TRANSITIONAL ISSUES - On ciprofloxacin and Flagyl to complete a 2 week course for cholangitis - Discontinued Fioricet given hepatotoxicity of Butalbital - Not discharged with pain medications. All of this is through Liver Clinic. - ___ with PCP scheduled - ___ with Liver Clinic scheduled Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ___ 1 TAB PO Q8H:PRN migraine 2. ___ estradiol ___ oral daily 3. DiCYCLOmine 20 mg PO TID W/MEALS 4. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 5. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain 6. HydrOXYzine 25 mg PO Q6H:PRN itching 7. Hyoscyamine 0.125 mg SL Q6H:PRN pain 8. Mesalamine ___ 2400 mg PO BID 9. Omeprazole 20 mg PO DAILY 10. Ondansetron 4 mg PO Q8H:PRN nausea 11. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H 12. Tacrolimus 2 mg PO Q12H 13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 14. Ursodiol 900 mg PO DAILY 15. Zolpidem Tartrate 5 mg PO HS:PRN insomnia Discharge Medications: 1. DiCYCLOmine 20 mg PO TID W/MEALS 2. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain 3. HydrOXYzine 25 mg PO Q6H:PRN itching 4. Hyoscyamine 0.125 mg SL Q6H:PRN pain 5. Mesalamine ___ 2400 mg PO BID 6. Omeprazole 20 mg PO DAILY 7. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H 8. Tacrolimus 2 mg PO Q12H 9. Ursodiol 900 mg PO DAILY 10. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #20 Tablet Refills:0 11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #30 Tablet Refills:0 12. ___ estradiol ___ oral daily 13. Ondansetron 4 mg PO Q8H:PRN nausea 14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 15. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 16. Zolpidem Tartrate 5 mg PO HS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Cholangitis Secondary diagnosis: Ulcerative colitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You are being discharged from ___ ___. You came in with fever and were found on liver biopsy to have mild cholangitis. You were treated with IV antibiotics for this and are being discharged on PO antibiotics which you should take for the next ___ days. We discussed your medications with the transplant pharmacist and she recommended that you stop taking Fioricet as it is not good for your transplant liver. Please be sure to take all of your medications as listed below. Please keep all of your ___ appointments. Followup Instructions: ___
10303503-DS-29	10,303,503	25,721,282	DS	29	2150-01-09 00:00:00	2150-01-10 09:13:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim / Penicillins Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: R IJ placement History of Present Illness: Ms. ___ is a ___ y/o female with a history of ulcerative colitis, PSC ___ years and 11 months s/p orthotopic liver transplant on tacrolimus, and chronic abdominal pain who presents with abdominal pain. The patient reports that the pain started around 4AM this morning and did not improve with home dilaudid or oxycodone and for this reason she presented to her PCP office and was then sent to ED for further evaluation. The pain is across her entire lower ribs and spreasd over the entire abdomen and described as dull craming in nature. The pain is reported to be so bad that she feels she cannot walk straight and has to lean forward to be able to move. She endorses chils but no fever and nausea without emesis. She also has had a decreased appetite. She also reports severe pruritis that has not improved with hydroxzine or benadryl and is keeping her up at night. Of note, the patient was most recently admitted from ___ to ___ for abdominal pain and treated for cholangitis. She was initially started on meropenem/linezolid given history of VRE abscess in the liver and was then transitioned to cipro/flagyl for ___nding on ___. In the ED, initial vitals were T 98.8, HR 88, BP 118/73, RR 18, O2 100% on RA. Lab work was significant for normal WBC, ALT 83, AST 52, AP 319, TBili 2.5, and normal electrolytes. Initially IV access was an issue and SQ morphine was given for pain control. A right IJ was placed for access. The patient was given 1mg IV dilaudid x 2, ativan 2mg. Abd US showed splenomegaly but patent vasculature and no ascites. CXR showed clear lungs. VS prior to transfer: 98.2 99 113/70 18 99% RA On the floor, standing from door, pt appears comfortable NAD, on entry into room, pt immediately tearful, complaining of abdominal pain and headache. Corroborates above story, says she felt well at recent discharge but had sudden onset of abdominal pain at 4 am this morning. Past Medical History: - Abdominal Pain earlier this month of unknown origin. Attributed to cholangitis after negative CT Abdomen. Improved with Antibiotics - PSC s/p OLT in ___ - Ulcerative colitis (last colonoscopy ___ - GERD - Iron deficiency anemia - HSV infection - Chronic neck pain - Asthma - Migraine headaches Social History: ___ Family History: Mother died of cervical cancer in ___. Uncle with ulcerative colitis. Physical Exam: On Admission: VS- T98 BP 120/69 ___ RR 20 O2 sat 100%RA General- Tearful appearing young female, NAD HEENT- NCAT, OP clear, PERRLA Neck- Right IJ in place, neck supple, no appreciable LAD CV- RRR, normal S1/S2, no M/R/G Lungs- CTAB no wheezing, rales, rhonchi Abdomen- Soft, Tender to soft palpation diffusely, hypoactive bowel sounds, cannot appreciate any hepatomegaly or splenomegaly GU- no foley Ext- WWP, 2+ pulses bilaterally, no clubbing, cyanosis or edema Neuro- CN ___ grossly intact, strength and sensation grossly normal Skin- mildly jaundiced, no rashes, lesions On Discharge: General- Tearful, anxious HEENT- NCAT, OP clear, PERRLA Neck- Former IJ site c/d/i no erythema or hematoma CV- RRR, normal S1/S2, no M/R/G Lungs- CTAB no wheezing, rales, rhonchi Abdomen- Soft, distractable tenderness to palpation, NABS GU- no foley Ext- WWP, 2+ pulses bilaterally, no clubbing, cyanosis or edema Neuro- CN ___ grossly intact, strength and sensation grossly normal Skin- no jaundice, no rashes, lesions Pertinent Results: On Admission: ___ 10:05AM BLOOD WBC-5.5 RBC-4.06* Hgb-11.4* Hct-35.9* MCV-88 MCH-28.0 MCHC-31.7 RDW-13.5 Plt ___ ___ 10:05AM BLOOD ___ PTT-38.2* ___ ___ 10:05AM BLOOD Glucose-97 UreaN-10 Creat-0.9 Na-141 K-4.0 Cl-108 HCO3-23 AnGap-14 ___ 10:05AM BLOOD ALT-83* AST-52* AlkPhos-319* TotBili-2.5* ___ 10:05AM BLOOD Calcium-9.6 Phos-3.7 Mg-1.6 ___ 05:51PM BLOOD Lactate-0.7 ON DISCHARGE: ___ 05:25AM BLOOD WBC-4.3 RBC-3.84* Hgb-11.0* Hct-33.4* MCV-87 MCH-28.8 MCHC-33.1 RDW-13.2 Plt ___ ___ 05:25AM BLOOD ___ PTT-36.0 ___ ___ 05:25AM BLOOD Plt ___ ___ 05:25AM BLOOD Glucose-98 UreaN-6 Creat-0.6 Na-143 K-4.1 Cl-109* HCO3-27 AnGap-11 ___ 05:25AM BLOOD ALT-109* AST-68* AlkPhos-273* TotBili-1.2 ___ 05:25AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.5* ___ 05:25AM BLOOD tacroFK-5.9 IMAGING: Abd US with Doppler: IMPRESSION: 1. No focal hepatic lesion or biliary dilatation. 2. Patent hepatic vasculature with appropriate waveforms. 3. Splenomegaly. CXR ___: Lung volumes are low, accentuating the cardiac silhouette and pulmonary vasculature. Cardiomediastinal silhouette and hilar contours are unremarkable. Lungs are clear. Pleural surfaces are clear without effusion or pneumothorax. A right internal jugular approach central venous catheter terminates at the cavoatrial junction. IMPRESSION: No acute cardiopulmonary abnormality. A right internal jugular central venous catheter terminating at the cavoatrial junction. CXR ___: PA and lateral views of the chest were provided. Right IJ central venous catheter is in unchanged position with its tip located at the level of the low SVC. The lungs remain clear. No effusion or pneumothorax. The cardiomediastinal silhouette is normal. No free air below the right hemidiaphragm. Brief Hospital Course: Ms. ___ is a ___ y/o F with PMH of ulcerative colitis and PSC now s/p OLT ___ who presented with acute on chronic abdominal pain. # Acute on Chronic Abdominal Pain: Patient is s/p orthotopic liver transplant, recently admitted w/similar complaints treated for cholangitis and improvement with antibiotics. US this admission unrevealing wtih patent vasculature, continues to have splenomegaly. UA without significant signs of infection. Patient treated intially with IV Dilaudid. Continued home dicyclomine. Blood cultures NGTD. Tbili intiatally trended up to 2.7 for unclear reasons but then decreased back to the normal range the next day. Patient was transitioned to oral diet and resumed her oral pain regimen. The pain service was consulted and felt that the pain was consistent with musculoskeletal pain (reproducible with palpation and certain movements). Reported pain was disproportionate to exam, and was distractable. Patient also requested IV pushes of dilaudid stating that when the medication was hung in a bag, it was ineffective. Flexeril was started at the recommendation of pain and at the strong request of the patient, though she was counseled that it can cause hepatotoxicity and her LFTs will need close monitoring. # Pruritus: Likely secondary to elevated bilirubin. Continued home Ursodiol and hydroxizine. # Liver transplant: s/p OLT in ___ secondary to Primary sclerosing cholangitis. Biopsy on ___ showed recurrent PSC with mild focal, moderate portal, minimal periportal and lobular mixed inflammation, focal lymphocytic cholangitis and scattered periductal neutrophils and no evidence of acute cell rejection. Continued home tacrolimus. # Ulcerative colitis: Denies any symptoms of flare. Last colonoscopy in ___ was normal with the exception of few inflammatory polyps. Continued home mesalamine. # Migraines: Holding Fioricet per Transplant Pharmacy. Gave tylenol prn. Patient should see headache specialist as outpatient. TRANSITIONAL: 1. Attempt to wean home opioids 2. Please follow LFTs closely while taking cyclobenzaprine. 3. Please arrange follow-up with pain clinic, would benefit from psychosocial support Medications on Admission: The Preadmission Medication list is accurate and complete. 1. DiCYCLOmine 20 mg PO TID W/MEALS 2. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain 3. HydrOXYzine 25 mg PO Q6H:PRN itching 4. Hyoscyamine 0.125 mg SL Q6H:PRN pain 5. Mesalamine ___ 2400 mg PO BID 6. Omeprazole 20 mg PO DAILY 7. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H 8. Tacrolimus 2 mg PO Q12H 9. Ursodiol 900 mg PO DAILY 10. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 11. desogestrel-ethinyl estradiol 0.15-30 mg-mcg oral daily 12. Ondansetron 4 mg PO Q8H:PRN nausea 13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 14. Zolpidem Tartrate 5 mg PO HS:PRN insomnia Discharge Medications: 1. desogestrel-ethinyl estradiol 0.15-30 mg-mcg oral daily 2. DiCYCLOmine 20 mg PO TID W/MEALS 3. HydrOXYzine 25 mg PO Q6H:PRN itching 4. Hyoscyamine 0.125 mg SL Q6H:PRN pain 5. Mesalamine ___ 2400 mg PO BID 6. Omeprazole 20 mg PO DAILY 7. Ondansetron 4 mg PO Q8H:PRN nausea 8. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H 9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 10. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 11. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain 12. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 13. Tacrolimus 2.5 mg PO Q12H RX tacrolimus 0.5 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 14. Cyclobenzaprine 5 mg PO BID:PRN muscle pain RX cyclobenzaprine 5 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:0 15. Ursodiol 300 mg PO TID RX ursodiol 300 mg 1 capsule(s) by mouth three times a day Disp #90 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Abdominal pain Abnormal liver function tests Liver transplant Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted because of abdominal pain. Your workup revealed no evidence of infection and you were not given any antibiotics. Your liver function tests were normal upon discharge. The pain you are having is most likely muscle strain. The pain specialists evaluated you and recommended flexeril, a muscle relaxant. You may use this medication sparingly, but please do not exceed the recommended dose, as it can cause liver injury. Please follow-up in the pain clinic upon discharge to further assist with pain control. We increased the dose of your tacrolimus from 2mg daily to 2.5mg daily. Please follow-up with the transplant specialists to ensure that the levels in your blood are appropriate. Followup Instructions: ___
10303503-DS-30	10,303,503	21,361,796	DS	30	2152-07-17 00:00:00	2152-07-17 19:47:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim / Penicillins / Feraheme Attending: ___ Chief Complaint: Nausea/vomiting, ___ Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo female h/o liver transplant ___ on tacrolimus, ulcerative colitis, chronic abdominal pain, reports of drug-seeking/drug diversion who presented to nausea/vomiting. Last night, patient ate barbecue food, eggs and a pasta salad at work, which were not things she usually eats. This morning, she developed severe nausea with diarrhea. Her nausea was initially similar in color to the food she ate, but later became bilious. Otherwise, no hematemesis, hematochezia or melena. Pt has had difficulty tolerating PO over the course of the days. She notes acute on chronic abdominal pain during the day as well. No one else she knows of had similar symptoms. She presented to ___ ED for further evaluation. Of note, pt missed her tacrolimus dose yesterday. At ___ ED, VS were: 97.6; 116; 93/70; 18; 97% RA Labs were notable for: Normal CBC Cr 1.4 (baseline 1.0-1.2) ALT: 50 AST: 39 AP: 374 Tbili: 0.5 Alb: 4.6 Imaging/studies: CT abd/pelv w contrast 1. No acute intra-abdominal or intrapelvic abnormalities. 2. Essentially noncontrast exam. Unremarkable transplant liver. She was given: ondansetron 4mg IV x2, ketorolac IV 15mg x1, 250mL D5W, 500cc NS, Mg 2g x1 IV, Hydromorphone 4mg PO x1 She was admitted to ET for further workup. At the time of our meeting, pt reported feeling much better and was able to tolerate PO. Past Medical History: - Abdominal Pain earlier this month of unknown origin. Attributed to cholangitis after negative CT Abdomen. Improved with Antibiotics - PSC s/p OLT in ___ - Ulcerative colitis (last colonoscopy ___ - GERD - Iron deficiency anemia - HSV infection - Chronic neck pain - Asthma - Migraine headaches Social History: ___ Family History: +Crohns, bone ca, HTN, HLD, DM. Physical Exam: ADMISSION EXAM ============ Vital Signs: 98.2; 117/79; 90; 18; 96 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-distended, bowel sounds present, no organomegaly. TTP in LLQ with some guarding but no rebound. GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. DISCHARGE EXAM ============ Vital Signs: ___ 97-100/RA General: NAD HEENT: no scleral icterus, MMMs CV: RRR no m/r/g Lungs: CTAB Abdomen: Soft nt/nd GU: No foley Ext: wwp no edema Neuro: A&Ox3 Pertinent Results: ============================== ADMISSION / DISCHARGE LABS ============================== ___ 11:00AM BLOOD WBC-7.7 RBC-4.93 Hgb-14.5 Hct-43.1 MCV-87 MCH-29.4 MCHC-33.6 RDW-12.4 RDWSD-39.4 Plt ___ ___ 05:10AM BLOOD WBC-3.1# RBC-3.48# Hgb-10.2# Hct-30.2# MCV-87 MCH-29.3 MCHC-33.8 RDW-12.5 RDWSD-39.4 Plt Ct-72# ___ 11:00AM BLOOD Glucose-134 UreaN-26* Creat-1.4* Na-139 K-3.8 Cl-103 HCO3-22 AnGap-18 ___ 05:10AM BLOOD Glucose-106* UreaN-25* Creat-1.0 Na-140 K-4.0 Cl-110* HCO3-21* AnGap-13 ___ 11:00AM BLOOD ALT-50* AST-39 AlkPhos-374* TotBili-0.5 ___ 05:10AM BLOOD ALT-29 AST-20 AlkPhos-237* TotBili-0.6 ___ 11:00AM BLOOD Albumin-4.6 Calcium-9.6 Phos-2.9 Mg-1.5* ___ 05:10AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.9 ___ 11:59AM BLOOD Lactate-2.1* ___ 12:45PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM ___ 12:45PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 TacroFK 2.6 ========================== IMAGING ============================= None ============================= MICROBIOLOGY ============================= Urine Cx - pending Brief Hospital Course: ___ yo female h/o PSC s/p liver transplant ___ on tacrolimus, ulcerative colitis, chronic abdominal pain, presents with nausea/vomiting and ___. ACUTE ISSUES: #Nausea/vomiting/diarrhea: Presentation most likely gastroenteritis or viral gastroenteritis given report of immediately sickening after eating food at a ___ picnic. Several others at the same meal came down with similar symptoms. A CT abdomen/pelvins done in the ED showed no acute processes. After administration of IVF at time of discharge patient had recovered virtually to baseline. # ___: Cr increased from baseline 1.0 to 1.4 on admission, likely pre-renal in the setting of volume depletion. After IVF patient returned to baseline of 1.0 on discharge. # PSC s/p liver transplant: Patient's tacrolimus level was low after missing 1 dose of tacro in the setting of nausea/vomiting. Her tacrolimus was restarted as normal upon discharge. Home ursodiol was continued. CHRONIC ISSUES: # Ulcerative colitis: Continued home mesalamine # Chronic pain: Continued home oxycontin and dilaudid # Depression: Continued home despiramine # Osteoporosis: Continued calcium/vitamin D TRANSITIONAL ISSUES: -Patient was noted to be pancytopenic during hospitalization (WBC 3.1, H/H 10.2/30.2, platelet count 72). This was thought to be secondary to underlying virus. Please obtain repeat CBC as outpatient to assess resolution of the pancytopenia. -Please re-check tacrolimus level as an outpatient. #CONTACT: ___ (father) ___ #CODE STATUS: Full Code (confirmed) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 4 mg PO Q8H:PRN Nausea 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 3. Desipramine 75 mg PO QHS 4. desogestrel-ethinyl estradiol 0.15-0.03 mg oral DAILY 5. DICYCLOMine 20 mg PO TID 6. Vitamin D ___ UNIT PO 1X/WEEK (MO) 7. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe 8. HydrOXYzine 25 mg PO Q6H 9. Hyoscyamine 0.125 mg PO Q6H:PRN Pain 10. Mesalamine 1600 mg PO TID 11. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H 12. Tacrolimus 3 mg PO Q12H 13. Ursodiol 300 mg PO TID 14. calcium carbonate-vitamin D3 1200-800 mg-U oral DAILY 15. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 2. Desipramine 75 mg PO QHS 3. DICYCLOMine 20 mg PO TID 4. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe 5. HydrOXYzine 25 mg PO Q6H 6. Hyoscyamine 0.125 mg PO Q6H:PRN Pain 7. Mesalamine 1600 mg PO TID 8. Ondansetron 4 mg PO Q8H:PRN Nausea 9. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H 10. Tacrolimus 3 mg PO Q12H 11. Ursodiol 300 mg PO TID 12. Vitamin D 1000 UNIT PO DAILY 13. desogestrel-ethinyl estradiol 0.15-0.03 mg oral DAILY 14. Vitamin D ___ UNIT PO 1X/WEEK (MO) 15. calcium carbonate-vitamin D3 1200-800 mg-U oral DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================= -Nausea/vomiting/diarrhea thought to be secondary to viral process versus food poisoning. -Primary Sclerosing Cholangitis s/p liver transplant ___. -Ulcerative colitis -Acute Kidney Injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ due to nausea/vomiting/diarrhea after recent food ingestion. You underwent an imaging study of your abdomen/pelvis which did not reveal a cause of the symptoms. The source was thought to be secondary to either a virus or from one of the foods that was ingested. Thankfully your symptoms improved during your hospitalization and you were able to tolerate a normal diet. Please ensure that you call your primary care physician and liver doctor's office to schedule an appointment within one week following discharge from the hospital. It was a pleasure taking care of you during your hospitalization! We wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___
10303503-DS-31	10,303,503	27,308,864	DS	31	2152-08-27 00:00:00	2152-08-27 21:37:00	Name: ___ Unit ___: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim / Penicillins / Feraheme Attending: ___ Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___ Central line placement ___ Central line placement History of Present Illness: ___ history of liver transplant ___ years ago secondary to PSC presents with4 days of fevers, chills, RUQ pain and general malaise. The patient was in her usual state of health when she noticed the gradual onset of RUQ abdominal pain that is exacerbated with deep breathing. Of note, the patient has had chronic, left sided abdominal pain since her liver transplant and notes that this pain is significantly different. Her last meal was 1 day ago and this was tolerated well. She denies any changes to her medications. ___ chest pain or dyspnea. ___ vomiting or diarrhea. ___ melena or hematochezia. Of note, the patient had a recent admission about 1 month ago for more mild abdominal pain thought to be from food poisoning. Increased pruritis. The patient presented to an outside hospital where, per ED sign out, her SBPs were in the ___ and she had an elevated lactate. She was given IV fluid and ___ antibiotics. She was transferred to ___ ED where she was given cefepime and found to have a normal lactate. The patient was then transported to the MICU before sign out between MDs could be obtained. Labs and final imaging was pending upon arrival to the floor. Hepatology was consulted in the ED who recommended Vanc/Cefepime/Flagyl along with a broad infectious work up. In the ED, initial vitals: 97.8 120 96/55 16 100% RA She received: ___ 19:39 IV CefePIME 2 g ___ ___ 19:53 IV HYDROmorphone (Dilaudid) .5 mg ___ On transfer, vitals were: 132 100/63 18 100% RA On arrival to the MICU, the patient was tachycardic to the 130s with SBPs 90-100s. She had a 20G PIV in the left AC. Review of systems: Per HPI. ___ chest pain/dyspnea. ___ vomiting, melena or hematochezia. Increase pruritus. Past Medical History: - Abdominal Pain earlier this month of unknown origin. Attributed to cholangitis after negative CT Abdomen. Improved with Antibiotics - PSC s/p OLT in ___ - Ulcerative colitis (last colonoscopy ___ - GERD - Iron deficiency anemia - HSV infection - Chronic neck pain - Asthma - Migraine headaches Social History: ___ Family History: +Crohns, bone ca, HTN, HLD, DM. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals: 97.8 143 107/69 77 31 100ra GEN: lethargic, pale HEENT: anicteric sclerae ___: Tachycardic, ___ murmurs RESP: ___ increased WOB, ___ crackles or wheezing ABD:L CVA tenderness Diffuse TTP worse in RUQ, ___ rebound or guarding EXT: Warm, ___ edema NEURO: CN II-XII grossly intact GU: rectal tone normal, guiac negative stool DISCHARGE PHYSICAL EXAM: ========================= VS: 98.1 \| 105/72 \| 71 \| 16 \| 98% RA GENERAL: laying in bed with heating pad on stomach, uncomfortable and anxious. HEENT: Atraumatic. ___ scleral icterus. CARDIAC: Regular rate and rhythm. ___ rubs, murmurs, or gallops. LUNGS:Clear to auscultation bilaterally with ___ wheezes, rales, or rhonchi. ABDOMEN: Nondistended, tender to palpation in left lower quadrant and with radiating pain to left when palpating right, normal bowel sounds. Difficult to assess guarding or rebound. EXTREMITIES: Warm and well-perfused. Peripheral pulses palpable. ___ edema. NEUROLOGIC: Face symmetric, moving extremities well PSCYHIATRIC: Flattened affect, poor eye contact Pertinent Results: LABS ==== ___ 10:41PM BLOOD WBC-3.0* RBC-3.16* Hgb-8.9* Hct-26.2* MCV-83 MCH-28.2 MCHC-34.0 RDW-13.3 RDWSD-40.1 Plt ___ ___ 08:40PM BLOOD WBC-3.7* RBC-3.00# Hgb-8.5# Hct-25.7# MCV-86 MCH-28.3 MCHC-33.1 RDW-12.9 RDWSD-39.8 Plt ___ ___ 04:11PM BLOOD Neuts-75.2 Lymphs-9.4* Monos-9.7 Eos-4.6 Baso-0.3 Im ___ AbsNeut-2.81 AbsLymp-0.35* AbsMono-0.36 AbsEos-0.17 AbsBaso-0.01 ___ 04:11PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-OCCASIONAL Polychr-OCCASIONAL Ovalocy-1+ Tear Dr-1+ Acantho-1+ ___ 01:42AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 08:40PM BLOOD ___ PTT-33.0 ___ ___ 11:45PM BLOOD ___ ___ 10:41PM BLOOD Parst S-NEGATIVE ___ 04:11PM BLOOD Parst S-NEG ___ 05:08AM BLOOD Ret Aut-1.7 Abs Ret-0.05 ___ 10:41PM BLOOD Glucose-102* UreaN-47* Creat-2.7* Na-135 K-4.1 Cl-106 HCO3-17* AnGap-16 ___ 07:42PM BLOOD Glucose-107* UreaN-63* Creat-4.1# Na-130 K-3.8 Cl-98 HCO3-18* AnGap-18 ___ 10:41PM BLOOD ALT-14 AST-12 AlkPhos-235* ___ 10:41PM BLOOD Calcium-8.3* Phos-3.3 Mg-2.6 ___ 07:42PM BLOOD Albumin-3.1* ___ 11:45PM BLOOD Hapto-214* ___ 12:02AM BLOOD Type-MIX Temp-37.8 pO2-42* pCO2-36 pH-7.32* calTCO2-19* Base XS--___ 12:02AM BLOOD Lactate-0.6 DIAGNOSTICS =========== ___ Blood (LYME) Lyme IgG-PENDING; Lyme IgM-PENDING INPATIENT ___ URINE URINE CULTURE-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD ___BD & PELVIS W/O CON ___ ___ ___ to CT of the abdomen and pelvis from ___. 1. ___ evidence of retroperitoneal hematoma. ___ free fluid. 2. Moderate right pleural effusion new from ___. 3. Evaluation of the liver transplant is extremely limited by the lack of intravenous contrast. Within these limits, transplant liver appears grossly similar to examination on ___ with expected the pneumobilia. 4. Splenomegaly measures 16.4 cm with a metallic clip within it, stable from ___. 5. Air-filled loops of large and small bowel are not pathologically dilated. 6. Normal appendix. ___ Imaging CHEST PORT. LINE PLACEM ___ ___ ___ pneumothorax or other relevant changes. ___ Imaging DX CHEST PORT LINE/TUBE ___ ___ ___ pneumothorax or other relevant changes. ___ Imaging LIVER OR GALLBLADDER ___ ___. ___ Imaging DUPLEX DOPP ABD/___ ___. Approved 1. ___ intra or extrahepatic biliary dilation. 2. Patent hepatic vasculature with appropriate waveforms. ___ Imaging CR CHEST Outside Facility ___ CT Abdomen/Pelvis IMPRESSION: 1. ___ hemorrhage is identified. 2. New trace ascites and increased small right pleural effusion, since ___. 3. 2 soft tissue lesions in the lower anterior mediastinum are larger than before. 4. Massive splenomegaly and portosystemic collateralization. ___ Duplex Dopp Abd/Pelvis IMPRESSION: 1. ___ intrahepatic or extrahepatic biliary dilatation. 2. Normal liver transplant parenchyma, with patent hepatic vasculature. 3. Stable splenomegaly. 4. Right pleural effusion. ___ CT chest IMPRESSION: 1. Minimal increase in size of the 2 soft tissue lesions in the lower rightanterior mediastinum since ___ represents mild epiphrenic lymphadenopathy. Lymph nodes in the anterior mediastinum are not enlarged by size criteria but are increased in number. These changes may be reactive in the setting of sepsis. 2. Since ___ and there has been increase in size of the bilateral pleural effusions with subjacent atelectasis, now moderate on the right and trace on the left. Brief Hospital Course: ___ history of remote liver transplant due to PSC presented from outside hospital with septic shock, leukopenia, anemia and renal failure. #Shock. Sepsis vs/ hemorrhagic: Patient presented with SBP in the ___, tachycardia >140 and WBC count <4. Differential showed ___ bands. Urinalysis was red and cloudy though ___ history of dysuria and UA is not c/w infection. CXR clear for PNA. Abdominal pain and h/o PSC would be concerning with biliary obstruction, however ultrasound and LFTs are not consistent with this diagnosis. Source is currently unclear. Patient has grown VRE from urine in ___, but there did not appear to be a urinary source. Patient is very agitated and her tachycardia may be worsened by this and pain. Hemoglobin is significantly decreased and is concerning for hemorrhage though ___ active signs of bleeding. Patient was started on vancomycin/cefepime/flagyl in the ICU, with a CT abdomen/pelvis demonstrating evidence of a R sided pleural effusion. This was initially deemed too small to tap by interventional pulmonology and by the ICU team. Patient was transferred to the medical floor after her central line access was removed. Patient remained on broad spectrum antibiotics as blood culture data matured from ___ and ___ ___. A central line was replaced on ___ after peripheral access was lost and there was serial difficulty with blood draws throughout the day. A CT chest on ___ demonstrated interval increase in size of the pleural effusions, though this was in the setting of IV fluid resuscitation from sepsis. She was breathing comfortably, and had SpO2 >95% on RA. #Anemia: patient has new Hgb drop on ___. ___ Sxs c/f GIB, guiac negative stool on exam. Given sepsis, thrombocytopenia and renal failure, initial concern for TTP but ___ schiztocytes on smear. Other hemolysis labs were not indicative of this diagnosis. Given history of UC and Liver disease in setting of abd pain, there was initial concern for intraabdominal hemorrhage though patient had a non-surgical abdomen. She did not require transfusions and was transferred to the medical floor. #Acute Renal Failure: Patient had a Cr of 4.1 on admission, slowly improving with volume resuscitation. Patient made adequate urine in response to volume resussitation. Given septic physiology this was thought to be likely pre-renal/ATN. Since patient was urinating concern for obstructive uropathy was low. Foley was discontinued and medications were renally dosed. Cr continued to improve upon transfer to the medical floor. #Sinus Tachycardia: Likely due to pain/anxiety and distributive shock physiology. Improved with pain medications and IVF. ___ oxygen requirement or dyspnea makes PE lower on differential, however given history of IBD, she is at higher risk of thrombosis. Patient was kept on telemetry upon transfer to the medical floor. #History of Liver Transplant: ___ signs of acute rejection on LFTs. RUQUS not concerning for obstruction. Tacrolimus levels were trended and dosage was adjusted to 1 mg AM and 0.5 mg ___. #Chronic Pain: Patient is on high dose narcotics at home for chronic abdominal pain. Given her lethargy and tenuous blood pressures exercised caution with pain control. She was transitioned from IV dilaudid to PO oxycontin and dilaudid upon transfer from MICU to medical floor. Home regimen was continued on discharge. #Ulcerative colitis: Pain not c/w flair. ___ hematochezia. Mesalamine briefly held while in ICU, but restarted by discharge. TRANSITIONAL ISSUES =================== - Should have interval chest XR to evaluate for resolution of effusion - Follow up pending tick-borne illness studies (___. ___, A. phagocytophilum) - Repeat CBC to evaluate anemia - Mediastinal lesions noted on chest imaging; re-evealuated with CT, found to be mild epiphrenic lymphadenopathy, felt to be reactive in setting of sepsis (not enlarged, by size criteria, but are increased in number) - Tacrolimus levels were trended and dosage was adjusted to 1 mg AM and 0.5 mg ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 2. Desipramine 75 mg PO QHS 3. DICYCLOMine 20 mg PO TID 4. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe 5. HydrOXYzine 25 mg PO Q6H 6. Hyoscyamine 0.125 mg PO Q6H:PRN Pain 7. Mesalamine 1600 mg PO TID 8. Ondansetron 4 mg PO Q8H:PRN Nausea 9. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H 10. Tacrolimus 3 mg PO Q12H 11. Ursodiol 300 mg PO TID 12. Vitamin D 1000 UNIT PO DAILY 13. desogestrel-ethinyl estradiol 0.15-0.03 mg oral DAILY 14. Vitamin D ___ UNIT PO 1X/WEEK (MO) 15. calcium carbonate-vitamin D3 1200-800 mg-U oral DAILY Discharge Medications: 1. Tacrolimus 1 mg PO QAM RX tacrolimus 1 mg 1 capsule(s) by mouth in the morning Disp #30 Capsule Refills:0 2. Tacrolimus 0.5 mg PO QPM RX tacrolimus [Prograf] 0.5 mg 1 capsule(s) by mouth every evening Disp #30 Capsule Refills:0 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 4. calcium carbonate-vitamin D3 1200-800 mg-U oral DAILY 5. Desipramine 75 mg PO QHS 6. desogestrel-ethinyl estradiol 0.15-0.03 mg oral DAILY 7. DICYCLOMine 20 mg PO TID 8. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe 9. HydrOXYzine 25 mg PO Q6H 10. Hyoscyamine 0.125 mg PO Q6H:PRN Pain 11. Mesalamine 1600 mg PO TID 12. Ondansetron 4 mg PO Q8H:PRN Nausea 13. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H 14. Ursodiol 300 mg PO TID 15. Vitamin D 1000 UNIT PO DAILY 16. Vitamin D ___ UNIT PO 1X/WEEK (MO) Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Septic shock with unidentified source Abdominal pain Primary sclerosing cholangitis s/p orthotopic liver transplant Secondary diagnoses: Ulcerative colitis Secondary diagnoses: Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were transferred to ___ with a very low blood pressure, concerning for an infection. You were resuscitated with extra fluids and looked for any source of infection. We gave you antibiotics to cover any possible source, for 5 days, as you improved. Your cultures did not grow any bacteria concerning for infections. We monitored you off antibiotics and you did well. Please follow up with your liver doctors at the ___ ___. Your tacrolimus medication was changed while in house. Please take 1 mg tacrolimus in the morning and 0.5 mg tacrolimus in the evening. We wish you the very best, Your team at ___ Followup Instructions: ___
10303503-DS-33	10,303,503	24,975,738	DS	33	2155-11-12 00:00:00	2155-12-18 14:28:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim / Penicillins / Feraheme / amoxicillin Attending: ___. Major Surgical or Invasive Procedure: ERCP attach Pertinent Results: WBC 5.5--> --> 2.2 plt 144--> 97-->--> 132 hgb 10.6--> --> 9.2 INR 2--> --> 1.4 creatinine 2.3--> --> 1.4 AP 276--> --> 196--> 226 ALT/AST WNL tbili 1.6 (direct 1.3)--> --> 1.0 lipase 16 troponin neg albumin 3.2--> 2.4 tacro level 8.8--> 15.1--> 10.3--> 7.7 Iron 29 TIBC 142 ferritin 217 hapto 223 Urine electrolytes: FeUrea 36.7% intrinsic renal UP/C 0.3 CMV/EBV pending lyme Ab positive, immunoblot pending anaplasma negative U/A trace blood, 30 protein, small bilirubin, 8 urobilirubin, neg leuks, few bacteria, 3 WBL UTox + opiates & oxycodone FluA/B neg UCx ___ neg BCx ___ x 2 pending cryptococcal Ag not detected MRCP ___: -Lower Thorax: Moderate-sized right pleural effusion with adjacent atelectasis. -No liver abscess. No evidence of cholangitis. -Splenomegaly, similar to prior imaging, with small volume of ascites inferior to the spleen. Brief Hospital Course: ___ is a ___ with ulcerative colitis c/b PSC s/p liver transplant (___) w/ recurrent PSC, anemia, chronic abdominal pain, who presented with SIRS secondary to unclear infectious source, now improved. # SIRS, c/b sepsis of unknown source Ms. ___ presented with fever(102.8), tachycardia, hypotension. She was briefly admitted to the MICU given hypotension, but she quickly improved on broad-spectrum Abx. This was initially thought to be ___ cholangitis or recurrent liver abscess. However, this was ruled out w/ ERCP & MRCP. The infectious diseases service was consulted. Infectious workup including blood cultures, urine culture, Flu swab, fungitell, anaplasma, cryptococcal Ag was negative. Her lyme Ab was positive but per the infectious diseases service this was thought to be ___ prior exposure and not requiring treatment. An immunoblot was sent and pending by the time of discharge. She was slowly tapered off antibiotics; she was sent home on a course of ciprofloxacin until ___ to complete a 7 day course of antibiotics. Upon discharge, the following studies were pending: CMV, EBV (incl viral load), lyme immunoblot. # ___ Baseline Cr of .___. She had a significant ___ on arrival likely prerenal, though urine electrolytes showed intrinsic renal. This was thought to be ___ ATN from initial hypotension, +/- some effect from Tacrolimus toxicity as ___ can happen easily iso dehydration +/- possible contribution of vancomycin. It downtrended through the admission. # Abnormal LFTs # Coagulopathy # Pancytopenia Cytopenia thought to be in ___ acute illness. Iron studies were c/w ACD, no hemolysis. Patient received vitamin K 5mg for 3 days, with improvement in INR. Her direct hyperbilirubinemia resolved over the course of the hospitalization. # s/p Liver Transplant (___) # Recurrent PSC # Splenomegaly Patient was followed inhouse by the hepatology team. She had an elevated tacrolimus level, and the dose was adjusted inhouse to 0.5mg qhs and 1mg qAM. She was noted to have an elevated alkaline phosphatase, which has been chronically elevated. She was continued on ursodiol and home hydroxyzine. CHRONIC ISSUES ======================= # Ulcerative colitis She was continued on her home Lialda 1.2 gram tablet 4 times daily # Chronic pain Her pain medications were initially decreased in s/o sepsis and somnolence. As she improved, she was increased back to her home dose of hydromorphone 4 mg tablet q6-8 hrs and oxycontin to 30 mg BID. The dosing was verified in ___. ########################## TRANSITIONAL ISSUES: [ ] repeat creatinine in 1 week to make sure creatinine is downtrending [ ] repeat tacrolimus level in 1 week, level was elevated on admission, and dose was decreased to 1mg qAm and 0.5mg qPM per hepatology recs [ ] recheck CBC in 1 week, pt with thrombocytopenia thought to be ___ sepsis. Also w/ anemia; iron studies c/w ACD, not hemolyzing. [ ] f/u lyme immunoblot: patient was noted to have a positive lyme Ab, immunoblot pending. Discussed with ID, thought no need to treat currently as Sx did not seem c/w lyme disease, but may need treatment in the outpatient setting if her immunoblot is positive. ########################### >30 minutes spent on discharge planning and care coordination on the day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Mesalamine 1200 mg PO QID 2. Ursodiol 300 mg PO TID 3. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Moderate 4. Tacrolimus 1 mg PO Q12H 5. HydrOXYzine 25 mg PO Q8H 6. DICYCLOMine 20 mg PO TID 1 hour prior to meals 7. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath 8. OxyCODONE SR (OxyCONTIN) 30 mg PO Q12H Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO BID Duration: 4 Days RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #7 Tablet Refills:0 2. Tacrolimus 0.5 mg PO QHS RX tacrolimus 0.5 mg 1 capsule(s) by mouth daily at night Disp #30 Capsule Refills:0 3. Tacrolimus 1 mg PO DAILY RX tacrolimus 1 mg 1 capsule(s) by mouth once a day in the morning Disp #30 Capsule Refills:*0 4. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath 5. DICYCLOMine 20 mg PO TID 1 hour prior to meals 6. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Moderate 7. HydrOXYzine 25 mg PO Q8H 8. Mesalamine 1200 mg PO QID 9. OxyCODONE SR (OxyCONTIN) 30 mg PO Q12H 10. Ursodiol 300 mg PO TID Discharge Disposition: Home Discharge Diagnosis: PSC liver transplant bacterial infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. GENERAL: Young Caucasian woman awake and alert, watching a movie EYES: Anicteric, pupils equally round; no conjunctival pallor. ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart RRR, no murmurs/rubs/gallops. No JVD. RESP: CTAB, no c/r/w GI: Abdomen soft, non-distended, no TTP GU: No suprapubic fullness or tenderness to palpation EXT: WWP, 2+ distal pulses, no ___ edema SKIN: scar from transplant surgery; NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: anxious Discharge Instructions: Dear Ms. ___, You were admitted to the hospital because of an infection that caused your blood pressure to drop. You were briefly in the ICU, and were given IV antibiotics. You were seen by the infectious diseases service and the liver transplant service. Your IV antibiotics were stopped and you did well. The liver team recommended that you continue oral antibiotics until ___ given your history of liver transplant and PSC. Please take your oral antibiotic until ___. Please go to your appointments are scheduled. It was a pleasure taking care of you. -Your ___ care team Followup Instructions: ___
10303710-DS-12	10,303,710	21,961,131	DS	12	2193-04-10 00:00:00	2193-04-11 21:09:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Percocet / ciprofloxacin / levofloxacin / Bactrim / hydrocodone / Percodan / lactose Attending: ___ Chief Complaint: Back pain, R leg pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male retired ___ with a past medical history of prostate cancer(HRT plus radiation) complicated by proctitis and urostomy, IDDM who presents to the ED for evaluation of his right lower leg weakness. He states that 3 weeks ago he was getting an lumbar epidural steroid injection for his left-sided leg pain. At the time of injection he noticed a sharp right-sided pain shooting down his legs. Since then he has noticed progressive right lower leg weakness which has progressed to him using a walker and not being able to walk around without assistance. He denies any fecal incontinence or perianal anesthesia. He denies any fevers or recent IV drug use. In the ED: - Initial vital signs were notable for: Temp 97.1 HR 82 BP 125/68 RR 16 satting 96% on RA - Exam notable for: RLE ___ strength. LLE ___ strength. UE ___ strength bilat. Sensation intact. - Labs were notable for: CBC 8.6 hgb 12.2 Plt 249 Na 145 Cl 110 BUN 18 SCr 1.2 K 4.0 HCO3 22 Gluc 107 Ca 9.4 Mg 1.8 Phos 3.2 - Studies performed include: MRI T/L spine w and without: - Severe neural foraminal narrowing at left L5-S1 compressing on the traversing L5 nerve root moderate right neural foraminal narrowing are noted at right L3-4 and left L4-5. - Disc bulge at T9-10 and T10-11 cause mild-to-moderate spinal canal narrowing and indenting on the spinal cord. - No epidural collection - Patient was given: Morphine 4 mg IV x3 Lidocaine patch Losartan 25 mg Allopurinol ___ mg Ketorolac 30 mg Prochlorperazine 10 mg 1L LR 1gm APAP IV Prednisone 40 mg - Consults: Spine: no urgent neurosurgical intervention needed, NSGY sign off, follow-up at pain clinic who performed injection, admit to medicine for pain control Vitals on transfer: 98.2 PO 123 / 73 R Lying 94 18 94 RA Upon arrival to the floor, he reports severe constant achey pain in his right front leg that has been ongoing since his epidural spine injection on ___. He has also had progressive weakness in his right leg and now can barely ambulate with a walker. When he stands, the leg feels tense and he cannot balance. He denies fevers/chills, chest pain, palps, n/v/d, incontinence, other weakness, any numbness/tingling. REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise negative. Past Medical History: Prostate cancer s/p HRT, radiation, prostatectomy Bladder removal with ileal conduit L spine surgery Diabetes mellitus HLD HTN Hx of uric acid kidney stones GERD Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHSYICAL EXAM: ====================== VITALS: 98.2 PO 123 / 73 R Lying 94 18 94 RA GENERAL: Alert and interactive. In no acute distress. EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection. ENT: MMM. No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. Ileal conduit draining clear yellow urine, no erythema or swelling at the site. MSK: No spinous process or paraspinal tenderness. No CVA tenderness. No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: AOx3. CN2-12 intact. ___ strength throughout except RLE has ___ strength. Normal sensation. Gait is normal. PSYCH: appropriate mood and affect DISCHARGE PHYSICAL EXAM: ======================= VS: 24 HR Data (last updated ___ @ 828) Temp: 97.9 (Tm 98.3), BP: 131/77 (111-131/69-77), HR: 58 (57-78), RR: 18, O2 sat: 94% (93-96), O2 delivery: RA GENERAL: Alert and interactive. In no acute distress. EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection. ENT: MMM. No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. Ileal conduit draining clear yellow urine, no erythema or swelling at the site. MSK: No spinous process or paraspinal tenderness. Slight tenderness of right lumbar paraspinal region. No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. Mild tenderness to palpation of right anterior thigh SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: AOx3. CN2-12 intact. Strength ___ in b/l ___ extremities this morning. ROM in tact. Decreased sensation LLE at baseline. Reflexes 2+ throughout. PSYCH: appropriate mood and affect Pertinent Results: ADMISSION LABS: ============== ___ 11:07PM BLOOD WBC-8.6 RBC-3.87* Hgb-12.2* Hct-37.2* MCV-96 MCH-31.5 MCHC-32.8 RDW-13.3 RDWSD-47.3* Plt ___ ___ 11:07PM BLOOD Neuts-73.0* Lymphs-16.3* Monos-6.5 Eos-3.2 Baso-0.5 Im ___ AbsNeut-6.30* AbsLymp-1.41 AbsMono-0.56 AbsEos-0.28 AbsBaso-0.04 ___ 11:07PM BLOOD Glucose-107* UreaN-18 Creat-1.2 Na-146 K-4.0 Cl-110* HCO3-22 AnGap-14 ___ 11:07PM BLOOD Calcium-9.4 Phos-3.2 Mg-1.8 PERTINENT INTERMITTENT LABS: ========================== ___ 06:15AM BLOOD Ret Aut-1.6 Abs Ret-0.06 ___ 06:15AM BLOOD ALT-18 AST-13 AlkPhos-114 TotBili-0.3 ___ 06:15AM BLOOD calTIBC-313 Ferritn-178 TRF-241 DISCHARGE LABS: ============== ___ 07:20AM BLOOD WBC-9.5 RBC-3.74* Hgb-11.8* Hct-35.6* MCV-95 MCH-31.6 MCHC-33.1 RDW-13.2 RDWSD-45.7 Plt ___ ___ 07:20AM BLOOD Glucose-121* UreaN-25* Creat-1.0 Na-142 K-4.7 Cl-101 HCO3-24 AnGap-17 IMAGING: ======== ___ CODE CORD COMPRESSIO: 1. There are degenerative changes at the T9-T10 and T10-T11 levels, with moderate spinal canal stenosis at T10-T11 causing remodeling of the ventral spinal cord but no convincing myelopathic signal change. 2. Degenerative changes in the lumbar spine are most pronounced at the L5-S1 level where there is severe left neural foraminal stenosis. Please see details above. 3. STIR hyperintense signal abnormality in the sacrum could reflect insufficiency fracture PREVALENCE: Prevalence of lumbar degenerative disk disease in subjects without low back pain: Overall evidence of disk degeneration 91% (decreased T2 signal, height loss, bulge) T2 signal loss 83% Disk height loss 58% Disk protrusion 32% Annular fissure 38% Jarvik, et all. Spine ___ 26(10):1158-1166 Lumbar spinal stenosis prevalence- present in approximately 20% of asymptomatic adults over ___ years old ___, et al, Spine Journal ___ 9 (7):___-550 These findings are so common in asymptomatic persons that they must be interpreted with caution and in context of the clinical situation. Brief Hospital Course: Key Information for Outpatient Providers:ASSESSMENT AND PLAN: ==================== Mr. ___ is a ___ male retired ___ with a past medical history of prostate cancer (HRT plus radiation) complicated by proctitis and urostomy, and insulin dependent diabetes who presented to the ED with a 3 week history of progressive right leg pain immediately after outpatient epidural steroid injection admitted to the floor for pain control, now discharged with improved pain control, on regimen consisting of PO Morphine ___, Tylenol, and Gabapentin; with plans for close follow up and outpatient ___. TRANSITIONAL ISSUES =================== [ ] Patient discharged on pain regimen of: - Acetaminophen 1000 mg PO Q8H - Morphine Sulfate ___ 7.5 mg PO Q6H:PRN x 5 days - Gabapentin 400 mg PO TID - Prednisone taper: s/p 40mg x 3d. Plan to continue 20mgx3d (___), followed by 10mg x3d (___). [ ] Ensure adequate bowel movements on morhpine [ ] Patient developed ___ with IV ketorolac to peak Cr 1.4, resolved with IVF. Please avoid ketorolac in future, though consideration of Naproxen if necessary likely reasonable. [ ] Patient discharged with prescription for outpatient ___ [ ] Patient to receive wheelchair from senior citizen, ensure able to receive this. [ ] Patient leaving for ___ in 2 weeks from discharge, please ensure he has follow up with outpatient ___ and continued pain management. [ ] Patient has elective surgery scheduled in the ___ with outside surgeon ___ at ___) for left L5 nerve root compression [ ] Discharge Hgb 12.2. Ferrtin wnl, however Tsat ~18% which may represent mild iron deficiency component in addition to anemia of chronic imflammation. Consider initiating ferrous sulfate QOD. ACUTE ISSUES: ============= #Severe Spinal stenosis #RLE pain and weakness Given severe spinal stenosis s/p laminectomy and chronic back pain, Mr. ___ had been receiving epidural steroid injections in the outpatient setting. On ___ he experienced immediate right leg pain during a repeat injection that progressively worsened over 3 weeks. Review of ___ records and conversation with the patient reveals a long standing history of lower back pain and spinal stenosis as a complication of radiation therapy for prostate cancer. He is s/p laminectomy and foraminectomy in ___. He usually has pain in the left leg, which responded well to steroid injection in early ___, but repeat injection ___ appears to be complicated by immediate, severe right leg pain that has been getting worse. It is possible that given his foraminal stenosis his connective tissue is very non-compliant and the introduction of fluid into the space resulted in an increase in pressure resulting in pain. Lumbar plexus injury is also a possibility. MRI T&L spine revealed severe foraminal stenosis but no imaging evidence to explain right sided ___ findings. Neurosurgery evaluated patient while in ED, decided there was no target for intervention, agreed that imaging did not correlate with symptoms, and that no immediate intervention was indicated at this time. Our inpatient chronic pain service evaluated patient, agreed that acute onset pain most likely ___ non-compliant tissue iso spinal stenosis that could not accommodate volume from steroid injection. Recommended standing Tylenol, morphine ___, and gabapentin for continued pain control. Patient also maintained a prednisone taper during hospitalization. Completed 40mg x 3d. Plan for 20mg x 3d, then 10mg x 3d. Patient worked with inpatient therapy with increasing success. On day of discharge ___ recommended okay for discharge home with outpatient ___. # Diarrhea Per patient has a ___ year history of diarrhea due to IBS controlled with PRN loperamide in the outpatient setting. - Continued Loperamide TID:PRN # Anemia Hb 12.2, normocytic. He does not have a clear baseline in the system. Ferrtin wnl, Tsat ~18% which may represent mild iron deficiency component. RESOLVED/CHRONIC ISSUES ======================= # ___ (resolved) Creatinine peaked to 1.4 this admission. Most likely poor PO intake due to pain combined with ketorolac, prednisone and losartan. Creatinine to 1.0 on ___ after 2L IVF. # IDDM - SSI and 30U glargine nightly (home dose 40U nightly) - continued home losartan for renal protection # HLD - held home atorvastatin as he stopped taking it at home due to leg muscle cramps. However continued this on discharge. # Hx of uric acid kidney stones - continued home allopurinol # HTN - continued home losartan Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 25 mg PO DAILY 2. Lactobacillus acidophilus 0.5 mg (100 million cell) oral BID 3. Allopurinol ___ mg PO DAILY 4. Atorvastatin 10 mg PO QPM 5. Glargine 40 Units Bedtime Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX acetaminophen 500 mg 2 tablet(s) by mouth Q8 Disp #90 Tablet Refills:0 2. Gabapentin 400 mg PO TID RX gabapentin 400 mg 1 capsule(s) by mouth three times a day Disp #90 Capsule Refills:0 3. Morphine Sulfate ___ 7.5 mg PO Q6H:PRN BREAKTHROUGH PAIN RX morphine 15 mg 0.5 (One half) tablet(s) by mouth every six (6) hours Disp #10 Tablet Refills:0 4. PredniSONE 20 mg PO DAILY Duration: 3 Days RX prednisone 20 mg 1 tablet(s) by mouth once a day Disp #3 Tablet Refills:0 5. PredniSONE 10 mg PO DAILY Duration: 3 Doses Tapered dose - DOWN RX prednisone 10 mg 1 tablet(s) by mouth once a day Disp #3 Tablet Refills:*0 6. Glargine 40 Units Bedtime 7. Allopurinol ___ mg PO DAILY 8. Atorvastatin 10 mg PO QPM 9. Lactobacillus acidophilus 0.5 mg (100 million cell) oral BID 10. Losartan Potassium 25 mg PO DAILY 11.Outpatient Physical Therapy ___ with severe RLE pain s/p epidural injection. Dx: ___ PCP: ___ Phone: ___ Fax: ___ Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Right lower extremity pain Severe spinal stenosis 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 taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== - You were experiencing severe pain and weakness in your right leg WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - You received pain medications to manage your pain immediately in the ED - Your pain medications were optimized to treat your pain - Your pain started to improve and you were ready to leave the hospital with plans for close follow up. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please be sure to make an appointment with our chronic pain service before leaving for ___ - Please be sure to work with your outpatient physical therapists - Please continue to take all your medications and follow up with your doctors at your ___ appointments. We wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___
10303776-DS-23	10,303,776	28,241,995	DS	23	2140-11-27 00:00:00	2140-11-30 21:49:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Iodine-Iodine Containing Attending: ___. Chief Complaint: Partial small bowel obstruction secondary to parastomal hernia Major Surgical or Invasive Procedure: Parastomal hernia reduction History of Present Illness: Ms. ___ is a ___ yo female with Crohn's disease who had a remote total proctocolectomy with end ileostomy and known parastomal hernia who presents to the ED with several hours of abdominal pain, nausea, and decreased stoma output. Patient has had episodes where hernia became enlarged and has had multiple partial small bowel obstructions in the past. She denies vomiting, but has had wretching and burping. She was seen in the clinic by Dr. ___ possible repair and a plan was made to continue non-operative management with an abdominal binder. Past Medical History: -Crohn's disease, s/p colectomy/colostomy, currently on no treatment but received a lot of steroids as a child. -Ocular myasthenia, currently not active, chest CT negative for thymoma, has not taken mestinon in years. -Possible Sjogren's disease -Recently diagnosed hypothyroidism. -No history of HTN, DM, or dyslipidemia. -No history of migraines, but has had mild sporadic headaches in the past that were not similar to this headache. Social History: ___ Family History: Multiple maternal family members with diabetes ___ and/or thyroid disease. Mother - colon CA, but question of Crohn's disease. Maternal aunt - lupus. Maternal aunt - ___ palsy. Physical Exam: VS 98.7 82 ___ 99 RA Gen: Well appearing, in no acute distress Cardiac: RRR Pulm: CTAB GI: Soft,non distended. Incisions well healed with no hernias, large parastomal hernia noted laterally (right side), bilious output within stoma bag, mildly tender at stoma Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ 02:00AM BLOOD WBC-9.0 RBC-3.76* Hgb-11.2 Hct-34.1 MCV-91 MCH-29.8 MCHC-32.8 RDW-13.7 RDWSD-44.9 Plt ___ ___ 02:00AM BLOOD Neuts-55.6 ___ Monos-7.1 Eos-2.2 Baso-0.3 Im ___ AbsNeut-4.97 AbsLymp-3.09 AbsMono-0.64 AbsEos-0.20 AbsBaso-0.03 ___ 02:00AM BLOOD Plt ___ ___ 02:00AM BLOOD Glucose-100 UreaN-15 Creat-0.8 Na-133 K-3.8 Cl-101 HCO3-21* AnGap-15 ___ 02:00AM BLOOD estGFR-Using this ___ 02:00AM BLOOD ALT-16 AST-19 AlkPhos-82 TotBili-0.8 ___ 02:00AM BLOOD Lipase-44 ___ 02:00AM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.4 Mg-1.8 ___ 02:00AM BLOOD HoldBLu-HOLD ___ 02:00AM BLOOD GreenHd-HOLD ___ 02:20AM BLOOD Comment-GREEN TOP ___ 02:20AM BLOOD Lactate-1.0 CT A/P (___): 1. Status post total colectomy, with end ileostomy in the right lower quadrant. Multiple dilated loops of small bowel are seen throughout the abdomen, to the level of the ostomy, where there is a large parastomal hernia. Enteric contrast material is present in the ostomy bag, which suggests a partial small bowel obstruction. Note is made of fluid surrounding loops of bowel in the right lower quadrant and parastomal hernia. 2. 9 mm nonobstructing stone in the interpolar region of the right kidney. 3. Chololithiasis. Abdominal Xray (___) Dilated loops of small bowel with multiple air-fluid levels, consistent with partial small bowel obstruction seen on the CT abdomen and pelvis performed after this study. Brief Hospital Course: Ms. ___ was admitted due to a partial SBO from her parastomal hernia. It was reduced in the ED and she was admitted for observation due to her continued tenderness. She was started on clears in the ED and she tolerated it well. Her pSBO continually improved throughout the evening. She was given IV dilaudid to control her pain. She had a UA done due to some urinary complaints but it came back negative. The next day, she was seen by the ostomy nurse who gave her an abdominal binder for her hernia. She was also started on a regular diet and tolerated it well. She had a discussion with Dr. ___ the pros/cons of surgery for her hernia and said she would follow up in clinic with Dr. ___ the timing of surgery for her parastomal hernia. She was tolerating a regular diet, pain was controlled with oral pain meds and she was ambulating. her small bowel obstruction has resolved so she was deemed fit for discharge. Medications on Admission: Levothyroxine 75mcg 1 tablet daily Pantoprazole 40mg XR 1 tablet in the morning Phenazopyridine 100mg BID PRN bladder pain Pyrodistigmine bromide 60mg 0.5 tablets by mouth BID Spironolactone 100mg once daily Vitamin D3 Vitamin B12 Multivitamin Discharge Medications: 1. Cyanocobalamin 1000 mcg PO DAILY 2. Levothyroxine Sodium 75 mcg PO DAILY 3. Pantoprazole 40 mg PO Q24H 4. Pyridostigmine Bromide Syrup 30 mg PO BID 5. Spironolactone 100 mg PO DAILY 6. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Partial small bowel obstruction from parastomal hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for a small bowel obstruction. You were given bowel rest and intravenous fluids. Your obstruction has subsequently resolved after conservative management. You have tolerated a regular diet, are passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next ___ days. It is not uncommon for patients to have some decrease in bowel function but you should not have prolonged constipation. Some loose stool are expected. However, if you notice that you are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: ___
10303776-DS-26	10,303,776	28,081,878	DS	26	2144-09-07 00:00:00	2144-09-07 15:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old woman with Crohn's s/p colectomy and end ileostomy with repeat resection in ___ due to disease recurrence at stoma site with narrowing and EC fistula, who has subsequently had a number of bowel obstructions who presents with symptoms and signs of recurrent SBO. Ms. ___ was recently diagnosed with metastatic pancreatic cancer with peritoneal implants. She started palliative chemotherapy yesterday with gemcitabine and nab-paclitaxel. She reported acutely worsened abdominal pain that started yesterday morning with associated decreased output from her stoma, consistent with her prior obstructions. She completed her chemotherapy session, but while at the oncology infusion unit, her abdominal pain and nausea progressively worsened, so she was sent to the ED for evaluation. In the ED, she was afebrile and with stable vital signs. CT abdomen was obtained which showed a high grade SBO with transition at the neck of a known para-stomal hernia. She was evaluated by colorectal surgery who recommended conservative management with fasting and NGT decompression. Patient had an NGT placed for decompression and was admitted to medicine for further care. On arrival to the floor, patient continued to feel nauseated and hiccupping despite presence of an NGT. NGT was flushed with subsequent output that tapered off quickly. Therefore, the NGT was removed and replaced. Pt reports that though she has had small amounts of stool in her ostomy since arrival to the ED, she has not seen gas. Review of Systems: A 10 point review of systems was performed in detail and negative except as noted in the HPI. Past Medical History: -Crohn's disease, s/p colectomy/colostomy, currently on no treatment but received a lot of steroids as a child. -Ocular myasthenia, currently not active, chest CT negative for thymoma, has not taken mestinon in years. -Possible Sjogren's disease -Recently diagnosed hypothyroidism. -No history of HTN, DM, or dyslipidemia. -No history of migraines, but has had mild sporadic headaches in the past that were not similar to this headache. Social History: ___ Family History: Multiple maternal family members with diabetes ___ and/or thyroid disease. Mother - colon CA, but question of Crohn's disease. Maternal aunt - lupus. Maternal aunt - ___ palsy. Physical Exam: Admission: VS - ___ 1637 Temp: 99.4 Axillary BP: 149/91 L Lying HR: 98 RR: 20 O2 sat: 98% O2 delivery: ra Dyspnea: 0 RASS: 0 Pain Score: ___ GEN - NAD HEENT - NCAT, no scleral icterus; NGT in R nare NECK - supple, no LAD CV - rrr, no r/m/g RESP - clear b/l ABD - soft, nontender, mildly distended; ostomy w/ small amounts of dark green stool w/o gas EXT - no edema NEURO - alert and oriented x 3 Discharge: ============================ GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. 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, mild diffuse tenderness, G tube in place with clean and dry dressing around, draining significant amount of green liquid 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 PSYCH: pleasant, appropriate affect Pertinent Results: Admission: ___ 07:00AM GLUCOSE-136* UREA N-12 CREAT-0.6 SODIUM-142 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-26 ANION GAP-12 ___ 07:00AM CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-2.3 ___ 07:00AM WBC-7.1 RBC-3.68* HGB-11.4 HCT-34.5 MCV-94 MCH-31.0 MCHC-33.0 RDW-14.1 RDWSD-48.3* ___ 07:00AM PLT COUNT-219 ___ 08:03PM URINE HOURS-RANDOM ___ 08:03PM URINE UHOLD-HOLD ___ 08:03PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08:03PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 07:46PM LACTATE-1.2 CREAT-0.6 ___ 07:46PM estGFR-Using this ___ 07:35PM GLUCOSE-156* UREA N-11 CREAT-0.6 SODIUM-137 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-25 ANION GAP-11 ___ 07:35PM estGFR-Using this ___ 07:35PM ALT(SGPT)-15 AST(SGOT)-22 ALK PHOS-93 TOT BILI-1.0 ___ 07:35PM LIPASE-14 ___ 07:35PM ALBUMIN-4.1 CALCIUM-9.1 PHOSPHATE-2.8 MAGNESIUM-1.9 ___ 07:35PM WBC-6.3 RBC-3.81* HGB-11.6 HCT-35.9 MCV-94 MCH-30.4 MCHC-32.3 RDW-13.8 RDWSD-47.5* ___ 07:35PM NEUTS-90.0* LYMPHS-8.4* MONOS-0.9* EOS-0.2* BASOS-0.0 IM ___ AbsNeut-5.69 AbsLymp-0.53* AbsMono-0.06* AbsEos-0.01* AbsBaso-0.00* ___ 07:35PM PLT COUNT-223 ___ 07:35PM ___ PTT-25.9 ___ ___ 11:30AM UREA N-17 CREAT-0.7 SODIUM-130* POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-24 ANION GAP-10 ___ 11:30AM ALT(SGPT)-11 AST(SGOT)-14 ALK PHOS-83 TOT BILI-0.8 ___ 11:30AM ALBUMIN-4.2 CALCIUM-9.9 PHOSPHATE-3.7 MAGNESIUM-1.8 ___ 11:30AM CEA-1.8 ___ 11:30AM WBC-9.2 RBC-3.97 HGB-12.2 HCT-36.6 MCV-92 MCH-30.7 MCHC-33.3 RDW-13.7 RDWSD-46.9* ___ 11:30AM NEUTS-68.9 LYMPHS-18.7* MONOS-9.0 EOS-2.8 BASOS-0.2 IM ___ AbsNeut-6.31* AbsLymp-1.71 AbsMono-0.82* AbsEos-0.26 AbsBaso-0.02 ___ 11:30AM PLT COUNT-255 Discharge: ================== ___ 04:45AM BLOOD WBC-13.8* RBC-2.86* Hgb-9.0* Hct-27.5* MCV-96 MCH-31.5 MCHC-32.7 RDW-15.5 RDWSD-51.8* Plt ___ ___ 06:35AM BLOOD RBC Mor-WITHIN NOR ___ 04:45AM BLOOD Plt ___ ___ 06:35AM BLOOD ___ PTT-27.0 ___ ___ 04:45AM BLOOD Glucose-161* UreaN-29* Creat-0.4 Na-140 K-3.7 Cl-101 HCO3-28 AnGap-11 Imaging: =================== CT A/P ___ IMPRESSION: 1. High-grade small-bowel obstruction with transition point at the neck of a peristomal hernia. The hernia, which contains small bowel, is unchanged in size since the ___ examination. 2. No pneumatosis or pneumoperitoneum. 3. No focal fluid collections. 4. Unchanged 1.8 cm pancreatic body mass and suspected left rectus and mesenteric metastatic nodules, as previously described on ___ study. 5. Cholelithiasis. Gasttrografin enema contrast study ___: IMPRESSION: Opacification of a short segment of bowel which appears to be within the body wall, likely within the known parastomal hernia. Contrast was unable to be passed more proximally into the intra-abdominal bowel via both gravity and hand injection. Manual advancement of the catheter failed to reach the intra-abdominal bowel. CT A/P ___ (unofficial read): IMPRESSION: 1. High-grade small-bowel obstruction with a transition point at the neck of a parastomal hernia in the right lower quadrant, similar to prior. 2. Redemonstration of a pancreatic body mass with enhancing nodules in the left rectus muscle and mesentery, the mesenteric nodule slightly less conspicuous compared with prior. 3. 1.6 cm enhancing nodule in the cul-de-sac is nonspecific, and may be related to the left ovary if still present versus a metastatic deposit. 4. Cholelithiasis. Microbiology: ======================= Blood culture ___: negative Urine Culture ___: negative Brief Hospital Course: ___ year old F with Crohn's s/p colectomy with end ileostomy who presents with small bowel obstruction with transition point at a parastomal hernia. # SBO: #Parastomal hernia: Presented with abdominal pain found to have small bowel obstruction with transition point at a parastomal hernia site. She was treated conservatively with bowel rest, IVF, and NG tube suction, as well as a gastrografin enema, and did not have any significant improvement. Colorectal was consulted as well and guided care. In consultation with her pancreatic cancer doctor Dr. ___ was placed for venting when patient was symptomatic. By the day of discharge, her ___ tube output significantly improved (0 cc over last 24 hours), and all of her output was through the ileostomy (~2L per day). Symptomatically her nausea and abdominal pain improved. On ___, the colorectal team offered surgical intervention to fix the parastomal hernia, but given improvement it was decided to hold any intervention at this point. TPN was started for her nutrition. She will follow up with colorectal on discharge. She was also tolerating full liquids prior to discharge. # Metastatic Pancreatic CA: Patient sees Dr. ___ in ___ clinic. She had received one round of chemotherapy prior to this admission. She will follow up as above with Dr. ___ in clinic to continue chemotherapy. #Acute renal failure: Resolved with IVF, prerenal in etiology. #Leukopenia: #Leukocytosis: WBC down to 1.7 initially, then peaked at 20, back down to 13 by discharge. ___ have been related to her bone marrow response to her initial chemo. No signs or symptoms of infection. #Hypotension #High Ostomy output: During the middle part of her hospitalization, she had a period of hypotension related to high ostomy output. Dr. ___ octreotide and decadron, both of which were weaned off prior to discharge. Her vitals remained stable and her ostomy output remained about 2L daily prior to discharge. Please monitor ostomy output carefully. Diphenoxylate/atropine was held due to ongoing SBO but could be restarted depending on ongoing progress of SBO and ostomy output. # Crohn's disease: no known recurrence s/p resections: Held diphenoxylate-atropine given SBO. She can restart it if her ileostomy output increases to >1.5-2 L daily as an outpatient. # Myasthenia ___: continued pyridostigmine # Hypothyroidism: continued synthroid >30 minutes were spent preparing this discharge Transitional Issues: [] 1.6 cm enhancing nodule in the cul-de-sac is nonspecific, and may be related to the left ovary if still present versus a metastatic deposit. [] Follow up with hematology/oncology, colorectal surgery [] She will be discharged home with ___ for TPN and tube care. The patient requires an ambulance to get home due to her weakness and poor endurance related to her chronic disease and prolonged hospitalization Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Pantoprazole 40 mg PO Q24H 2. Levothyroxine Sodium 88 mcg PO DAILY 3. Levothyroxine Sodium 132 mcg PO QSUN 4. Modafinil 150 mg PO DAILY 5. Pyridostigmine Bromide 30 mg PO DAILY 6. Acetaminophen 1000 mg PO Q6H 7. Simethicone 40-80 mg PO QID:PRN gas 8. Spironolactone 100 mg PO DAILY 9. Diphenoxylate-Atropine 1 TAB PO BID:PRN loose stool 10. Hyoscyamine 0.125 mg SL TID:PRN nausea Discharge Medications: 1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN heartburn, dyspepsia 2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Severe RX hydromorphone 2 mg ___ tablet(s) by mouth q4h prn Disp #40 Tablet Refills:0 RX hydromorphone 4 mg ___ tablet(s) by mouth q4 hr prn Disp #18 Tablet Refills:0 3. Acetaminophen 1000 mg PO Q6H 4. Hyoscyamine 0.125 mg SL TID:PRN nausea 5. Levothyroxine Sodium 88 mcg PO DAILY 6. Levothyroxine Sodium 132 mcg PO QSUN 7. Modafinil 150 mg PO DAILY 8. Pantoprazole 40 mg PO Q24H 9. Pyridostigmine Bromide 30 mg PO DAILY 10. Simethicone 40-80 mg PO QID:PRN gas 11. HELD- Diphenoxylate-Atropine 1 TAB PO BID:PRN loose stool This medication was held. Do not restart Diphenoxylate-Atropine until you discuss it further with your doctor 12. HELD- Spironolactone 100 mg PO DAILY This medication was held. Do not restart Spironolactone until you discuss this with your doctor Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Small bowel obstruction Secondary: Leukopenia, Crohn's disease, pancreatic Cancer, myasthenia ___, hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ because you were having a bowel obstruction. You were seen by the colorectal surgeons. They placed a ___ tube, which allowed you to drain, or "vent" your G tube whenever you had nausea. We also started you on TPN to help with your nutrition. You should follow up with your oncologist and Dr. ___ colorectal surgery. We wish you the best. Sincerely, Your care team at ___. Followup Instructions: ___
10303799-DS-17	10,303,799	29,420,386	DS	17	2139-06-23 00:00:00	2139-06-23 17:39:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Ace Inhibitors / amlodipine / clindamycin / metoprolol / calcium channel blocker Attending: ___. Chief Complaint: Left Subdural Hemorrhage Major Surgical or Invasive Procedure: ___: craniotomy for evacuation of left subdural hematoma History of Present Illness: Ms ___ is an ___ year old ___ speaking female with history of atrial fibrillation on Apixaban /Plavix s/p Watchman device (___), embolic stroke, cardiac amyloid by biopsy, sCHF EF ___, CAD s/p NSTEMI who presents with new right arm and right leg weakness. Per report from her SNF, she was noted by staff in her nursing home to have new onset right arm and leg weakness. She was seen by her PCP who referred her to an OSH; NCHCT at OSH showed a 2cm left-sided subacute subdural hematoma with 5mm midline shift. She was given 10mg Vitamin K and 1 unit FFP for INR of 2.7 and transferred to ___ for evaluation. Past Medical History: ___: Hypertension Hyperlipidemia DM Paroxysmal atrial fibrillation CHF GERD Hemorrhoids Asthma ___: acute left sided stroke, minor right sided hemi-paresis. ___ s/p second CVA in cerebellum with right facial droop. ? seizures s/p thyroidectomy ___: s/p pelvic fracture and operative repair as well as right patellar fracture ___: appy Social History: ___ Family History: Father with asthma. Otherwise, patient does not know family medical problems. Physical Exam: ADMISSION: O: Vitals: T: ___ F P:80 R: 16 BP:116/75 SaO2:99% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs Full Neck: Supple. Lungs: No respiratory distress Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, "hospital" Language: Speech fluent with good comprehension and repetition. Mild dysarthria. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3mm, sluggishly reactive. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Right facial asymmetry. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength right upper ___ delt/bi/tri, ___ grip, right lower IP ___, otherwise full power ___ throughout. ON DISCHARGE: Eyes open spontaneously. Alert and oriented to self, hospital with choices. Dysarthric speech. PERRLa. EOMs intact. Right facial droop. Tongue midline. Right drift. RUE ___, R grip ___. RLE ___, R gastroc ___. Left upper and left lower extremity is full strength ___. Her incision is well approximated without redness, swelling, or discharge. Pertinent Results: =========== IMAGING =========== CHEST (PRE-OP PA & LAT) Study Date of ___ 2:13 ___ IMPRESSION: Stable severe cardiomegaly. No acute cardiopulmonary process. HEAD CT: ___ IMPRESSION: 1. No acute hemorrhage. 2. 5 mm linear hypodensity in the right cerebellar hemisphere corresponds to the acute infarction seen on the ___ MRI. 3. Chronic infarctions in the left basal ganglia/corona radiata and left occipital lobe are again noted. HEAD CT: ___ IMPRESSION: 1. Since ___, interval decrease in size of the mixed density left extra-axial hematoma, with some new high-density material seen along the tract of the previously seen drain, which is not unexpected in the setting of drain manipulation. 2. No new area of hemorrhage identified. ___ CXR IMPRESSION: 1. Interval decrease in lung volumes with accentuation of mild interstitial and worsening bibasilar opacities, left greater than right, likely due to small bilateral pleural effusions and associated compressive atelectasis. ___ NCHCT IMPRESSION: 1. No significant change in the size of the mixed density left extra-axial hematoma compared to the prior study from ___. 2. No new hemorrhage detected. VIDEO OROPHARYNGEAL SWALLOW Study Date of ___ 11:22 AM IMPRESSION: Aspiration with thin liquids prior to swallow due to delayed initiation. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. CT HEAD W/O CONTRAST Study Date of ___ 4:50 ___ IMPRESSION: 1. No significant interval change in the size of mixed density left extra-axial hematoma compared to ___. 2. No new area of intracranial hemorrhage or large territory infarction. US EXTREMITY LIMITED SOFT TISSUE RIGHT Study Date of ___ 10:03 AM IMPRESSION: 12.4 x 2.2 x 3.7 cm subcutaneous, subacute hematoma in the right anterolateral mid thigh corresponding to the area of clinical concern. No internal vascularity seen in the more echogenic portion of this collection. =========== LABS =========== ___ 05:45AM BLOOD WBC-4.7 RBC-5.08 Hgb-10.3* Hct-37.1 MCV-73* MCH-20.3* MCHC-27.8* RDW-23.3* RDWSD-59.7* Plt ___ ___ 03:45PM BLOOD Neuts-62.2 Lymphs-18.2* Monos-10.3 Eos-7.9* Baso-0.9 Im ___ AbsNeut-2.67 AbsLymp-0.78* AbsMono-0.44 AbsEos-0.34 AbsBaso-0.04 ___ 05:45AM BLOOD Plt ___ ___ 05:45AM BLOOD ___ PTT-24.8* ___ ___ 05:45AM BLOOD Glucose-86 UreaN-13 Creat-0.8 Na-146* K-3.7 Cl-105 HCO3-27 AnGap-18 ___ 04:45AM BLOOD CK-MB-3 cTropnT-0.08* ___ 03:45PM BLOOD cTropnT-0.07* ___ 05:45AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.8 Brief Hospital Course: The patient presented on ___ with right arm weakness. She was found to have a left SDH on CT scan but was admitted to medicine due to concern for NSTEMI. Her elevated troponins were attributable to her history of cardiac amyloidosis, she was evaluated by cardiology and deemed to be high risk but okay for surgery. She was taken to the OR on ___ for left craniotomy and evacuation of subdural hematoma. She was transferred to the PACU in stable condition and subsequently transferred to the ICU. Post-op head CT revealed appropriate drain placement and improvement of bleed. On ___, the patient was transferred to the ___ for further management. The patient remained neurologically and hemodynamically stable. The drain was draining adequately. On ___, the patient remained stable. The SD drain was d/c without difficulties, A post pull CT was obtained which showed high-density material seen along the tract along the previously seen catheter. The patient remains neurologically and hemodynamically stable. Transfer orders were placed to the floor, and ___ consults were obtained. On ___, the patient remained stable, continued to wait for floor bed. ___ completed- recommend rehab. Her potassium level was low, 2.9, K+ repleted. On ___, the patient remained neurologically and hemodynamically stable. K+ up to 3.9. Screening for rehab initiated. On ___, patient is neurologically stable. There was concern that the patient had worsening aphasia however with a translator patient able to state name clearly. Keppra increased to 750mg BID due to risk of seizures. Speech/swallow evaluated patient, changed to NPO with video swallow to be completed tomorrow. CXR ordered for cough and yellow sputum, it showed bilateral pleural effusions and atelectasis. Sputum culture and nystatin SSP were ordered however was contaminated. Encourage IS and respiratory/chest ___. Speech evaluated the patients swallow and recommended video swallow tomorrow. A non-contrast head CT was grossly stable. On ___, the patient was sleepy in the morning however aroused to voice. She responded well with encouragement by ___ ___ interpreter. The patient underwent video swallow which showed aspiration with thin liquids prior to swallow due to delayed initiation. She was cleared by speech to initiate puree/nectar diet. Postassium was repleted. On ___, her neurologic exam improved. She continued on her current diet without issues. On ___, she remained neurologically stable. On ___ she remained neurologically stable. Her magnesium was repleted. Keppra d/c'd as she is greater than 7 days out from surgery without evidence of seizures. Nutrition advised adding additional nutritional supplements and initiating remeron to stimulate her appetite for poor caloric intake. Her son was called and was in agreement with this plan. He prefers not to place peg for supplemental nutrition since she is able to take in POs. The patient's Aspirin was decreased to 81mg per cardiology recommendations. She does not need to resume Coumadin or Plavix. Her sutures and staples were d/c'd. Her incision is well approximated without redness, swelling, or discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheezing 2. Atorvastatin 80 mg PO QPM 3. Diltiazem Extended-Release 120 mg PO DAILY 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Polyethylene Glycol 17 g PO DAILY 6. Tiotropium Bromide 1 CAP IH DAILY 7. Torsemide 20 mg PO BID ___ MD to order daily dose PO DAILY16 9. HydrALAZINE 10 mg PO Q8H 10. Isosorbide Dinitrate 10 mg PO TID 11. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 4. Docusate Sodium 100 mg PO BID 5. Famotidine 20 mg IV DAILY 6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 7. Glucose Gel 15 g PO PRN hypoglycemia protocol 8. Heparin 5000 UNIT SC BID 9. Insulin SC Sliding Scale Fingerstick q6h Insulin SC Sliding Scale using REG Insulin 10. Mirtazapine 15 mg PO QHS 11. Senna 17.2 mg PO QHS 12. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 13. Torsemide 40mg mg PO QAM 14. Torsemide 20 mg PO QPM 15. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheezing 16. Atorvastatin 80 mg PO QPM 17. Diltiazem Extended-Release 120 mg PO DAILY 18. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 19. HydrALAZINE 10 mg PO Q8H 20. Isosorbide Dinitrate 10 mg PO TID 21. Polyethylene Glycol 17 g PO DAILY 22. Tiotropium Bromide 1 CAP IH DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left subdural hematoma Dysphagia Elevated Troponin Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Surgery You underwent a surgery called a craniotomy to have blood removed from your brain. It is best to keep your incision open to air but it is ok to cover it when outside. Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted, you are NOT allowed to drive by law. No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications Please do NOT take any blood thinning medication (Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. You were cleared to take Aspirin. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: You may have difficulty paying attention, concentrating, and remembering new information. Emotional and/or behavioral difficulties are common. Feeling more tired, restlessness, irritability, and mood swings are also common. You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: Headache is one of the most common symptoms after a brain bleed. Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: ___
10304137-DS-10	10,304,137	21,679,272	DS	10	2169-11-22 00:00:00	2169-11-23 18:57:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Multiple falls Major Surgical or Invasive Procedure: ___ Cardiac catheterization History of Present Illness: Mr. ___ is a ___ year old male with history of critical aortic stenosis, type 2 diabetes, depression, HTN, HLD, and alcoholism (sober since ___ who presented after three falls at home over the past day, the final fall resulting in a head strike on the left side. Patient describes a mechanical fall in which he was descending the stairs and thought he was at the bottom, but had one stair remaining and fell on to his left side striking his rib and his head. He denies loss of consciousness, lightheadedness, dizziness, chest pain, palpitations, nausea, diaphoresis, or other prodrome of symptoms preceding the fall. He described another mechanincal fall within the past day as well as he was exiting his Jeep and his foot was stuck. He struk his left elbow during this fall. Patient was experiencing rib pain from his final fall and presented to the ED. Of note, his wife insists that his falls must be related to his aortic stenosis, but the patient denies this. He denies having any lightheadedness, dizziness, or chest pain, prior to these falls. He does note lightheadedness on standing quickly, but does not have symptoms of presyncope, chest pain, or dyspnea with exertion. He denies lower extremity swelling or weight gain (current weight 214 lbs). He is followed by Dr. ___ his AS, and has cardiac catheterization planned for ___ for aortic valve replacement. In the ED, initial vitals were T 97.0 HR 94 BP 111/99 RR 18 O2 sat 96% RA, pain 10. Exam was notable for AS murmur. ECG showed sinus rhythm at 89, CXR revealed no rib fracture or pneumothorax. FAST exam was unremarkable and CT abdomen pelvis did not show any evidence of trauma. Labs were unremarkable. He was admitted to cardiology given his history of severe aortic stenosis. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. Past Medical History: - Severe aortic stenosis ___ cath: valve area 0.7 cm2, mean gradient 42 L/min) - Hypertension - Hyperlipidemia - Type 2 diabetes mellitus, on oral meds (A1c 6.7 in ___ - Depression - Gout - MGUS - Transaminitis and ?NASH (CT abdomen from ___ shows hypodense liver, consistent with fatty liver) Social History: ___ Family History: Father had CAD, CABG for angina. Father and brother have diabetes. Mother and brother both have hypertension. Mother with colon cancer. Mother and daughter with breast cancer. Daughter diagnosed with breast cancer at age ___, had a small mass removed. Physical Exam: ADMISSION EXAM: VS: 97.9 144/72 86 95%RA Weight: 102kg GENERAL: Obese man lying in bed in moderate distress, holding left hip in pain. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple, could not appreciate JVP due to habitus. CARDIAC: RRR, normal S1, S2. III/VI systolic crescendo/decrescendo murmur at the base, radiating to the carotids. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. CHEST: Tenderness to palpation at the 11th rib anteriorly, no ecchymosis, no flail chest. ABDOMEN: Obese, distended, firm, normal bowel sounds, nontender. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ DP pulses DISCHARGE EXAM: PHYSICAL EXAMINATION: VS: 97.7/98.6 84 (80s-100s) 129/70 (100s-130s/60s-80s) 18 97%RA Weight: 102kg (admit) -> 95.8 -> 96.3 GENERAL: Obese man lying in bed in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple, could not appreciate JVP due to habitus. CARDIAC: RRR, normal S1, S2. III/VI systolic crescendo/decrescendo murmur at the base, radiating to the carotids. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. CHEST: Tenderness to palpation at the 11th rib anteriorly, no ecchymosis, no flail chest. ABDOMEN: Obese, distended, firm, normal bowel sounds, nontender. EXTREMITIES: No c/c/e. No femoral bruits. Full range of motion of shoulder, but notes pain with movement and pain at the joint anteriorly. Left elbow abrasion with swelling and warmth. No erythema. Full range of motion. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ DP pulses Pertinent Results: Admission labs: ___ 03:50PM BLOOD WBC-9.7 RBC-3.95* Hgb-12.1* Hct-36.3* MCV-92 MCH-30.5 MCHC-33.2 RDW-14.3 Plt ___ ___ 03:50PM BLOOD Neuts-60.8 ___ Monos-6.3 Eos-6.1* Baso-0.9 ___ 03:50PM BLOOD ___ PTT-29.8 ___ ___ 03:50PM BLOOD Glucose-252* UreaN-24* Creat-1.2 Na-139 K-4.8 Cl-102 HCO3-24 AnGap-18 ___ 03:50PM BLOOD Calcium-9.8 Phos-4.5 Mg-2.1 ___ 03:50PM BLOOD ALT-43* AST-40 AlkPhos-58 TotBili-0.2 Notable labs: ___ 03:50PM BLOOD cTropnT-<0.01 ___ 07:40AM BLOOD %HbA1c-8.5* eAG-197* ___ 04:04PM BLOOD Lactate-2.1* Discharge labs: ___ 07:40AM BLOOD Albumin-4.1 ___ 07:40AM BLOOD WBC-10.0 RBC-3.91* Hgb-12.0* Hct-36.8* MCV-94 MCH-30.8 MCHC-32.7 RDW-14.2 Plt ___ ___ 07:40AM BLOOD UreaN-19 Creat-1.1 Na-139 K-4.5 Cl-105 HCO3-25 AnGap-14 Micro: ___ URINE URINE CULTURE-PENDING INPATIENT ___ Staph aureus Screen Staph aureus Screen-PRELIMINARY {STAPH AUREUS COAG +} INPATIENT Studies: ___ Carotid series: Pending at the time of discharge. ___ CXR: FINDINGS: As compared to the previous radiograph, there is no relevant change. Relatively low lung volumes, minimal atelectasis at the right lung base, elevated right hemidiaphragm. Normal size of the cardiac silhouette. No pulmonary edema, no pneumonia, no pleural effusions. ___ Cardiac catheterization: Hemodynamics: The right and left heart pressures were normal (PCWP 16 mmHg). The cardiac output was 4.59 L/min and the cardiac index was 2.29 L/Min/M2. The mean aortic valve gradient was 41.79 L/min and the aortic valve 0.72 cm2. Coronary angiography: right dominant LMCA: Normal LAD: The LAD had minor lumen irregularities. There were medium sized ___ and ___ diagonal branches without disease. The distal LAD wrapped around the apex. LCX: The left circumflex had minor irregularities in the proximal and distal portion. There was a medium sized ___ OMB and a large second OMB without stenoses. The distal LCx terminated in a small OMB. RCA: There was a 60% stenosis proximally and an 80% stenosis in the distal RCA. The RCA terminated in a large PDA and posterolateral branch. Assessment & Recommendations 1.Single vessel coronary artery disease 2.Severe aortic stenosis 3.Referral for AVR-CABG ___ TTE: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal. Quantitative biplane LVEF =56%. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area 0.9 cm2). Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Severe aortic valve stenosis. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Mild aortic regurgitation. Compared with the prior study (images reviewed) of ___, the aortic stenosis and aortic regurgitation are new. CLINICAL IMPLICATIONS: The patient has severe aortic valve stenosis. Based on ___ ACC/AHA Valvular Heart Disease Guidelines, if the patient is symptomatic (angina, syncope, CHF) and a surgical or TAVI candidate, a mechanical intervention has been shown to improve survival. ___ CXR (prelim): FINDINGS: PA and lateral radiographs of the chest demonstrate clear lungs, which are underinflated. The hilar and cardiomediastinal contours are normal. There is no pneumothorax or pleural effusion. Pulmonary vascularity is normal. No displaced rib fracture is seen. IMPRESSION: No displaced rib fracture. ___ CT abdomen: 1. No evidence of traumatic injury to the imaged abdomen and pelvis. 2. Gastric distention with air and fluid, possible mural edema near the pylorus, which ___ be artifactual due to peristalsis. Otherwise, no evidence of obstructing lesion. Query slow gastric transit. 3. Extensive atherosclerotic disease as outlined above. ___ TTE (OSH): Left ventricle: The left ventricle is normal in size. There is normal LV wall thickness. Left ventricular systolic function is normal. The left ventricular ejection fraction is 60-65%. No regional wall motion abnormalities noted. Grade 1 diastolic dysfunction (abnormal relaxation pattern). Right ventricle: The right ventricle is normal in size and function. Atria: There is no visual or Doppler evidence for an atrial septal defect; however, a small ASD or PFO cannot be fully ruled out. The left atrial volume index for BSA is 21.4 mL/m2. The left atrium is mildly dilated. The right atrial size is normal. IVC appears normal. Mitral valve: The mitral valve leaflets appear thickened but opened well. There is mild mitral annular calcification. There is no mitral valve stenosis. There is mild mitral regurgitation. Tricuspid valve: The tricuspid valve is normal in structure and function. There is trace tricuspid regurgitation. Doppler findings do not suggest pulmonary hypertension. PA pressure estimated at 36 mmHg. Aortic Valve: Aortic valve leaflets are moderately thickened and/or calcified. Aortic valve mean gradient is 41 mmHg. The maximal aortic valve gradient is 78 mmHg. The aortic valve area is 0.8 cm2. Severe valvular aortic stenosis. Mild aortic regurgitation. Pulmonic valve: The pulmonic valve is not well seen, but is grossly normal. There is no pulmonic valvular stenosis. Trace pulmonic valvular regurgitation. Great vessels: The aortic root is normal in size. The visualized portion of the ascending aorta is normal in size. Pericardium and pleura: There is no pericardial effusion. There is no pleural effusion. Brief Hospital Course: ___ year old male with history of critical aortic stenosis, type 2 diabetes, depression, HTN, HLD, and alcoholism (sober since ___ who presented after multiple falls at home over the past day. # Aortic stenosis: TTE in ___ with aortic valve area of 0.8 and gradient of 41 mmHg at OSH indicating severe AS. TTE here confimed this finding with valve area of 0.9 and gradient of 22, but subsequent catheterization revealed more severe disease with valve area of 0.7 and mean gradient of 42. He is followed by Dr. ___ the plan was to procede with AVR-CABG on ___. # s/p fall, ? presyncope: Patient describes mechanical falls without a presyncopal prodrome, though his wife is insistent that his aortic stenosis and presyncope must be contributing. He did not lose consciousness, though did have a head strike. Neuro exam is nonfocal. Rib pain, but no fracture on x-ray and no evidence of trauma on CT abdomen. TTE and cardiac cath revealed severe aortic stenosis, and surgery is planned for ___, as above. # CAD: Cardiac cath on ___ revealed a 60% stenosis proximally and an 80% stenosis in the distal RCA. Patient will go for AVR-CABG, as above. # Diabetes, type 2: Well controlled with last A1c of 6.7 in ___. Home metformin and glipizide were held in favor of insulin sliding scale while in house. Home medications restarted on discharge. # Hypertension: Continued lisinopril. # Hyperlipidemia: Continued atorvastatin. # Gout: Stable. Continued allopurinol. Did not require indomethacin. # Depression: Stable. Continued citalopram and venlafaxine. # Pain: Continued home gabapeintin 100 mg PO TID and provided oxycodone as needed. # Insomnia: Continued mirtazapine 3.75 mg PO HS. # Transitional issues: - Code status: Full (confirmed ___ - Emergency contact: ___ (wife) ___ - Patient completed pre-op workup for AVR-CABG while in house (carotid series pending at discharge). Surgery planned for ___, ___. - Elbow pain persisted throughout admission with swelling and warmth. Did not appear erythematous, and he remained afebrile without leukocytosis, so no antibiotics were started. Please re-evaluate on follow up. No imaging has been done of the left elbow. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO BID 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO DAILY 4. Citalopram 40 mg PO DAILY 5. Cyanocobalamin ___ mcg PO DAILY 6. MetFORMIN XR (Glucophage XR) 1500 mg PO DAILY Do Not Crush 7. Multivitamins 1 TAB PO DAILY 8. GlipiZIDE 2.5 mg PO DAILY 9. Indomethacin 25 mg PO TID:PRN pain 10. Lisinopril 10 mg PO DAILY 11. Venlafaxine XR 75 mg PO DAILY 12. Gabapentin 100 mg PO TID 13. Mirtazapine 3.75 mg PO HS Discharge Medications: 1. Allopurinol ___ mg PO BID 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO DAILY 4. Citalopram 40 mg PO DAILY 5. Cyanocobalamin ___ mcg PO DAILY 6. Gabapentin 100 mg PO TID 7. Lisinopril 10 mg PO DAILY 8. Mirtazapine 3.75 mg PO HS 9. Multivitamins 1 TAB PO DAILY 10. Venlafaxine XR 75 mg PO DAILY 11. Acetaminophen 650 mg PO Q6H 12. GlipiZIDE 2.5 mg PO DAILY 13. Indomethacin 25 mg PO TID:PRN pain 14. MetFORMIN XR (Glucophage XR) 1500 mg PO DAILY 15. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth every eight (8) hours Disp #15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: - Critical aortic stenosis - Coronary artery disease - s/p multiple falls Secondary diagnoses - Depression - Gout - Hypertension - Hyperlipidemia - Type 2 diabetes mellitus, on oral meds (A1c 6.7 in ___ - MGUS - Transaminitis and ?NASH (CT abdomen from ___ shows hypodense liver, consistent with fatty liver) 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 ___. You were admitted to the hospital because you have been falling very frequently and you wife was worried that these falls are related to symptoms from your severe aortic stenosis. We did an ultrasound of your heart and a catheterization procedure which showed that you do have severe aortic stenosis and this should be managed surgically in the near future. You had a cardiac catheterization which showed that you have severe aortic stenosis and coronary artery disease and you would benefit from an aortic valve replacement and a coronary artery bypass. You were continuing to have elbow pain on discharge and you should follow up with your primary care doctor to discuss this if the pain continues. Followup Instructions: ___
10304137-DS-12	10,304,137	27,055,320	DS	12	2170-06-23 00:00:00	2170-06-25 08:17:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENT ILLNESS: ___ with PMH of HTN, DM, HLD, AS s/p AVR (___), MGUS, ETOH abuse presents with altered mental status. Patient with a history of alcohol abuse recently discharged from a six-week stay and alcohol abuse treatment center in ___. He was picked up by a friend from the airport who is noted to have altered mental status. He reports that he is forgetful at times confused. At time of evaluation patient has no consistent complaints. He was recently prescribed baclofen for his back pain which worsened while sitting for long hours at rehab. He reports being told that he took extra, but doesn't recall doing so. He denies that this was a suicide attempt, however does endorse passive suicidal ideation. He at times is agitated and tangential, threatening to leave and does not want his wife or family to know anything about him being hospitalized. In the ___, initial VS: T98.2 P93 BP173/73 RR18 O2 sat 99%. Labs were notable for normal CBC, Bicarb 18, Cr 1.4 (baseline 0.9-1.0), Lactate of 2.7, TnT 0.02, MB 13 (MBI negative), negative tox screen and normal VBG. CT head showed no acute process and CXR was negative for acute lung pathology. MD in ___ called ___ (___ in ___ and was told that he was in fact discharge on ___ with the dx of addiction and narcissistic personality traits. During his time there he had paranoid thoughts and was on trileptal for a short while, but it was not on his d/c med list. He also started refusing to speak w/family and rescinded his initial wishes to have his wife as his contact person. Patient was seen by toxicology and SW in ___. Toxicology did not think that his presentation was clinically consistent with baclofen toxicity although he was noted to have an acidosis with AG of 14 and lactate of 2.7. SW will help patient contact his lawyer and PO in the AM. In the ___, patient refused any treatment including IVF and spit out his pills that ___ team attempted to give. He was then admitted to medicine for further evaluation of his AMS. Vitals prior to transfer: T98.0 P76 BP168/89 RR20 O2 sat 96% RA. On arrival to the floor, the patient refused vitals on multiple attempts. He reports that he does not want his wife notified of his hospitalization. Patient reports feeling depressed at times, but not currently. He reports that he is sick of being "in the place and I just want it to be over." He does not have a plan to kill himself, but states that he wants to die. When asked to give IVF because he might be dehydrated, he stated that "Well if I don't get IVF or drink anything i'll just get more dehydrated, then all this will be over and I'll be gone." ROS notable for occasional DOE. Otherwise negative. Review of Systems: (+) (-) 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: - Severe aortic stenosis ___ cath: valve area 0.7 cm2, mean gradient 42 L/min) - Hypertension - Hyperlipidemia - Type 2 diabetes mellitus, on oral meds (A1c 6.7 in ___ - Depression - Gout - MGUS - Transaminitis and ?___ (CT abdomen from ___ shows hypodense liver, consistent with fatty liver) Social History: ___ Family History: Father had CAD, CABG for angina. Father and brother have diabetes. Mother and brother both have hypertension. Mother with colon cancer. Mother and daughter with breast cancer. Daughter diagnosed with breast cancer at age ___, had a small mass removed. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals- patient refusing vitals General- Alert, oriented x 1 (to self, no to place or month/time) no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- CTAB, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, II/VI SEM LSB, rubs, gallops Abdomen- obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 grossly intact, motor function grossly normal Psych - patient reports feeling depressed at times, reports that he is sick of being "in the place and I just want it to be over." He does not have a plan to kill himself, but states that he wants to die. DISCHARGE PHYSICAL EXAM Pertinent Results: ADMISSION LABS: ___ 08:25PM ___ O2-21 PO2-88 PCO2-36 PH-7.36 TOTAL CO2-21 BASE XS--4 ___ 02:46PM ___ PTT-29.3 ___ ___ 02:40PM COMMENTS-GREEN TOP ___ 02:40PM GLUCOSE-176* LACTATE-2.7* NA+-143 K+-5.1 CL--111* TCO2-19* ___ 02:40PM HGB-12.3* calcHCT-37 ___ 02:00PM GLUCOSE-173* UREA N-40* CREAT-1.4* SODIUM-142 POTASSIUM-5.1 CHLORIDE-110* TOTAL CO2-18* ANION GAP-19 ___ 02:00PM estGFR-Using this ___ 02:00PM ALT(SGPT)-47* AST(SGOT)-34 CK(CPK)-307 ALK PHOS-54 TOT BILI-0.2 ___ 02:00PM LIPASE-45 ___ 02:00PM cTropnT-0.02* ___ 02:00PM CK-MB-13* MB INDX-4.2 ___ 02:00PM ALBUMIN-4.7 CALCIUM-9.4 PHOSPHATE-4.5 MAGNESIUM-1.8 ___ 02:00PM VIT B12-708 ___ 02:00PM TSH-1.5 ___ 02:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 02:00PM WBC-9.4 RBC-3.86* HGB-12.0* HCT-36.4* MCV-94 MCH-31.0 MCHC-32.9 RDW-13.2 ___ 02:00PM NEUTS-67.8 ___ MONOS-7.3 EOS-0.5 BASOS-0.3 ___ 02:00PM PLT COUNT-265 INTERIM LABS: ___ 06:58AM BLOOD Lactate-1.1 ___ 12:45PM URINE Color-Yellow Appear-Clear Sp ___ ___ 12:45PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 12:45PM URINE RBC-<1 WBC-4 Bacteri-NONE Yeast-NONE Epi-0 ___ 12:45PM URINE CastHy-10* ___ 12:45PM URINE Mucous-RARE ___ 12:45PM URINE Hours-RANDOM Creat-109 Na-33 K-67 Cl-35 Calcium-1.0 ___:45PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG DISCHARGE LABS: ___ 08:35AM BLOOD WBC-6.2 RBC-3.66* Hgb-11.1* Hct-34.8* MCV-95 MCH-30.2 MCHC-31.8 RDW-13.3 Plt ___ ___ 08:35AM BLOOD Glucose-167* UreaN-26* Creat-1.0 Na-141 K-4.3 Cl-109* HCO3-21* AnGap-15 ___ 08:35AM BLOOD CK(CPK)-374* ___ 08:35AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.5* IMAGING: ___ R HIP XRAY FINDINGS: Comparison is made to a CT scan from ___. Bilateral hip joint spaces are preserved. There are no signs for acute fractures or dislocation. There are mild degenerative changes of the left sacroiliac joint at the superior aspect. No focal lytic or blastic lesions are present. There are vascular calcifications. There is chondrocalcinosis in the right labrum. IMPRESSION: No signs for acute bony injury or significant degenerative changes of either hips. ___ CT HEAD W/O CONTRAST FINDINGS: There is no evidence of intracranial hemorrhage, acute major vascular territorial infarction, shift of the normally midline structures, mass effect or edema. The ventricles and sulci are normal in size and configuration. The basal cisterns appear patent. The gray-white matter differentiation is preserved. No fractures are identified. The cranial and facial soft tissues are unremarkable. The orbits are unremarkable. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. IMPRESSION: No acute intracranial process. ___ CXR FINDINGS: There is no evidence of intracranial hemorrhage, acute major vascular territorial infarction, shift of the normally midline structures, mass effect or edema. The ventricles and sulci are normal in size and configuration. The basal cisterns appear patent. The gray-white matter differentiation is preserved. No fractures are identified. The cranial and facial soft tissues are unremarkable. The orbits are unremarkable. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. IMPRESSION: No acute intracranial process. Brief Hospital Course: ___ with PMH HTN, DM, HLD, AS s/p AVR (___), MGUS, ETOH abuse presents with altered mental status in the setting of taking more than prescribed baclofen found to have worsening ___, AG acidosis, elevated lactate, CK, CKMB. # AMS - Delerium vs delerium with underlying mania/personality disorder. Etiologies for delerium include baclofen OD, metabolic derangement and underlying medical condition. Pt may also have component of bipolar disorder/psych dx. NL neuro exam and negative head CT in ___. Serum and urine tox screens were negative, so acute drug/alcohol intoxication was considered less likely. He was placed on CIWA precautions. Other causes of AMS wre considered. Patient's TSH (1.5)and B12 (708) were normal. He was continued on folic acid/thiamine supplementation. He was seen by Psychiatry who placed him under ___. He was further evaluated, and it was recommeneded that after discharge he receive further outpatient psychiatric evaluation for depression and continued treatment of alcohol abuse. # Troponin leak: Patiet's trop was initially elevated to 0.02 on admission, rose to 0.03, but returned <0.01. His CK was elevated, possibly due to baclofen withdrawal. Cardiac etiology was unlikely as his troponins returned to normal and EKGs were unchanged from prior EKGs. He was monitored on telemetry throughout his hospitalization without events. # ___: Likely pre-renal in etiology given elevated lactate, TNT leak and return to normal with IVFs. His Cr was 1.4 on admission, rose to 1.7, but was 1.0 at the time of discharge. His oral hypoglycemics were held during his hospitalization. # Lactic Acidosis: Possibly from decrease perfusion as evidenced by ___ and mild troponin elevation possible complicated by taking metformin while at rehab in ___. Lactate levels returned to normal shortly after admission. # R Hip Pain: Patient reports he has a history of sciatica. R Hip XR showed no acute process. # Headache: Patient with chronic headache (throughout rehab) for which he was taking ibuprofen bid. Ibuprofen dose limited during admission due to ___. # Cough: Patient also complained of cough, productive of white sputum. Afebrile. No leukocytosis. Chronic Issues: # DM - HISS # HTN - hold home Lisinopril given ___ # MGUS - stable, B2 microglobulin decreased recently # Depression - continue home effexor, mirtazepine # HLD - continue home statin #TRANSITIONAL ISSUES - Patient will need outpatient psychiatric evaluation for depression and continued treatment of alcohol abuse. - Follow-up with PCP if headache, hip pain or cough does not improve or worsen. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Thiamine 100 mg PO DAILY 4. GlipiZIDE XL 5 mg PO DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. Metoprolol Tartrate 25 mg PO BID 7. Lisinopril 5 mg PO BID 8. Gabapentin 100 mg PO TID 9. Aspirin 81 mg PO DAILY 10. Atorvastatin 20 mg PO DAILY 11. MetFORMIN (Glucophage) 1000 mg PO BID 12. Baclofen 10 mg PO PRN Back pain Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 20 mg PO DAILY 3. Cyanocobalamin 1000 mcg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Metoprolol Tartrate 25 mg PO BID 6. Multivitamins 1 TAB PO DAILY 7. Thiamine 100 mg PO DAILY 8. GlipiZIDE XL 5 mg PO DAILY 9. Lisinopril 5 mg PO BID 10. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY Altered mental status Baclofen overdose Acute Kidney Injury Secondary Alcohol abuse 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 to the hospital with confusion, likely due to an overdose of baclofen, a medication you were taking for back pain. You were given supportive care and your symptoms resolved. You also had kidney problems due to dehydration, which improved with fluids. You were seen by Psychiatry and they recommend you followup with an outpatient psychiatrist for alcohol and depression treatment. Please take your medications as prescribed and follow up with the appointments listed below. Followup Instructions: ___
10304137-DS-13	10,304,137	21,557,664	DS	13	2172-12-20 00:00:00	2172-12-21 10:28:00	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: None History of Present Illness: Mr. ___ is a ___ with PMH of HTN, DM, HLD, AS s/p AVR (___), smoldering myeloma, past ETOH abuse presenting with abdominal pain. He was initially taken to ___ by EMS after he developed abdominal pain several days ago. He had imaging done showing diverticulitis and was discharged on ___ on cipro/flagyl. He presented to the ED on ___ because of persistent abdominal pain. He reports that initially the pain seemed to get slightly better after discharge, but then it returned and became progressively worse. His pain is in the lower abdomen bilaterally and is band like without radiation. He denies any nausea or vomiting. He has eaten very little due to the pain, although food does not particularly worsen his symptoms. He has not had any diarrhea or fevers at home. Last BM was day of presentation. His last and only other episode of diverticulitis was ___ years ago. He does report that he has developed constipation over the past 5 months. His stools appear slightly thinner than previously. He has not noticed any blood. He also feels that he is not eating well due to lack of appetite which has persisted for ~2 months. He also notes that he lost around 10 pounds (213 to 203) in 3 weeks-1 month. He thinks this weight loss is unintentional. In the ED, initial vitals were: 98 102 113/90 18 98% RA. Labs notable for WBC 8.7, H/H 11.9/35.9, Plt 256, no bands or left shift, Cr 1.2 (at baseline), BUN 13, lactate 2.7. Imaging notable for uncomplicated sigmoid diverticulitis, and a 7mm new pulmonary nodule in LLL. He was given 2mg IV morphine X 2, Iv cipro/flagyl, and 1L IV NS. Decision was made to admit for IV antibiotics given "failure" of outpatient treatment. On the floor, initial vitals were 97.6 122/74 72 18 97% RA. He reported that his pain had improved with morphine in the ED. Past Medical History: - Severe aortic stenosis ___ cath: valve area 0.7 cm2, mean gradient 42 L/min) - Hypertension - Hyperlipidemia - Type 2 diabetes mellitus, on oral meds (A1c 6.7 in ___ - Depression - Gout - MGUS - Transaminitis and ?___ (CT abdomen from ___ shows hypodense liver, consistent with fatty liver) Social History: ___ Family History: Father had CAD, CABG for angina. Father and brother have diabetes. Mother and brother both have hypertension. Mother with colon cancer. Mother and daughter with breast cancer. Daughter diagnosed with breast cancer at age ___, had a small mass removed. Physical Exam: ON ADMISSION ============ Vital Signs: 97.6 122/74 72 18 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-distended, tenderness to palpation in lower abdomen R > L with mild voluntary guarding but rebound or rigidity GU: No foley Ext: Warm, well perfused, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact, moving all extremities equally ON DISCHARGE ============== Vital Signs: 98.1 123/68 78 18 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, obese, tenderness to palpation in lower abdomen R > L with mild voluntary guarding but no rebound or rigidity GU: No foley Ext: Warm, well perfused, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact, moving all extremities equally Pertinent Results: LABS ON ADMISSION ================= ___ 01:45PM BLOOD WBC-8.7 RBC-3.98* Hgb-11.9* Hct-35.9* MCV-90 MCH-29.9 MCHC-33.1 RDW-12.1 RDWSD-39.3 Plt ___ ___ 01:45PM BLOOD Neuts-62.7 ___ Monos-9.6 Eos-2.5 Baso-0.3 Im ___ AbsNeut-5.43 AbsLymp-2.11 AbsMono-0.83* AbsEos-0.22 AbsBaso-0.03 ___ 01:45PM BLOOD Glucose-157* UreaN-13 Creat-1.2 Na-142 K-4.8 Cl-105 HCO3-23 AnGap-19 ___ 01:45PM BLOOD ALT-31 AST-40 AlkPhos-50 TotBili-0.3 ___ 01:45PM BLOOD cTropnT-<0.01 ___ 01:45PM BLOOD Albumin-4.3 ___ 01:53PM BLOOD Lactate-2.7* LABS ON DISCHARGE ================== ___ 04:45AM BLOOD WBC-8.1 RBC-3.73* Hgb-11.3* Hct-34.1* MCV-91 MCH-30.3 MCHC-33.1 RDW-12.3 RDWSD-40.7 Plt ___ ___ 04:45AM BLOOD Glucose-133* UreaN-13 Creat-1.2 Na-136 K-3.9 Cl-100 HCO3-22 AnGap-18 ___ 04:45AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.1* ___ 11:57PM BLOOD Lactate-1.2 IMAGING ======= CT abd/pelvis IMPRESSION: 1. Uncomplicated sigmoid diverticulitis. 2. Since the CT abdomen and pelvis of ___, there has been interval development of a 7 mm pulmonary nodule in the left lower lobe. RECOMMENDATION(S): 3 month follow-up chest CT of the 7 mm left lower lobe pulmonary nodule is recommended. Brief Hospital Course: ___ with PMH of HTN, DM, HLD, AS s/p AVR (___), smoldering myeloma, ETOH abuse presenting with abdominal pain due to diverticulitis. # Diverticulitis: Originally diagnosed at ___ and was discharged there on ___. Presented to ___ bc of ongoing pain. On repeat imaging on this admission, remains uncomplicated. Most likely not a failure of PO antibiotics from ___ since symptoms may take some time to resolve. He has fortunately not developed complicated disease. Last colonoscopy in ___, recommend repeat in ___ due to only fair prep. Continued on cipro/flagyl while in house. He was able to tolerate food at discharge. Would recommend follow up colonoscopy after acute diverticulitis resolves to exclude underlying malignancy, particularly given weight loss and change in stool pattern. # Elevated lactate: likely dehydration, and after fluids, resolved. # Pulmonary nodule: new 7mm pulmonary nodule. Reimaging recommended at ___ months. Colonoscopy as above. # History of alcohol abuse: reports no alcohol in the past ___ years. Continued thiamine, multivitamin, folate # DM: Held home metformin and glipizide. ISS continued while hospitalized # CAD s/p CABG: Continued home aspirin and atorvastatin # Hypertension: Held home amlodipine 5mg in the setting of initial poor PO intake. TRANSITIONAL ISSUES =================== []Should finish cipro and flagyl course- take up to and including ___. []3 month follow-up chest CT of the 7 mm left lower lobe pulmonary nodule is recommended. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 1000 mg PO BID 2. amLODIPine 5 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Multivitamins 1 TAB PO DAILY 5. Aspirin 81 mg PO DAILY 6. GlipiZIDE 5 mg PO BID 7. FoLIC Acid 1 mg PO DAILY 8. Thiamine 100 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Thiamine 100 mg PO DAILY 6. Ciprofloxacin HCl 750 mg PO Q12H RX ciprofloxacin HCl 750 mg 1 tablet(s) by mouth q12hr Disp #15 Tablet Refills:0 7. MetroNIDAZOLE 500 mg PO Q8H RX metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth q8hr Disp #15 Tablet Refills:0 8. amLODIPine 5 mg PO DAILY 9. GlipiZIDE 5 mg PO BID 10. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Uncomplicated diverticulitis SECONDARY DIAGNOSIS ===================== Pulmonary nodule Diabetes Mellitus Type II Coronary Artery Disease Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted to ___ for abdominal pain. Imaging showed that you had uncomplicated diverticulitis, which is an infection of your intestines. You were continued on your oral antibiotics, and you were able to tolerate some food. You should continue your ciprofloxacin and flagyl up through and including ___. We are providing you with prescriptions in case you do not have these medications from your prior hospitalization at ___ and Women's. See medication instructions below. Please make an appointment with your primary care physician in the upcoming week so they can monitor your symptoms. If you develop fever, worsening abdominal pain, or your pain does not improve over the next 2 days, please go to an emergency room, as this could be a sign of a serious worsening of the infection. -Your ___ Team Followup Instructions: ___
10304137-DS-14	10,304,137	27,151,540	DS	14	2174-01-09 00:00:00	2174-01-09 08:48:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: L should pain Major Surgical or Invasive Procedure: L shoulder closed reduction History of Present Illness: ___ male presents with the above fracture s/p mechanical fall yesterday ___. Patient slipped coming out of the shower and landed on his left shoulder and upper arm. Denies head strike or loss of consciousness. Has significant pain in his shoulder and states he is able to move the arm but is unable to fully range his shouhlder. No pain in the elbow or wrist. Good pulses and normal strength and sensation. Not on any blood thinners. Past Medical History: - Severe aortic stenosis ___ cath: valve area 0.7 cm2, mean gradient 42 L/min) - Hypertension - Hyperlipidemia - Type 2 diabetes mellitus, on oral meds (A1c 6.7 in ___ - Depression - Gout - MGUS - Transaminitis and ?NASH (CT abdomen from ___ shows hypodense liver, consistent with fatty liver) Social History: ___ Family History: Father had CAD, CABG for angina. Father and brother have diabetes. Mother and brother both have hypertension. Mother with colon cancer. Mother and daughter with breast cancer. Daughter diagnosed with breast cancer at age ___, had a small mass removed. Physical Exam: Gen: NAD CV: RRR P: unlabored breathing left upper extremity: - Skin intact - No deformity, no edema, +ecchymosis, no erythema, no induration - Soft, non-tender arm and forearm - Full, painless ROM at elbow, wrist, and digits - ROM of shoulder limited ___ pain - Fires EPL/FPL/DIO - SILT axillary/radial/median/ulnar nerve distributions - 2+ radial pulse, WWP Brief Hospital Course: Pt presented with a L shoulder dislocation + Hill Sach's lesion on ___. He was closed reduced in the operating room on ___. He was subsequently discharged on ___ with a sling. He will follow up in ___ weeks. Discharge Medications: 1. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours Disp #30 Capsule Refills:*0 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Chlorthalidone 25 mg PO DAILY 6. Escitalopram Oxalate 10 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Losartan Potassium 50 mg PO DAILY 9. Thiamine 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: L shoulder dislocation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - non weight bearing of left upper extremity in sling at all times 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. - You may come out of the sling and leave your arm at your side to shower. Afterward, please return immediately to the sling. 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 - 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 FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. ___. You will have follow up with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Followup Instructions: ___
10304258-DS-8	10,304,258	27,467,730	DS	8	2163-04-14 00:00:00	2163-04-14 17:23:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Fluoxetine / Citalopram Attending: ___ Chief Complaint: #Hyponatremia Major Surgical or Invasive Procedure: NONE History of Present Illness: Mr. ___ is a ___ yo M with hx of GERD, PTSD, bipolar d/o, COPD, who presented with nausea and nonbloody emesis x2 months. Emesis occurs approximately once per day after eating solid foods (worse after greasy food), and is nonbloody and non-billious. He sometimes feels dizzy after these episodes. He has noted significant decrease in appetite, though he is able to tolerate some food. He denies diarrhea, blood in the stool, constipation, or abdominal pain. He endorses weight loss (20lb weight loss over last 2months, 40lb over the last year) and has had night sweats for years. He began drinking heavily at the beginning of this year (1.75 L vodka/day x4 months), but has reduced intake to ~1 beer per day over the last 6 months. He also reports some changes in his psychiatric medications in the past 2 months. Pt went to ___ on ___, labs were ordered and he was found to be hyponatremic to 125. Of note he was also diagnosed with Hep C during this set of labs. At ___ ED, VS 98.0 88 135/79 16 99%, Na 117. He was given 2L NS and repeat Na was 122. Upon admission to the floor yesterday evening, pt was awake and alert. He denied nausea and had not vomited since 3 days PTA. Past Medical History: # DVT: ___ yrs ago, found to have Factor V Leiden, has been on warfarin since # Hep C: (recent dx) # Bipolar d/o # Depression # PTSD # GERD: symptoms have diminished with weight loss, well-controlled with nexium # COPD: Hospitalized in ___ for pneumonia, ___ for COPD exacerbation Social History: ___ Family History: Father--cirrhosis, heavy drinker Mother--hemorrhagic stroke, passed away in ___ Sister--factor ___ ___ Physical Exam: ADMISSION EXAM: VS Temp 97.9 HR 64 BP 130/79 RR 17 O2 sat 99/RA General--well appearing, no apparent distress HEENT--firm 3-4cm bony nodule in occipital area (per pt, stable since childhood), pupils equally dilated 4-5mm, reactive to light, sclera anicteric, 2mm white lesion on uvula, conjunctiva clear Neck--submandibular LAD, no JVD Cardio--distant heart sounds, RRR, no murmurs, rubs, or gallops Lungs--poor air movement, occasional wheeze, diminished breath sounds throughout Abdomen--NABS, nontender, nondistended, liver palpated ~3cm below costal margin, no splenomegaly appreciated Ext--warm, well-perfused, no cyanosis or clubbing MSK--good ROM throughout, no swelling or deformity Skin--numerous linear scars on abdomen and upper extremity (per pt, from suicide attempts) Neuro--alert, oriented, CN II-XII intact, no gross motor deficits DISCHARGE EXAM: Physical Exam: VS Temp 98.2 HR 66 BP 131/85 RR 18 O2 sat 93/RA General--well appearing, no apparent distress HEENT--firm 3-4cm bony nodule in occipital area (per pt, stable since childhood), sclera anicteric, conjunctiva clear, MMM Neck--submandibular LAD, no JVD Cardio--distant heart sounds, RRR, no murmurs, rubs, or gallops Lungs--poor air movement, occasional wheeze, diminished breath sounds throughout Abdomen--NABS, nontender, nondistended Ext--warm, well-perfused, no cyanosis or clubbing MSK--good ROM throughout, no swelling or deformity Skin--numerous linear scars on abdomen and upper extremity (per pt, from suicide attempts) Neuro--alert and oriented, no gross motor deficits Pertinent Results: ___ 08:45PM BLOOD WBC-4.6 RBC-4.83 Hgb-14.2 Hct-42.3 MCV-88 MCH-29.5 MCHC-33.7 RDW-14.4 Plt ___ ___ 08:45PM BLOOD Neuts-61.5 ___ Monos-6.1 Eos-1.8 Baso-0.7 ___ 08:45PM BLOOD ___ PTT-40.7* ___ ___ 08:45PM BLOOD Glucose-126* UreaN-6 Creat-0.6 Na-117* K-4.1 Cl-83* HCO3-28 AnGap-10 ___ 08:45PM BLOOD ALT-23 AST-22 AlkPhos-87 TotBili-0.4 ___ 08:45PM BLOOD Albumin-4.6 Calcium-8.9 Phos-2.6* Mg-1.8 ___ 08:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 01:10PM BLOOD T4-4.3* ___ 01:15AM BLOOD TSH-4.8* ___ 01:15AM BLOOD Osmolal-249* ___ 08:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 08:50PM URINE Hours-RANDOM Creat-87 Na-12 K-43 Cl-43 ___ 08:50PM URINE Osmolal-408 ___ 08:50PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG ___ 01:33PM BLOOD Glucose-144* UreaN-6 Creat-0.6 Na-128* K-3.8 Cl-96 HCO3-22 AnGap-14 ___ 05:25AM BLOOD WBC-3.1* RBC-4.84 Hgb-14.1 Hct-42.9 MCV-89 MCH-29.2 MCHC-32.9 RDW-14.4 Plt ___ ___ 05:25AM BLOOD ___ PTT-35.7 ___ Brief Hospital Course: #HYPONATREMIA Pt presented to ___ on ___ with nausea/vomiting x2months. There, he was found to be hyponatremic to 125, and HCV Ab (+). He was advised to go to the ___ ED. At ___ ED on ___, VS 98.0 88 135/79 16 99%, Na 117. He was given 2L NS and repeat Na was 122. RUQ US and EKG were normal. Upon admission to the floor he was awake and alert. He was started on continues IV NS 100ml/hr. He denied nausea and had not vomited since 3 days PTA and last EtOH was 1 beer 6d PTA. By the morning of ___, his Na had gradually risen to 124, by late afternoon Na was 129, and NS was discontinued. By ___ his Na was 132 in the AM. His urine studies showed Na of 12 and osms >40 with serum osms of 249. He was thought to have hypovolemic hyponatremia given his history of poor po intake and vomiting. He was therefore volume resuscitated. His presentation was not consistent with SIADH or polydipsia. He was found to be very subtly hypothyroid (TSH 4.8, fT4 4.3), but this wasn't thought to be contributing. Given the constellation of thrombocytopenia (110s), leukopenia (3.2), and hyponatremia there was significant suspicion that oxcarbazepine may be contributing to these findings as it is a known myelosuppressant and has been associated with increased ADH sensitivity at the nephron. Thus, it is most likely that he had hypovolemic hyponatremia with possible increased ADH sensitivity concomittantly. The patient was discharged with salt tabs 2g/day to take for a few days until he can receive labs. He needs urgent reevaluation of his sodium within 2 days. #Hypothyroidism: He was found to be very subtly hypothyroid (TSH 4.8, fT4 4.3), but this wasn't thought to be contributing to his hyponatremia. He had no findings on exam. This should be followed up in the outpatient setting. #Leukopenia/Thrombocytopenia: Per ___ records may have been thrombocytopenic previously. Given the constellation of thrombocytopenia (110s), leukopenia (3.2), and hyponatremia there was significant suspicion that oxcarbazepine may be contributing to these findings as it is a known myelosuppressant. Consideration should be given to adjustment of medication regimen. He was not thought to have infection or malignancy as a cause of his cytopenias and he was recently tested for HIV. #As for his nausea and weight loss, he was felt to be at low risk for myelophthisic infection (TB, HIV) and has recently been tested for HIV. His partner ___ indicated that much of his weight loss may be behavioral and reactive to his mother's recent death this ___. Lipase and LFTs were normal. A RUQ US was normal. Anti-TTG was pending at discharge. He sounds like he has not been drinking EtOH but may also have gastritis. Outpatient follow up of his psychiatric issues that may be contributing to weight loss is advised. A PPD was placed on his L radial forearm on ___ that needs to be evaluated on ___ or ___. TRANSITIONAL ISSUES: -Hyponatremia -HCV VL and treatment -Hypothyroidism tx -Adjustment of psych regimen Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob 2. Warfarin 4 mg PO 5X/WEEK (___) 3. Warfarin 5 mg PO 2X/WEEK (___) 4. Nicotine Patch 14 mg TD DAILY 5. ALPRAZolam 0.5 mg PO QHS:PRN insomnia 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 7. ClonazePAM 0.5 mg PO QAM 8. ClonazePAM 1 mg PO LUNCH 9. ClonazePAM 2.5 mg PO QHS 10. Oxcarbazepine 900 mg PO DAILY 11. Sertraline 300 mg PO DAILY 12. Haloperidol 2.5 mg PO QAM 13. Haloperidol 12.5 mg PO HS 14. NexIUM (esomeprazole magnesium) 40 mg oral daily Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob 2. ALPRAZolam 0.5 mg PO QHS:PRN insomnia 3. ClonazePAM 0.5 mg PO QAM 4. ClonazePAM 1 mg PO LUNCH 5. ClonazePAM 2.5 mg PO QHS 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 7. Haloperidol 2.5 mg PO QAM 8. Haloperidol 12.5 mg PO HS 9. Oxcarbazepine 900 mg PO DAILY 10. Sertraline 300 mg PO DAILY 11. Warfarin 4 mg PO 5X/WEEK (___) 12. Warfarin 5 mg PO 2X/WEEK (___) 13. NexIUM (esomeprazole magnesium) 40 mg oral daily 14. Sodium Chloride 1 gm PO BID RX sodium chloride 1 gram 1 tablet(s) by mouth twice daily Disp #14 Tablet Refills:*0 15. Nicotine Patch 14 mg TD DAILY Discharge Disposition: Home Discharge Diagnosis: Hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking part in your care at ___. You were admitted to the hospital because the level of sodium in your blood was low (hyponatremia). We think this may have been caused either by (1) dehydration because you were vomiting frequently, (2)poor dietary salt intake, (3) or a medicine you take called oxcarbazepine (Trileptal) and/or sertraline. While you were here, you were given fluids that helped to hydrate you and correct your hyponatremia (low blood sodium). At discharge we gave you salt pills to take for the next few days until you can get repeat blood work at ___. We included details for your primary doctor to consider changing your Trileptal (oxcarbazepine) which may be associated with low blood sodium. It is very important that you follow up for lab work tomorrow at your primary care doctor's office because low blood sodium can be life-threatening. We also found that your blood counts (white blood cells and platelets) were low. Sometimes this can be caused by infection, medications, malnutrition, and even cancers. We suspect the most likely cause is also oxcarbazepine. You should discuss with your doctors if there is an alternative to this medication. We also placed a PPD skin test to see if you had been exposed to tuberculosis in the past, this needs to be read tomorrow at your primary care doctor's office. Followup Instructions: ___
10304284-DS-4	10,304,284	27,095,133	DS	4	2113-09-29 00:00:00	2113-09-30 17:03:00	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: ___ lap cholecystectomy History of Present Illness: This is a ___ year-old female with history of hypothyroidism and known cholelithiasis, presenting with a 4-day history of abdominal pain. For the past 6 month, patient has been experiencing occasional episodes of severe, dull, epigastric/right upper quadrant pain that worsen with food intake, lack concomitant symptoms, and resolve spontaneously after a couple of days. Four days prior to presentation, patient experienced another episode of symptoms as described. However, on this occasion, they did not resolve after the typical two days, for which purpose she decided to seek medical attention. She denies fever and vomiting, but endorses mild nausea and ?chills. No changes in bowel or urinary habits. Past Medical History: Hypothyroidism, depression, anxiety Social History: ___ Family History: Non-contributory Physical Exam: On admission, Vital signs - 99.4 79 134/82 16 100% RA Constitutional - Well appearing, in no acute distress Cardiopulmonary - RRR, normal S1 and S2. No murmurs. CTAB Abdominal - Soft, non-distended, right upper quadrant and epigastric tenderness. Positive ___ sign. No rebound tenderness Extremities - Atraumatic. No clubbing, cyanosis or edema Neurologic - Grossly intact. Alert and oriented x 3 On discharge, Afebrile, vital signs stable Constitutional - Well appearing, in no distress Cardiopulmonary - RRR, normal S1 and S2. No murmurs Abdomen - Soft, non-distended, appropriately tender. Incisions with SteriStrips in place, appear clean, dry and intact Extremities - Atraumatic. No clubbing, cyanosis, or edema Neurologic - Grossly intact Pertinent Results: ___ 01:55PM BLOOD WBC-6.4 RBC-4.76 Hgb-11.1* Hct-35.0* MCV-74* MCH-23.3* MCHC-31.7 RDW-15.8* Plt ___ ___ 01:55PM BLOOD Neuts-72.0* Lymphs-17.8* Monos-6.9 Eos-2.2 Baso-0.8 Im ___ ___ 01:55PM BLOOD Glucose-87 UreaN-10 Creat-0.9 Na-135 K-4.1 Cl-96 HCO3-26 AnGap-17 ___ 01:55PM BLOOD ALT-11 AST-14 AlkPhos-76 TotBili-0.3 ___ 01:55PM BLOOD Albumin-4.5 ___ 01:55PM BLOOD HCG-0 ___: abd. US: 1. Large stone impacted in the neck of the gallbladder. There is no US evidence of cholecystitis or choledocholithiasis, however cholecystitis cannot be excluded and if clinically indicated a HIDA scan is recommended for further evaluation. Brief Hospital Course: Mrs ___ was admitted to the Acute Care Surgery Service for management of acute cholecystitis. On ___, she underwent a laparoscopic cholecystectomy, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, she arrived on the floor in good condition. Neuro: The patient received oral medications with good effect and adequate pain control. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: Diet was advanced upon arrival to the floor, which was well tolerated. Postoperative nausea was controlled with both Zofran and Reglan. Patient's intake and output were closely monitored, and IV fluid was discontinued once adequate PO intake was achieved. ID: The patient's fever curves were closely watched for signs of infection, of which there were none. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; she was encouraged to get up and ambulate as early as possible. At the time of discharge, Mrs ___ was doing well, afebrile with stable vital signs. She was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. She received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. bupropion HCl XL 450 mg 24 hr tablet, extended release daily 2. levothyroxine 88 mcg tablet daily 3. paroxetine HCl -- 15 mg tablet(s) Once Daily, QHS Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN pain RX acetaminophen 500 mg 1 tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:0 2. BuPROPion (Sustained Release) 450 mg PO QAM 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #40 Tablet Refills:0 4. Levothyroxine Sodium 88 mcg PO DAILY 5. Paroxetine 15 mg PO DAILY 6. Senna 8.6 mg PO BID:PRN constipation RX sennosides [senna] 8.6 mg 8.6 mg by mouth DAILY QHS Disp #15 Capsule Refills:0 7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain Do not drink or drive while taking narcotics. RX hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Acute cholecystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with abdominal pain. You were found to have a gallstone in the gallbladder neck. You were taken to the operating room to have your gallbladder removed. You are slowly recovering from your surgery. You are being discharged with the following recommendations: You were admitted to the hospital with acute cholecystitis. You were taken to the operating room and had your gallbladder removed laparoscopically. You tolerated the procedure well and are now being discharged home to continue your recovery with the following instructions. Please follow up in the Acute Care Surgery clinic at the appointment listed below. ACTIVITY: Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. Don't lift more than ___ lbs for 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. You may start some light exercise when you feel comfortable. You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. You may have a sore throat because of a tube that was in your throat during surgery. You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. You could have a poor appetite for a while. Food may seem unappealing. All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steristrips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). Your incisions may be slightly red around the stitches. This is normal. You may gently wash away dried material around your incision. Avoid direct sun exposure to the incision area. Do not use any ointments on the incision unless you were told otherwise. You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: Constipation is a common side effect of narcotic pain medicaitons. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. Your pain medicine will work better if you take it before your pain gets too severe. Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. If you are experiencing no pain, it is okay to skip a dose of pain medicine. Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. DANGER SIGNS: Please call your surgeon if you develop: - worsening abdominal pain - sharp or severe pain that lasts several hours - temperature of 101 degrees or higher - severe diarrhea - vomiting - redness around the incision that is spreading - increased swelling around the incision - excessive bruising around the incision - cloudy fluid coming from the wound - bright red blood or foul smelling discharge coming from the wound - an increase in drainage from the wound Followup Instructions: ___
10304567-DS-17	10,304,567	21,100,682	DS	17	2123-06-25 00:00:00	2123-07-03 19:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins Attending: ___ Chief Complaint: Mechanical fall Major Surgical or Invasive Procedure: None History of Present Illness: The patient was walking out the door to attend to her dog when she fell down her stair with a head strike and loss of consciousness. She was brought to ___ where she had a ___ demonstrating a small 1mm SDH. She was transferred to ___ for management of the ___ and a radial fracture. Past Medical History: PMHx: per patient borderline hypertension PSHx: none Social History: ___ Family History: non-contributory Physical Exam: Admission Physical Exam: Temp: 98.4 HR: 92 BP: 170/86 Resp: 18 O2 Sat: 99 Constitutional: Comfortable Head / Eyes: Pupils equal, round and reactive to light, Extraocular muscles intact ENT / Neck: Oropharynx within normal limits Chest/Resp: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds GI / Abdominal: Soft, Nontender, Nondistended Musc/Extr/Back: ecchymosis R wrist dorsum, NVID, closed - otherwise no traumatic injuries identified Skin: No rash, Warm and dry Neuro: Speech fluent. Psych: Normal mood, Normal mentation ___: No petechiae Discharge Physical Exam: VS: T: 97.7 PO BP: 125/76 HR: 95 RR: 18 O2: 97% Ra GEN: NAD CV: ns1, s2 PULM: clear ABD: soft, non-tender EXT; no pedal edema bil, no calf tenderness bli NEURO: alert and oriented x 3, speech clear, no tremors, right arm cast, left upper ext. +5/+5, lower ext +5/+5 Pertinent Results: IMAGING: ___: Right wrist x-ray: Re-demonstration of comminuted distal radial fracture with intra-articular extension, with fracture components in near anatomic alignment. LABS: ___ 07:25PM GLUCOSE-116* UREA N-16 CREAT-1.0 SODIUM-139 POTASSIUM-5.7* CHLORIDE-102 TOTAL CO2-23 ANION GAP-14 ___ 07:25PM WBC-12.1* RBC-4.69 HGB-13.5 HCT-40.9 MCV-87 MCH-28.8 MCHC-33.0 RDW-13.5 RDWSD-42.8 ___ 07:25PM NEUTS-87.8* LYMPHS-6.0* MONOS-5.1 EOS-0.4* BASOS-0.2 IM ___ AbsNeut-10.57* AbsLymp-0.72* AbsMono-0.62 AbsEos-0.05 AbsBaso-0.03 ___ 07:25PM PLT COUNT-205 ___ 07:25PM ___ PTT-27.2 ___ Brief Hospital Course: Ms. ___ is a ___ female who presented to ___ s/p mechanical fall with + head strike and LOC. She was initially brought to ___ where she had a ___ demonstrating a small 1mm SDH. She was also noted to have a right radial fracture. She was transferred to ___ for further care. Neurosurgery evaluated the patient and recommended keppra 1gm BID x 7 days. No repeat head imaging was necessary as an inpatient. Orthopedic Surgery evaluated the patient's right wrist fracture and placed the patient in a splint with post reduction x-rays revealing excellent alignment. This injury was managed non-operatively and it was recommended that she remain non weight bearing on the right upper extremity, elevate the RUE on pillows, and follow up in the Orthopedic Surgery trauma clinic in 1 week. ___ evaluated the patient and she was cleared for discharge home. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Follow-up appointments were made in the Neurology and ___ clinic. Medications on Admission: none Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 2. Docusate Sodium 100 mg PO BID 3. LevETIRAcetam 1000 mg PO Q12H Duration: 7 Days last dose ___ RX levetiracetam 1,000 mg 1 tablet(s) by mouth every twelve (12) hours Disp #14 Tablet Refills:0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #10 Tablet Refills:0 5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 6. Senna 8.6 mg PO BID:PRN Constipation - First Line Discharge Disposition: Home Discharge Diagnosis: Right distal radius fracture Subdural hemorrhage 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 Trauma Surgery Service after a fall sustaining a bleed in your head and a right wrist fracture. You were evaluated by the neurosurgery team who recommended a seizure prophylaxis medication for 7 days and outpatient follow up. You were evaluated by the orthopedic surgery team for your wrist fracture and a splint was placed to help align the bones while they continue to heal. Please continue to be non-weight bearing and elevate your right wrist with pillows as much as possible. You were seen and evaluated by the physical and occupational therapist who recommend discharge to home. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Because you struck your head, please note increase in : headache nausea/vomiting visual changes facial drooping, facial weakness difficulty speaking weakness in extremitiy dizziness If note above symptoms, please go to the emergency room. Followup Instructions: ___
10304846-DS-14	10,304,846	25,736,904	DS	14	2135-09-12 00:00:00	2135-09-12 20:23:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Aspirin / Motrin / Macrolide Antibiotics / Erythromycin Base / Amoxicillin Attending: ___ Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo female with pmh of DM II, CKD stage 4, bipolar disorder who presents after a mechanical fall from sitting on the ___. Lost balance while reaching for toilet paper. No dizziness or lightheadedness, and no palpitations at the time. Pt reports hitting her head, no loss of consciousness. She was found immediately but was on the floor was for 30mins because she was being cleaned up. She reported headache, neck pain, and backpain. No chest pain, sob. No dizziness or lightheadedness prior to fall. Also endorses "tingling" and pain in her left leg, and feels like she cannot move it ___ to pain. At baseline uses walker to ambulate, goes to day program, assist for showers, fall hx per pt < 1x/month, >/= 1x/year. In the ED, initial vitals were: 98.2 75 129/58 16 98% RA Labs sig for WBC 5.1, Hgb 11.9, Hct 36, Plt 177. Na 141, K 5.2, Cl 103, CO2 26, BUN 49 Cr 1.8, gluc 175 Continued to endorse tingling and pain especially in L leg Head CT showed no acute process. CT pelvis and spine showed no fracture or acute changes. Was seen by ___, who recommended that patient may benefit from rehab, or may be able to go back to ___ Home with additional services. On the floor, pt continues to have neck, rib, and left leg pain, though she thinks it is somewhat improved. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache. 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: arthritis bipolar disorder left hip replacement stage IV chronic kidney disease DM II HTN HL Urinary incontinence cholecystectomy hysterectomy appendectomy C. diff colitis Pseudomonas UTI Social History: ___ Family History: Father - passed away from cirrhosis Mother - passed away from heart disease Physical Exam: ======================= EXAM ON ADMISSION ======================= Vital Signs: 98.1 72 114/48 18 100%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Chest: tenderness to palpation over ribs Abdomen: Obese, Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 1+ edema to mid calf. L knee nonswollen, nonerythematous, mildly tender with palpation. Unable to flex ___ pain Neuro: CNII-XII intact, sensation of upper and lower extremities intact. ___ strength upper extremities, unable to assess left lower extremity strength ___ pain, gait deferred ======================= EXAM ON DISCHARGE ======================= Vitals: T: 98.5 BP: 118/52 P: 77 R: 20 O2: 96%RA General: Alert, oriented, no acute distress CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Chest: tenderness to palpation over ribs Abdomen: Obese, Soft, non-tender, non-distended Ext: Warm, well perfused, 1+ edema to mid calf. L knee swollen compared to R, nonerythematous, mildly tender with palpation. Unable to flex ___ pain Pertinent Results: ======================= LABS ON ADMISSION ======================= ___ 11:15AM BLOOD WBC-5.1 RBC-3.63* Hgb-11.8 Hct-36.0 MCV-99* MCH-32.5* MCHC-32.8 RDW-17.1* RDWSD-62.4* Plt ___ ___ 11:15AM BLOOD ___ PTT-30.1 ___ ___ 11:15AM BLOOD Glucose-175* UreaN-49* Creat-1.8* Na-141 K-5.2* Cl-103 HCO3-26 AnGap-17 ___ 05:50AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.3 ======================= PERTINENT INTERVAL LABS ======================= ___ 11:15AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 02:09PM URINE Hours-RANDOM UreaN-638 Creat-66 Na-27 K-53 Cl-27 ___ 05:50AM BLOOD Valproa-67 ======================= LABS ON DISCHARGE ======================= ___ 07:25AM BLOOD WBC-3.6* RBC-3.35* Hgb-10.8* Hct-33.8* MCV-101* MCH-32.2* MCHC-32.0 RDW-17.5* RDWSD-64.3* Plt ___ ___ 07:25AM BLOOD Glucose-133* UreaN-43* Creat-1.8* Na-142 K-4.8 Cl-108 HCO3-28 AnGap-11 ======================= MICROBIOLOGY ======================= ___ U/a - negative for signs of infection ======================= IMAGING ======================= ___ CXR: - Atelectasis at the left lung base. No focal consolidation. ___ CT Head W/O Contrast -- 1. No acute fracture or hemorrhage. 2. Age-related involutional changes. ___ CT C-Spine W/O Contrast 1. No acute fracture, malalignment, or prevertebral soft tissue abnormality. Multilevel degenerative changes 2. Re- demonstration of a large hypodensity with peripheral calcification in the right thyroid lobe, unchanged compared to ___. This can be further evaluated with dedicated ultrasound as clinically indicated on a non emergent,outpatient basis, if not already performed. ___ CT T-Spine W/O Contrast -- 1. No acute fracture or malalignment. Multilevel degenerative changes. 2. Consolidation at the visualized lung bases, incompletely imaged, may reflect atelectasis but infection cannot be excluded in the right clinical setting. ___: CT L-Spine W/O Contrast -- - No acute fracture or malalignment of the lumbar spine. ___ CT Pelvis W/Contrast-- - No acute fracture or dislocation. ___ Knee Plain Films (3 Views) - Severe tricompartmental degenerative changes progressed when compared to the prior study. No acute bony injury seen. Brief Hospital Course: ___ yo female with pmh of DMII, CKD stage 4, bipolar disorder who presents after a mechanical fall and hitting her head with no LOC. # S/p Fall: Per patient's report, fall appears to have been mechanical. The patient hit her head, and experienced no loss of consciousness. In the ED, a CT head showed no acute process. The patient was complaining of tingling in her left leg, and so a CT scan of her spine and pelvis was done which showed no fracture or acute bony change. The patient was seen by physical therapy in the ED, who recommended that patient may benefit from rehab, or may be able to go back to ___ Home with additional services. The patient was transferred to the floor. She continued to have neck, rib, and knee pain, and had plain films of the left knee done on ___, which showed severe tricompartmental degenerative changes, and no acute bony process. Her pain in her leg continued to improve throughout the hospitalization, and her mental status remained stable. #prerenal ___ on CKD Stage 4. On admission, the patient had a Cr of 1.8, which was increased from what appeared to be her baseline of 1.6. The patient's lasix was held. A valproate level was drawn as patient is on divalproex, and this was 67 (normal). On ___, the Cr increased to 2. A U/a was bland. Urine lytes showed a FeNa of 0.6%, suggesting prerenal etiology. Patient received 1L NS, and on the morning of ___ Cr improved to 1.8. Lasix may be restarted at PCP's discretion. #DMII: Oral medications were held, and patient was continued on home glargine 15u at breakfast with ISS. #HLD: continued atorvastatin 80 mg PO QPM # Bipolar disorder: No acute issues, continued home medications: - Bupropion (Sustained Release) 100 mg PO DAILY - Sertraline 200 mg PO QHS - Divalproex (EXTended Release) 1500 mg PO QHS # Hypertension: Cont home metoprolol Succinate XL 12.5 mg PO DAILY. LAsix held as above. # urinary Incontinence - Pt normally takes trospium 20 mg oral BID at home, which we do not carry here. She will restart this on discharge # rhinitis: cont fluticasone # GERD - Continued home omeprazole 20 mg PO DAILY ========================= TRANSITIONAL ISSUES ========================= - The patient's lasix were held on admission due to ___. These were held at time of discharge, and can be restarted at the discretion of her primary care doctor. - The patient should have her Cr checked at her next PCP appointment to ensure that ___ has resolved. - The CT spine incidentally showed a large hypodensity with peripheral calcification in the right thyroid lobe, unchanged compared to ___. This can be further evaluated with dedicated ultrasound as clinically indicated on a non emergent, outpatient basis # CODE: Full (confirmed) # CONTACT: ___ (___) ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Glargine 15 Units Breakfast 2. Fluticasone Propionate NASAL 1 SPRY NU DAILY 3. Multivitamins 1 TAB PO DAILY 4. BuPROPion (Sustained Release) 100 mg PO DAILY 5. GlipiZIDE 15 mg PO QAM 6. Furosemide 20 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Metoprolol Succinate XL 12.5 mg PO DAILY 10. trospium 20 mg oral BID 11. Fiber-Lax (calcium polycarbophil) 625 mg oral BID 12. Acetaminophen 650 mg PO BID 13. Nyamyc (nystatin) 100,000 unit/gram topical DAILY 14. Artificial Tears ___ DROP BOTH EYES TID 15. Balmex (white petrolatum;<br>zinc oxide-vitamin B5-vit E) 11.3 % topical TID 16. Sertraline 200 mg PO QHS 17. GlipiZIDE 10 mg PO QPM 18. Atorvastatin 80 mg PO QPM 19. Divalproex (EXTended Release) 1500 mg PO QHS 20. Docusate Sodium 100 mg PO BID:PRN constipation 21. LOPERamide 2 mg PO DAILY:PRN diarrhea 22. Acetaminophen 325-650 mg PO Q4H:PRN pain 23. Simethicone 80 mg PO QID:PRN abdominal pain Discharge Medications: 1. Acetaminophen 325-650 mg PO Q4H:PRN pain 2. Artificial Tears ___ DROP BOTH EYES TID 3. Atorvastatin 80 mg PO QPM 4. BuPROPion (Sustained Release) 100 mg PO DAILY 5. Divalproex (EXTended Release) 1500 mg PO QHS 6. Docusate Sodium 100 mg PO BID:PRN constipation 7. Fluticasone Propionate NASAL 1 SPRY NU DAILY 8. Glargine 15 Units Breakfast 9. Metoprolol Succinate XL 12.5 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Sertraline 200 mg PO QHS 13. Vitamin D 1000 UNIT PO DAILY 14. Acetaminophen 650 mg PO BID 15. Balmex (white petrolatum;<br>zinc oxide-vitamin B5-vit E) 11.3 % topical TID 16. Fiber-Lax (calcium polycarbophil) 625 mg oral BID 17. GlipiZIDE 15 mg PO QAM 18. GlipiZIDE 10 mg PO QPM 19. LOPERamide 2 mg PO DAILY:PRN diarrhea 20. Nyamyc (nystatin) 100,000 unit/gram topical DAILY 21. Simethicone 80 mg PO QID:PRN abdominal pain 22. trospium 20 mg oral BID Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary Diagnosis - mechanical fall Secondary Diagnosis - prerenal ___ on CKD stage IV - HTN - DMII - bipolar disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, It was a pleasure being a part of your care team at ___ ___ ___. You were admitted after you fell and hit your head. We took an image of your head which did not show any bleeding. You also had some pain and tingling down your leg, and so we took pictures of your spine and knee which showed us that nothing is broken. Your kidneys were not working as well as we would like when you first came in. We gave you some fluids, and they got better. We would like for you to see your primary care doctor in ___ weeks. ___ Home should help to arrange this for you. It was very nice to meet you and assist with your care. We all wish you the best! Sincerely, Your ___ Care Team Followup Instructions: ___
10304923-DS-10	10,304,923	23,348,778	DS	10	2130-03-04 00:00:00	2130-03-05 23:58:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Elevated Creatinine, abdominal pain, N/V/Chills Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old man with PMHx third degree heart block s/p pacemaker and recent of M presents from Urgent Care with renal failure. Patient recently admitted to ___ from ___ after he developed rhabdomyelysis ___ power lifting. His CK on admission was 32,800. He was treated with IV hydration and discharged home when his CK level was ___ as he did not want to stay in the ___. He had labs drawn on ___, and ___. His CK was still elevated at 5500 on ___ and he did not have it drawn on ___. His creatinine went from 1.1 to 1.3 from ___ to ___ and increased to 3.1 on ___ in the setting of the abdominal pain. He reports that the pain started on ___ in the evening. It was periumbilical, came in waves, he was unable to sit still and the pain radiated to his testicles. He was seen in the ___ urgent care had a CT scan that was not diagnostic of the cause of his pain (although by the time of the CT he was already starting to feel slightly better). He recieved several injections of toradol since he was discharged from the hospital and had recieved lisinopril at the OSH when he was hospitalized fro rhabdo. In the ED initial vitals were: 99.6 68 139/86 20 95%RA - Labs were were drawn at ___ prior to presnetation and are notable for: 8.8<44.2>207 PMN: 70.9 141/104/37<96 3.8/27/3.1 CPK: 123 U/A with moderate blood - Patient was given nothing and was admitted to medicine from the waiting room for further work-up. Vitals prior to transfer were:99.6 68 139/86 20 95%RA On the floor, the patient reports that his abdominal pain has resolved. He reports that the pain had been periumbilical with radiation to his testicals. He reports that the pain was at its worst the night prior to admission and that it has progressivly gotten better since then. He reports that he feels like he may have passed a kidney stone. He reports that otherwise he feels well. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Hospitalization for Rhabdo due to power lifting hx of third degree heart block s/p pacemaker Social History: ___ Family History: Father with kidney stones, Grandfather with ___ cancer. Physical Exam: ADMISSION EXAM: =============== Vitals - T:97.7 BP:140/90 HR:50 RR:18 02 sat:100%RA GENERAL: NAD, laying in bed, ___ ___: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, patent nares, MMM NECK: nontender supple neck, no LAD CARDIAC: RRR, S1/S2, no murmurs LUNG: CTAB, no wh/r/rh, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, mildly tender in the RLQ and LLQ to deep palpation, no rebound/guarding 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 DISCHARGE EXAM: =============== VS T 98 BP 149/95 P 49 R 18 100% on RA General: NAD, sitting comfortably in bed on phone ___: atraumatic, PERRLA, no lymph adenopathy Neck: No JVD CV: RRR, no murmurs Lungs: CTAB Abdomen: soft, non-distended, no rebound or gaurding, non-tender to palpation GU: No CVA tenderness. Ext: no edema Neuro: CN intact, speech clear, moving all limbs Skin: no rashes appreciated Pertinent Results: ADMISSION LABS: =============== ___ 07:35AM BLOOD WBC-6.2 RBC-4.60 Hgb-14.2 Hct-42.9 MCV-93 MCH-30.8 MCHC-33.1 RDW-13.0 Plt ___ ___ 07:35AM BLOOD Glucose-91 UreaN-37* Creat-3.2* Na-139 K-3.8 Cl-103 HCO3-24 AnGap-16 ___ 07:35AM BLOOD ALT-26 AST-20 AlkPhos-35* TotBili-0.5 ___ 07:35AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.4 PERTINENT LABS: =============== ___ 08:00AM BLOOD Lipase-29 ___ 08:00AM BLOOD ALT-31 AST-23 AlkPhos-33* Amylase-62 TotBili-0.4 DISCHARGE LABS: =============== ___ 07:40AM BLOOD WBC-6.0 RBC-4.85 Hgb-14.9 Hct-44.3 MCV-91 MCH-30.8 MCHC-33.7 RDW-12.8 Plt ___ ___ 07:40AM BLOOD Glucose-84 UreaN-31* Creat-3.0* Na-141 K-4.5 Cl-104 HCO3-25 AnGap-17 ___ 07:40AM BLOOD Calcium-9.8 Phos-4.2 Mg-2.0 MICRO: ====== ___ URINE Chlamydia trachomatis, Nucleic Acid Probe, with Amplification: Negative for Chlamydia trachomatis NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION: Negative for Neisseria gonorrhoeae IMAGING: ======== ___ CTU (ABD/PEL) W/O CONTRAST -- PRELIMINARY READ IMPRESSION: No stone or evidence of other acute process within the abdomen or pelvis. ___ RENAL U.S./ DUPLEX DOPP ABD/PEL FINDINGS: The right kidney measures 12.9 cm. The left kidney measures 13.9 cm. There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The spleen measures 12.5 cm and demonstrates normal echogenicity. The resistive indices of the intrarenal arteries are within normal range. Acceleration times and peak systolic velocities of the main renal arteries are normal bilaterally. The renal veins are bilaterally patent and show normal waveforms. The bladder is moderately well distended and normal in appearance. IMPRESSION: Normal renal ultrasound. Brief Hospital Course: Mr. ___ is a ___ year old male with PMH significant for ___ degree heart block s/p pacemaker placement in ___ and with recent admission to ___ ___ for rhabdomyolysis, who presented to urgent care on ___ with severe periumbilical crampy pain that radiated to his testicles, and was found to have a creatinine of 3.1. # ___: Multiple reasons for ___, including recent rhabdomylsis and recent nephrotoxic drugs in the setting of rhabdo (he was taking lisinopril until 4 days before this admission, he received 2 doses of Tordol at urgent care (one on ___, one on ___, and he took 1200 mg of Advil on ___ Urine studies were significant for an elevated urine Na and FeNa of 2.8, most consistent with Acute Tubular Necrosis. Urine was spun multiple times without any diagnostic findings. Renal was consulted, and agreed with the diagnosis of acute tubular necrosis in the setting of rhabdo/nephrotoxic medications. A CT abdomen and renal U/S on ___ showed no evidence of stone or other abnormalities. The patient was discharged home with nephrology follow-up in place. #Abdominal Pain: Colicky pain that radiated to testicles, and back most consistent with renal colic. His father has hx of multiple kidney stones. However no stone seen on non-con CT scan, and no red blood cells on UA and Renal US also normal. Pain controlled with ultram, tylenol, and cyclobenzaprine. No tenderness on exam, no testicular abnormalities on 3 testicular exams during hospital admission. DRE was negative for prostatitis. No evidence of infection. Ghonorrhea/Chlamidia negative. Urine strained without stone. A CT abdomen and renal U/S on ___ showed no evidence of stone or other abnormalities. Most likely this represents musculoskeletal pain. # 3rd Degree Heart Block: pace-maker placed ___. Last ECHO with normal EF. Lisinopril held on admission and at discharge given above ___. ===================== TRANSITIONAL ISSUES: ===================== [] Check Chem 10 panel within the next 7 days. Please fax results to Dr. ___/ Dr. ___ at ___. [] Lisinopril held on discharge in light ___ [] follow-up on final read of CT scan from ___ unsigned read with no abnormalities, and CT reviewed by primary team [] follow-up urine protein:creatanine from ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY Discharge Medications: 1. Outpatient Lab Work ICD-9 code ___.5 -- Please check a Chem 10 within 1 week of discharge and fax results to Dr. ___ at ___. 2. Acetaminophen ___ mg PO Q6H:PRN pain 3. Cyclobenzaprine 10 mg PO TID:PRN pain RX cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day Disp #15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: Acute renal failure secondary to ATN SECONDARY DIAGNOSES: 3rd degree heart block s/p pacemaker Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted to ___ for abdominal pain. You were also noted to have worsening kidney failure on your lab work. We feel that your kidney failure is likely a combination of your recent bout of rhabdomyolysis (muscle breakdown causing kidney injury) in combination with continuing your lisinopril and taking NSAIDs. The renal doctors ___ and ___ that your kidney failure should get better with time. We also did a CT scan of your abdomen to look for a cause of your pain. The CT scan showed no evidence of kidney stone or any other abnormality. Do not take your lisinopril until your kidney function improves. Please consult with your doctor on when ___ be safe to restart your lisinopril. Please avoid NSAID medication and be sure that any other medication that you will need is dosed at a level appropriate for someone with kidney failure. Also, we recommend that you stop taking protein supplements and reduce the amount of protein in your diet to prevent further kidney damage. We are trying to arrange a follow up appointment for you with your primary care doctor. Please call their office and request an appointment in the next ___ days for post-hospitalization follow up. Thank you for allowing us to participate in your care. Sincerely, Your ___ Team Followup Instructions: ___
10305005-DS-12	10,305,005	28,185,136	DS	12	2180-04-30 00:00:00	2180-04-30 17:01:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Naprosyn / lisinopril / latex / peanuts / latex Attending: ___. Chief Complaint: Severe Aortic Stenosis, s/p mechanical fall Major Surgical or Invasive Procedure: TAVR ___ History of Present Illness: Ms. ___ was due to undergo transcatheter aortic valve replacement, but 2 days prior to admission was walking through the ___ doors in her home, 1 of which was locked, which caught her off guard and led to a tumble with bilateral knee trauma and head trauma. Orthopedic evaluation fortunately has revealed no fractures. Given that, she was kept in anticipation of her getting her transcatheter aortic valve replacement planned for ___. On admission interview in the emergency room, she denied any resting shortness of breath. She acknowledges dyspnea on more than average exertion. She says that her oxygen level at home is routinely 88%, but she only wears oxygen at nighttime. In the emergency room she is on 3 L of oxygen with saturations in the low to mid ___. She has not gotten any of her blood pressure medications today and yet has had normal blood pressure. She had gone 80 mg of IV Lasix with unclear ins and outs. A chest x-ray was performed which I reviewed showing no overt pulmonary edema. No blood in the stool of the urine, no palpitations, no resting chest discomfort. No double vision. Past Medical History: CARDIOVASCULAR PROBLEMS: 1. Severe aortic stenosis 2. Chronic diastolic heart failure 3. Coronary artery disease 4. Type 2 diabetes with nephropathy 5. Hypertension 6. Mixed dyslipidemia Social History: ___ Family History: Diabetes Mellitus Physical Exam: PHYSICAL EXAMINATION on Admission: VITALS: BP 132/92, 94% on 3 L, HR 65, afebrile HEENT: Sclerae anicteric, mucous membranes moist, trauma over right eye resolving ecchymosis NECK: JVP ___, Carotid upstrokes delayed CHEST: Lungs with bilateral crackles CARDIAC: Normal S1, absent S2, 3 out of 6 late peaking systolic ejection murmur, no gallops or rubs ABDOMEN: Soft nontender normal active bowel sounds MSK/VASC: Right knee larger than left knee due to an effusion, trivial edema below the knee SKIN: No rashes NEURO: Mental status appropriate PHYSICAL EXAM on Discharge: 24 Hour DATA: VS: 98.2, 132/57-152/57, HR 76-80,m RR 20, 02 sat 90-95% (intermittently on RA versus 2L NC) Fluid Balance: 360/1100cc (cumulatively -1185cc since admit) ___: 215 lbs, 97.84 kg ___ 215 lbs (all bedscale) ___: 219.3 lbs ___: 216.2 lbs EKGs: Prior- ___ SR, rate 68, PR 187, QRS 116 Post TAVR- ___ 09:47 SR, rate 70, PR 170, QRS 146ms LBBB ___ 13:35 SR, rate 66, PR 180, QRS 140ms ___: SR, nl QRS Tele: SR with borderline first degree ___ Physical Examination: General: Sitting in chair, NAD, easily engaged NEURO: Alert and oriented x4. Pleasant and cooperative. Speech speech clear and appropriate incomprehensible. Tongue midline smile symmetric. Move all extremities. HEENT: mucous membranes moist, resolving ecchymosis over r eye r/t prior head strike CHEST: LS no crackles, diminished at bases. CARDIAC: III/VI systolic murmur right upper sternal border ABDOMEN: Soft non-tender normal, active bowel sounds, tolerating p.o. MUSK/VASC: Right knee larger than left knee due to an effusion, trivial edema below the knee SKIN: No rashes INTEG: 2 abrasion to right medial side of face, also has some bruising Labs: Na 142, K+ 5.5 (hemolyzed, recheck 4.8), Bicarb 20, Glucose 130, Creat 1.2, Hct 36.5, Plts 156, BUN 40, Hgb 11.1 POC: 120/171 Pertinent Results: TTE ___: IMPRESSION: Well seated, normal functioning Evolut TAVR with normal gradient and trace paravalvular aortic regurgitation. Mild-moderate mitral regurgitation. Mild-moderate pulmonary artery systolic hypertension. Mild symmetric left ventricular hypertrophy with normal cavity size and regional/global biventricular systolic function. Mildly dilated aortic arch. Compared with the prior TTE (images not available for review) of ___ , the aortic valve has replaced with a normal functioning TAVR and the severity of mitral regurgitation has increased with mild-moderate pulmonary artery hypertension now identified. CLINICAL IMPLICATIONS: Based on the echocardiographic findings and ___ ACC/AHArecommendations, antibiotic prophylaxis IS recommended prior to dental cleanings and other non-sterile procedures. Catheterization ___: 1. Severe aortic stenosis 2. Successful TAVR ECHO ___: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). There is moderate symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. There is severe aortic valve stenosis (valve area <1.0cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is no pericardial effusion. Status post TAVR. Aortic valve peak gradient 5 mmHg and mean gradient 3 mmHg with minimal aortic regurgitation. No valvular stenosis. Left and right ventricular function is preserved. LV EF >55%. No pericardial effusion. All findings communicated to surgeon intraoperatively. Unilateral Lower Extemities Vein Testing-Right: ___ No evidence of deep venous thrombosis in the right lower extremity veins. CXR ___: No acute intrathoracic process. CT Spine w/o Contrast ___: No cervical spine fracture or malalignment. ___: No acute cardiopulmonary process. Xray R foot/ankle (___): IMPRESSION: No fracture involving the right tibia fibula, ankle, or foot. CXR ___ FINDINGS: The lungs are clear without consolidation, effusion, or edema. Cardiomediastinal and hilar silhouettes are similar compared to prior noting prominence of the right hilar contour. No acute osseous abnormalities. Reverse left shoulder arthroplasty changes are noted. Hypertrophic changes seen the spine. IMPRESSION: No acute cardiopulmonary process. TEE ___: Conclusions: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). There is moderate symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. There is severe aortic valve stenosis (valve area <1.0cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is no pericardial effusion. Status post TAVR. Aortic valve peak gradient 5 mmHg and mean gradient 3 mmHg with minimal aortic regurgitation. No valvular stenosis. Left and right ventricular function is preserved. LV EF >55%. No pericardial effusion. All findings communicated to surgeon intraoperatively. TTE ___: CONCLUSION: The left atrial volume index is normal. The right atrium is mildly enlarged. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative 3D volumetric left ventricular ejection fraction is 63 %. Left ventricular cardiac index is normal (>2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch is mildly dilated. An Evolut aortic valve bioprosthesis is present. The prosthesis is well seated with normal leaflet motion and gradient. The effective orifice area index is moderately reduced (0.65-0.90 cm2/m2). There is a paravalvular jet of trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is moderate mitral annular calcification. There is mild to moderate [___] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. There is mild-moderate pulmonary artery systolic hypetension. There is no pericardial effusion. IMPRESSION: Well seated, normal functioning Evolut TAVR with normal gradient and trace paravalvular aortic regurgitation. Mild-moderate mitral regurgitation. Mild-moderate pulmonary artery systolic hypertension. Mild symmetric left ventricular hypertrophy with normal cavity size and regional/global biventricular systolic function. Mildly dilated aortic arch. TTE ___: LVEF: 65% AV Peak/Mean Gradient: 46 mmHg/26 mmHg ___ 0.8 cm2 Conclusion: The left atrial volume index is normal. There is normal left ventricular wall thickness with a normal cavity size. There is suboptimal image quality to assess regional left ventricular function. Overall left ventricular systolic function is normal. The visually estimated left ventricular ejection fraction is 65%. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. The aortic valve leaflets are severely thickened. There is severe aortic valve stenosis (valve area less than 1.0 cm2). There is no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. There is no pericardial effusion. TAVR and Torso CTA ___: IMPRESSION: 1. Aortic valve stenosis with leaflet calcifications. Mild dilatation of the ascending thoracic aorta measuring 4.1 x 3.7 cm at approximately 4.5 cm above the aortic valve. 2. Patent common femoral arteries bilaterally with lumen diameter greater than 6 mm. Patent bilateral subclavian arteries with small luminal size, less than 6 mm. Please see the body of the report for more detailed description and measurements. 3. Mildly dilated main pulmonary artery up to 3.4 cm, suggestive but not diagnostic of pulmonary arterial hypertension. 4. No acute process within the chest, abdomen, or pelvis. Cardiac cath ___: LM: The Left Main, arising from the left cusp, is a large caliber vessel. This vessel bifurcates into the Left Anterior Descending and Left Circumflex systems. LAD: The Left Anterior Descending artery, which arises from the LM, is a large caliber vessel. There is a 20% stenosis in the proximal segment. The Septal Perforator, arising from the proximal segment, is a small caliber vessel. The Diagonal, arising from the proximal segment, is a medium caliber vessel. Cx: The Circumflex artery, which arises from the LM, is a large caliber vessel. There is a 40% stenosis in the proximal segment. The ___ Obtuse Marginal, arising from the proximal segment, is a medium caliber vessel. The ___ Obtuse Marginal, arising from the mid segment, is a medium caliber vessel. RCA: The Right Coronary Artery, arising from the right cusp, is a large caliber vessel. There is a 50% stenosis in the proximal and mid segments. The Acute Marginal, arising from the proximal segment, is a small caliber vessel. The Right Posterolateral Artery, arising from the distal segment, is a medium caliber vessel. The Right Posterior Descending Artery, arising from the distal segment, is a medium caliber vessel. ___ 06:23PM BLOOD Plt ___ ___ 06:40AM BLOOD ___ ___ 07:15AM BLOOD Plt ___ ___ 06:23PM BLOOD Neuts-78.2 Lymphs-11.9* Monos-7.7 Eos-1.4 Baso-0.4 Im ___ AbsNeut-7.40* AbsLymp-1.13* AbsMono-0.73 AbsEos-0.13 AbsBaso-0.04 ___ 06:23PM BLOOD WBC-9.5 RBC-4.13 Hgb-12.4 Hct-39.7 MCV-96 MCH-30.0 MCHC-31.2* RDW-13.9 RDWSD-48.9* Plt ___ ___ 06:18AM BLOOD WBC-7.9 RBC-3.87* Hgb-11.6 Hct-36.9 MCV-95 MCH-30.0 MCHC-31.4* RDW-14.0 RDWSD-48.1* Plt ___ ___ 05:08AM BLOOD WBC-11.1* RBC-4.03 Hgb-12.1 Hct-38.2 MCV-95 MCH-30.0 MCHC-31.7* RDW-13.6 RDWSD-47.0* Plt ___ ___ 06:40AM BLOOD WBC-9.6 RBC-3.69* Hgb-11.1* Hct-35.0 MCV-95 MCH-30.1 MCHC-31.7* RDW-13.5 RDWSD-46.4* Plt ___ ___ 07:15AM BLOOD WBC-7.4 RBC-3.62* Hgb-10.9* Hct-34.4 MCV-95 MCH-30.1 MCHC-31.7* RDW-13.5 RDWSD-47.1* Plt ___ ___ 07:15AM BLOOD Hgb-11.1* Hct-36.5 Plt ___ Brief Hospital Course: Ms. ___ is an ___ with known AS and NYHA CLass III symptoms with DOE and fatigue who presented for an elective TAVR. She was admitted through the emergency department where she presented on ___ after a mechanical fall striking her right forehead and bilateral knees. In the emergency department she ruled out for ICH, fractures, and DVT. She was admitted and underwent her TAVR as scheduled on ___. She had an evolute placed. She developed new LBBB initially post procedure which has since resolved. Her atenolol was initially held post procedure and was resumed to her home regimen which she tolerated well. She has remained in sinus rhythm with borderline first degree AV block. She has utilized oxygen via nasal cannula intermittently which is her baseline at home. She does occasionally drop her O2 sat to the high ___ which, she reports is her chronic baseline. Her bilateral access sites are benign without bruit bleeding or ecchymosis. Her echo post procedure showed a peak/mean gradient of 16 and 9 with ___ 1.___R. She is on her normal dose of Lasix 60 mg daily per her home regimen and does not appear fluid overloaded at this time. Her anticoagulation plan is aspirin and Plavix. She has had ongoing pain control issues with a right knee effusion post traumatic fall prior to admission. She has been on oxycodone, Lidoderm patch, and scheduled Tylenol. She is reportedly less ambulatory than her baseline at home, though has been able to get out of bed to chair and mobilize carefully with a walker within her hospital room. She also had issues with what she describes as overactive bladder and was using a female external urinary catheter which worked very well for her. She is deconditioned from her fall and will be going to rehab for physical therapy needs. Her lab data has been unremarkable with the exception of a potassium of 5.5 on day of discharge which was noted to be hemolyzed. A redraw was normal. She will be discharged to rehab today. A paper oxycodone prescription has been provided. She has been discharged to rehab this afternoon and will follow up with structural heart team in 1 month with an echocardiogram. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO NOON 2. Amoxicillin ___ mg PO PREOP 3. Atenolol 50 mg PO QAM 4. Atorvastatin 40 mg PO NOON 5. Furosemide 60 mg PO QAM 6. GlipiZIDE XL 10 mg PO BID 7. Losartan Potassium 100 mg PO NOON 8. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 9. mirabegron 50 mg oral QPM 10. nystatin 100,000 unit/gram topical DAILY:PRN 11. Januvia (SITagliptin) 100 mg oral DAILY 12. Tizanidine 2 mg PO QHS:PRN muscle spasm 13. Aspirin 81 mg PO QAM 14. biotin 10,000 mcg oral DAILY 15. Calcium Magnesium (Ca carb-Ca gluc-Mg ox-Mg gluco) 500 mg calcium -250 mg oral DAILY 16. cranberry 405 mg oral DAILY 17. Cyanocobalamin 1000 mcg PO DAILY 18. Multivitamins 1 TAB PO DAILY 19. Fish Oil (Omega 3) 1000 mg PO DAILY 20. PreserVision AREDS (vitamins A,C,E-zinc-copper) ___ unit-mg-unit oral DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line 3. Clopidogrel 75 mg PO DAILY 4. Gabapentin 200 mg PO BID 5. Heparin 5000 UNIT SC BID 6. Lidocaine 5% Patch 1 PTCH TD QPM 7. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - Severe 8. Polyethylene Glycol 17 g PO DAILY 9. Senna 8.6 mg PO BID 10. amLODIPine 5 mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Amoxicillin ___ mg PO PREOP 13. Atenolol 50 mg PO QAM 14. Atorvastatin 40 mg PO NOON 15. biotin 10,000 mcg oral DAILY 16. Calcium Magnesium (Ca carb-Ca gluc-Mg ox-Mg gluco) 500 mg calcium -250 mg oral DAILY 17. cranberry 405 mg oral DAILY 18. Cyanocobalamin 1000 mcg PO DAILY 19. Fish Oil (Omega 3) 1000 mg PO DAILY 20. Furosemide 60 mg PO QAM 21. GlipiZIDE XL 10 mg PO BID 22. Januvia (SITagliptin) 100 mg oral DAILY 23. Losartan Potassium 100 mg PO NOON 24. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 25. mirabegron 50 mg oral QPM 26. Multivitamins 1 TAB PO DAILY 27. nystatin 100,000 unit/gram topical DAILY:PRN 28. PreserVision AREDS (vitamins A,C,E-zinc-copper) ___ unit-mg-unit oral DAILY 29. Tizanidine 2 mg PO QHS:PRN muscle spasm Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Aortic Stenosis Acute on chronic diastolic heart failure Left bundle branch block Diabetes type 2 Hypertension CAD Dyslipidemia Chronic kidney disease, stage III Discharge Condition: Overnight Events: none Post-Procedure Day ___ s/p TAVR Subjective: Feeling better, no overnight events. ROS: negative unless noted below [] CP [] SOB [x] Pain: Right thigh and leg, well controlled [] Dizziness [] Headache [] Nausea/Vomiting [] Decreased appetite 24 Hour DATA: VS: 98.2, 132/57-152/57, HR 76-80,m RR 20, 02 sat 90-95% (intermittently on RA versus 2L NC) Fluid Balance: 360/1100cc (cumulatively -1185cc since admit) ___: 215 lbs, 97.84 kg ___ 215 lbs (all bedscale) ___: 219.3 lbs ___: 216.2 lbs EKGs: Prior- ___ SR, rate 68, PR 187, QRS 116 Post TAVR- ___ 09:47 SR, rate 70, PR 170, QRS 146ms LBBB ___ 13:35 SR, rate 66, PR 180, QRS 140ms ___: SR, nl QRS Tele: SR with borderline first degree ___ Physical Examination: General: Sitting in chair, NAD, easily engaged NEURO: Alert and oriented x4. Pleasant and cooperative. Speech speech clear and appropriate incomprehensible. Tongue midline smile symmetric. Move all extremities. HEENT: mucous membranes moist, resolving ecchymosis over r eye r/t prior head strike CHEST: LS no crackles, diminished at bases. CARDIAC: III/VI systolic murmur right upper sternal border ABDOMEN: Soft non-tender normal, active bowel sounds, tolerating p.o. MUSK/VASC: Right knee larger than left knee due to an effusion, trivial edema below the knee SKIN: No rashes INTEG: 2 abrasion to right medial side of face, also has some bruising Current medications reviewed [X] Labs: Na 142, K+ 5.5 (hemolyzed, recheck 4.8), Bicarb 20, Glucose 130, Creat 1.2, Hct 36.5, Plts 156, BUN 40, Hgb 11.1 POC: 120/171 DIAGNOSTIC TESTING: ECHO ___: Well seated, normal functioning Evolut TAVR with normal gradient and trace paravalvular aortic regurgitation. Mild-moderate mitral regurgitation. Mild-moderate pulmonary artery systolic hypertension. Mild symmetric left ventricular hypertrophy with normal cavity size and regional/global biventricular systolic function. Mildly dilated aortic arch. peak/mean grad ___, ___ 1.8 Assessment/Plan: Ms. ___ is an ___ y/o F with known aortic stenosis and NYHA Class III symptoms of DOE and fatigue who presented to the ED with mechanical fall (2 nights before her planned TAVR procedure) with head and bilat knee trauma. ED workup ruled out ICH, fractures, DVT. Does have effusion to R knee. Received IV initially. Now, POD day ___ s/p TAVR. ACTIVE ISSUES: ------------- # Aortic stenosis: s/p trans femoral TAVR today with 26mm evolut valve. ___ RFA perclose x 2 & angiosealed; ___ LFA groin angiosealed, ___ LFV manual pressure. No procedural complications. LBBB resolved. Post TAVR echo shows greatly improved gradients. - Continue aspirin 81mg daily - Continue Plavix 75mg daily - Continue Lasix 60mg daily - Resume atenolol (held initially due to LBBB) - SBE ppx (already does this with amoxicillin) - ___ in 1 month - ___ with ___ (cards) after seen by SHT # Chronic diastolic heart failure: Received IV diuresis initially, transitioned to PO on ___. Home diuretic regimen is furosemide 60mg QD. According to patient, she does not have a history of COPD or interstitial lung disease. She states she uses O2 at home because of heart failure, only at night and sometimes does not put it on. She states her home O2 sat is 88%. Currently on 2 L nasal cannula and does not appear fluid overloaded on exam. -Restarted home dose of Lasix 60 daily -Restarted losartan - strict I&O's - daily weight - low sodium diet - Continue O2 as needed to maintain O2 sat greater than 88%-90% # s/p Fall: Evaluated by ortho in ED. Xray showed no fx of leg/ankle. Head CT negative, LENIs negative for DVT. Found to have knee effusion and intact extensor mechanism. Unlikely to be septic given related onset with fall. - ___ consult: awaiting rehab - ___ in ___ weeks in outpatient ___ clinic - Increased oxycodone and added gabapentin for improved pain control. CHRONIC CONDITIONS: ------------------- #CAD: s/p ___ ___. No CP. - Continue aspirin - Atenolol on hold iso new LBBB - Continue Atorvastatin #DM2: Home regimen is glipizide, metformin, Januvia. A1C 6.3%. - Hold oral regimen in house - ___ QID - Diabetic Diet - HISS #HTN: Home regimen is amlodipine, losartan, atenolol. -Continue amlodipine, losartan #OSA: Unclear if OSA, patient told her sleep study was negative. Not on CPAP but does use 2L NC O2 at night. PFT's in ___ showed mod restrictive pattern. - Supplemental O2 as needed with sleep for O2 sat goal 88-90% #Dyslipidemia: ___ lipids- Chol 194, Trig 197, HDL 62, CHOL/HD 3.1, LDL 93. - Continue atorvastatin 40mg daily #CKD stage III GFR 53-65: Baseline Cr appears to be 0.9-1.1, BUN 33-38. - Montitor - Renally dose meds as needed - Avoid nephrotoxins #Overactive Bladder: Uses Myrbetriq at home. NF, but husband will bring in if she feels she needs it. - External female catheter for diuresis which has worked very well this admission # PROPHYLAXIS: - DVT prophylaxis with: heparin SC - Pain management with: tylenol - Bowel regimen with Senna/Colace # Code status: presumed full # DISPO: Plan to discharge to rehab this afternoon # Transitional issues: Health Care Proxy: ___ (husband) ___ * Above plan reviewed and discussed with Dr. ___. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for a trans catheter aortic valve repair (TAVR)to treat your aortic valve stenosis which was done on ___. By repairing the valve your heart can pump blood more easily and your shortness of breath should improve. It is very important to take all of your heart healthy medications. In particular, you are now taking aspirin and plavix. These medications help to prevent blood clots from forming on the new valve. If you stop these medications or miss ___ dose, you risk causing a blood clot forming on your new valve. This could cause it to malfunction and it may be life threatening. Please do not stop taking aspirin or Plavix without taking to your heart doctor, even if another doctor tells you to stop the medications. As you already do, you should continue to take prophylactic antibiotics prior to any dental procedure. Please inform your dentist about your recent cardiac procedure. One hour prior to your dental procedure take amoxicillin 2 gram once. Please weigh yourself every day in the morning after you go to the bathroom and before you get dressed. If your weight goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please call your heart doctor or your primary care doctor and alert them to this change. Your weight at discharge is 97.84 kg or 215.24 lbs. We have made changes to your medication list, so please make sure to take your medications as directed. You will also need to have close follow up with your heart doctor and your primary care doctor. If you have any urgent questions that are related to your recovery from your procedure or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital, please call the ___ HeartLine at ___ to speak to a cardiologist or cardiac nurse practitioner. You will follow-up with the ___ valve clinic in one month. Please call as noted below if you do not hear from them within one week. It has been a pleasure to have participated in your care and we wish you the best with your health! Followup Instructions: ___
10305005-DS-13	10,305,005	21,263,705	DS	13	2180-06-04 00:00:00	2180-06-07 02:39:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Naprosyn / lisinopril / latex / peanuts / latex Attending: ___. Chief Complaint: Acute Blood Loss Anemia due to GI Bleeding Major Surgical or Invasive Procedure: EGD Colonoscopy Capsule endoscopy History of Present Illness: ___ year old Female with history of recent TAVR here at ___ by Dr. ___ critical aortic stenosis anticoagulated on aspirin and Plavix, HFpEF, CAD recently admitted to ___ for klebsiella UTI, now presents with 1 week of progressive fatigue and confusion, now found to be severely anemic. The patient reports having melena several days prior to admission. The patient reports some orthostatic symptoms. The patient had significantly disturbed sleep/wake cycle for the past week, and has been sleeping during the day, and unable to sleep overnight. The initial vitals in the ___ ED wer 97.9, 70, 120/40, 16, 100%2LNC. Of note she is chronically hypoxemic on room air. She was given IV fluids and GI was consulted. 2 units of PRBCs were ordered to be transfused. Past Medical History: 1. Severe aortic stenosis 2. Chronic diastolic heart failure 3. Coronary artery disease s/p DES to ___ ___ 4. Type 2 diabetes with nephropathy 5. Hypertension 6. Mixed dyslipidemia 7. CKD Stage III Social History: ___ Family History: Diabetes Mellitus Physical Exam: Vital Signs: 24 HR Data (last updated ___ @ 1113) Temp: 98.4 (Tm 98.4), BP: 153/75 (124-153/61-75), HR: 77 (72-92), RR: 18 (___), O2 sat: 94% (94-95), O2 delivery: RA, Wt: 206.6 lb/93.71 kg Physical Exam: GENERAL: Pleasant older woman in hospital bed, in no apparent distress. EYES: PERRL. EOMI. Anicteric sclerae. ENT: Ears and nose without visible erythema, masses, or trauma. Posterior oropharynx without erythema or exudate, uvula midline. CV: Regular rate and rhythm. ___ SEM. No JVD. PULM: Breathing comfortably on room air. Lungs clear to auscultation. No wheezes or crackles. Good air movement bilaterally. GI: Bowel sounds present. Abdomen non-distended, soft. TTP in epigastric region, slightly TTP in RUQ. GU: No suprapubic fullness or tenderness to palpation. EXTR: Trace ankle lower extremity edema. Distal extremity pulses palpable throughout. SKIN: No rashes, ulcerations, scars noted. NEURO: Alert. Oriented to person/place/time/situation. Face symmetric. Gaze conjugate with EOMI. Speech fluent. Moves all limbs spontaneously. No tremors, or other involuntary movements observed. PSYCH: Pleasant, cooperative. Follows commands, answer questions appropriately. Appropriate affect. Pertinent Results: ================= LABS: ================= Initial Hgb 6.1->7.5 (after 2 units pRBC) -->7.7 ___: Hgb 8.7 ___ AM: Hgb 8.1, ___: Hgb 8.6 ___ BMP wnl. BUN 10, Cr 0.9 ================= MICRO: ================= ___ Urine culture: GRAM POSITIVE BACTERIA. >100,000 CFU/mL. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. ================= IMAGING & STUDIES: ================= ___ Capsule endoscopy: Gastric and duodenal erosions but no small bowel source of bleeding\ ___ Colonoscopy: normal mucosa for the entire colon and 10cm into the terminal ileum ___ EGD: normal esophageal and gastric mucosa ___ CXR: No acute cardiopulmonary abnormality. Brief Hospital Course: ___ female with medical history notable for HFpEF, CAD, severe AS s/p TAVR ___, and recent Klebsiella UTI complicated by sepsis requiring admission to ___ ___ who presented with x1 week history of increased fatigue and confusion found to have acute blood loss anemia and melena. # Anemia, melena She was started on BID PPI therapy and her clopidogrel and aspirin 81mg were held upon admission. Patient had never had colonoscopy before, only a Cologard screening which was negative. EGD ___ was unrevealing, as was CT torso same day. EGD ___ was unremarkable and colonoscopy ___ was unremarkable, so capsule study initiated but also didn't demonstrate the likely etiology of her bleed. Her interventional cardiologist Dr. ___ that she can be just on aspirin 81mg daily rather than clopidogrel given this bleed. Her Hgb and hemodynamics remained stable during the hospitalization. Her Hgb at discharge was 8.6. She was discharged on aspirin 81mg daily, no clopidogrel, and was to follow-up with her outpatient cardiologists and PCP, and GI was to set her up with follow-up as well after discharge. # HFpEF # AVS s/p TAVR TAVR done ___. No clinical evidence of heart failure- had only trace lower extremity edema and no JVD. Her home atenolol, losartan, and furosemide were held initially given the anemia and suspected recent blood loss. Clopidogrel and aspirin also held per above. Her hemodynamics were fine during the hospitalization and she was discharged back on all her home medications other than clopidogrel, which was discontinued, and the furosemide dose was reduced to 40mg daily from 60mg given the unimpressive exam for health failure. Post-discharge follow-up per above. # s/p ___ Initial Cr 1.6 and BUN 80. Most likely related to blood loss. Normalized with some fluids and time to Cr 0.9 and BUN 10 by ___. Eventually restarted her home medications per above. Home gabapentin was initially held given the renal dysfunction. # Type 2 Diabetes complicated by neuropathy While in the hospital she got qACHS fingersticks with insulin sliding scale coverage. Metformin and her other oral anti-glycemic medications were restarted at discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 100 mg PO DAILY 2. Gabapentin 200 mg PO BID 3. Fish Oil (Omega 3) 1000 mg PO DAILY 4. Atenolol 50 mg PO DAILY 5. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY 6. Tizanidine 2 mg PO QHS:PRN Muscle spasm 7. amLODIPine 7.5 mg PO DAILY 8. SITagliptin 100 mg oral DAILY 9. Atorvastatin 40 mg PO QPM 10. Furosemide 20 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - Moderate 13. ___ (cranberry extract) 405 mg oral DAILY 14. Clopidogrel 75 mg PO DAILY 15. nystatin 100,000 unit/gram topical BID:PRN 16. Aspirin 81 mg PO DAILY 17. mirabegron 50 mg oral DAILY 18. GlipiZIDE XL 10 mg PO DAILY 19. biotin 10,000 mcg oral DAILY 20. Cyanocobalamin 1000 mcg PO DAILY Discharge Medications: 1. Furosemide 40 mg PO DAILY 2. amLODIPine 7.5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atenolol 50 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. biotin 10,000 mcg oral DAILY 7. ___ (cranberry extract) 405 mg oral DAILY 8. Cyanocobalamin 1000 mcg PO DAILY 9. Fish Oil (Omega 3) 1000 mg PO DAILY 10. Gabapentin 200 mg PO BID 11. GlipiZIDE XL 10 mg PO DAILY 12. Losartan Potassium 100 mg PO DAILY 13. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY 14. mirabegron 50 mg oral DAILY 15. Multivitamins 1 TAB PO DAILY 16. nystatin 100,000 unit/gram topical BID:PRN 17. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - Moderate 18. SITagliptin 100 mg oral DAILY 19. Tizanidine 2 mg PO QHS:PRN Muscle spasm Discharge Disposition: Home Discharge Diagnosis: Anemia GI Bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with weakness and found to have anemia and a GI bleed. You were given blood and got scopes from top and bottom and a capsule endoscopy. The source of your bleed was not discovered but there was no further evidence of a bleed or worsening anemia after you stopped getting the clopidogrel (Plavix). Please stop taking this and just take aspirin 81mg daily. We discussed this plan with your interventional cardiologist Dr. ___. Please continue taking furosemide 20mg daily and discuss adjustment of your dose with your cardiologist. but - given the recent valve surgery that may have improved your heart function, given your relatively limited leg swelling here - you could try taking 40mg once in the day instead of 60mg daily. Weigh yourself every morning, and call your cardiologist if weight goes up more than 3 lbs. You have cardiology appointments soon as well as another ultrasound study to look at your heart. We recommend discussing simplification of your medication regimen with your primary care doctor. Sincerely, Your ___ Team Followup Instructions: ___
10305005-DS-15	10,305,005	24,427,013	DS	15	2180-07-20 00:00:00	2180-07-21 13:32:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Naprosyn / lisinopril / latex / peanuts / latex Attending: ___ Chief Complaint: Weight gain, abnormal lab tests Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. ___ is an ___ yo woman with H/O HFpEF, severe aortic stenosis now s/p TAVR, hypertension, hyperlipidemia, CAD who presents with volume overload and ___. Of note, the patient was recently admitted to ___ from ___ to ___ for HFpEF exacerbation. She initially presented with hypoxemia and underwent RHC with finding of RA mean 12, RV 68/11, PA 68/27, and mean PCWP 22. She was subsequently diuresed with furosemide 120-160 mg IV with good effect. At discharge, she was transitioned from furosemide 60 mg po (her previous home regimen) to torsemide 40 mg daily for better absorption. At discharge, the patient's weight was 95.2kg and Cr 1.3. Since discharge, the patient reported that she has been feeling well. She reported that she has been taking the torsemide daily as instructed. When asked her more specifically, she reports that she has been taking "one pill" of torsemide daily, which would correspond to torsemide 20 mg instead of the 40 mg she was discharged on. She feels that she hasn't been urinating as much as she had been when she was taking furosemide 60 mg daily. Additionally, the patient has been eating significant amounts of deli meats ___ ham) about twice daily since leaving the hospital. In this setting, she has noticed that her weight has been increasing about one pound per day. The patient otherwise denied orthopnea, dyspnea, chest pain, syncope, or palpitations. She was seen by her PCP in clinic ___ on ___. At that time, her Cr was noted to be elevated to 1.7 from discharge of 1.2, prompting her PCP to decrease the torsemide dose. A repeat Cr on ___ was 2.1, prompting the patient's PCP to refer the patient into ___ ED for further evaluation. In the ED, the patient's initial vitals were T 98.6F, HR 70, BP 130/57, RR 20, O2 sat 90% on RA. The patient's labs were notable for Hgb 10.0, BUN 78, and Cr 1.7. Troponin-T x2 was <0.01. NT-Pro-BNP was 411. EKG demonstrated sinus bradycardia at a rate of 54 BPM with PR interval prolongation, normal axis and intervals, mild <___levations in V2-4, III, and aVF, unchanged from prior tracings. CXR did not demonstrate increased vascular markings or frank pulmonary edema. The patient was seen by cardiology and felt to be volume overloaded. As a result, she was given furosemide 120 mg IV and atorvastatin 40 mg, and admitted to Cardiology for further management. On arrival to the cardiology ward, T 98.6F, BP 135/58, HR 72, RR 16, O2 sat 92% on 3 LPM via NC. Patient confirmed the above history. REVIEW OF SYSTEMS: Positive per HPI Past Medical History: 1. CAD RISK FACTORS - Diabetes mellitus type 2 - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD s/p DES to LCx ___ - HFpEF - Severe aortic stenosis s/p TAVR 3. OTHER PAST MEDICAL HISTORY - CKD stage 3 - Severe OSA Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: On admission GENERAL: Elderly white woman in NAD VS: T 98.6F, HR 70, BP 130/57, RR 20, O2 sat 90% on RA HEENT: AT/NC, anicteric sclera, mucous membranes moist NECK: unable to visualize JVP CV: normal S1, S2 without murmurs, rubs, or gallops PULM: faint bibasilar crackles on inspiration GI: abdomen soft, not distended, non-tender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: 1+ pretibial edema to the knees bilaterally PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric DERM: warm and well perfused, no excoriations or lesions, no rashes At discharge GENERAL: in NAD Temp: 97.6 PO BP: 127/62 L Lying HR: 57 RR: 16 O2 sat: 91% O2 delivery: RA FSBG: 147 I/O: -190 mL in past 24 hrs (net -___ since admission) Weight: 95.5 kg (discharge weight on ___ kg) HEENT: AT/NC, anicteric sclera, mucous membranes moist NECK: unable to visualize JVP CV: normal S1, S2 without murmurs, rubs, or gallops CHEST: tenderness to palpation on left rib along the axillary region (chronic) PULM: faint crackles in lower lung fields GI: abdomen soft, not distended, non-tender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no lower extremity edema PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric DERM: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ___ 03:00PM BLOOD WBC-8.4 RBC-3.67* Hgb-10.8* Hct-34.5 MCV-94 MCH-29.4 MCHC-31.3* RDW-13.4 RDWSD-45.7 Plt ___ ___ 03:00PM BLOOD UreaN-90* Creat-2.1* Na-136 K-5.0 Cl-91* HCO3-28 AnGap-17 ___ 04:20PM BLOOD proBNP-411 ___ 04:20PM BLOOD cTropnT-<0.01 ___ 07:47PM BLOOD cTropnT-<0.01 ___ 07:42PM BLOOD %HbA1c-6.0 eAG-126 CXR(PA & LAT) on ___ Heart size is normal with evidence of prior transcatheter aortic valve replacement. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. Lungs are hyperinflated without focal consolidation. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. Anterior bridging osteophytes are seen in the thoracic spine. A left shoulder arthroplasty is incompletely imaged. IMPRESSION: No acute cardiopulmonary abnormality. ECG ___ 15:22:25 Sinus bradycardia. Prolonged PR interval. Compared with previous ECG, no significant change DISCHARGE LABS: ___ 10:27AM BLOOD WBC-9.3 RBC-3.38* Hgb-10.1* Hct-32.1* MCV-95 MCH-29.9 MCHC-31.5* RDW-13.0 RDWSD-44.7 Plt ___ ___ 10:27AM BLOOD Glucose-144* UreaN-61* Creat-1.2* Na-139 K-4.1 Cl-96 HCO3-31 AnGap-12 ___ 10:27AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.0 Brief Hospital Course: TRANSITIONAL ISSUES: [ ] Patient should have BMP on ___ at pulmonary appointment and sent to her PCP to make sure ___ continues to resolve. [ ] Patient's losartan was held in setting of ___. Please restart if Cr continues to remain stable. [ ] Patient's diuretic was changed to Torsemide 40 mg prior to discharge. (She appeared euvolemic during hospitalization on this dose.) [ ] Please ensure that patient weighs herself daily. Continue to monitor Cr closely. [ ] Patient should follow up with pulmonology. Patient has an appointment scheduled on ___ for PFTs. [ ] Patient has a cardiology appointment on ___. [ ] Continue to engage patient on CPAP use for OSA. Patient should have outpatient sleep study. - Discharge weight: 95.5 kg - Discharge Cr: 1.3 - Discharge diuresis: Torsemide 40 mg daily SUMMARY STATEMENT: Patient is an ___ year old woman with H/P HFpEF (LVEF 65%), severe aortic stenosis now s/p TAVR, CAD S/P DES, hypertension, hyperlipidemia, recently discharged on ___ from ___ for HF exacerbation. She was found to have Cr 1.7 at PCP ___, presented on ___ with volume overload and continued ___ in setting of halving of her outpatient oral diuretic dose and dietary indiscretion. HOSPITAL COURSE: # HFpEF exacerbation: Patient presents with increasing weight over the past several days although NT-Pro-BNP not elevated at 411, CXR and lungs clear. Precipitating factor for her acute exacerbation most likely due to dietary indiscretion given her frequent consumption of deli meats and recent halving of her torsemide when her Cr rose to 1.7 from 1.2 (and recent discharge weight 95.2 kg). She was actively diuresed with furosemide and her ___ was stopped with improvement in renal function to 1.3. Her prior discharge torsemide regimen was resumed as 20 mg daily was clearly insufficient to maintain fluid balance. - PRELOAD: PO Torsemide 40 mg - BLOOD PRESSURE: continued home amlodipine; held losartan given ___ - NHBK: if renal function improves, please restart losartan. - Nutrition education for low salt diet # ___ on CKD: Patient has stage 3 CKD (baseline Cr 0.9 to 1.1), discharged on ___ with Cr 1.2. At ___ office on ___, the patient's Cr noted to be 1.7, prompting halving of her torsemide dose. Cr was then rechecked on ___ and had continued to uptrend to 2.1 with increased weight from 208 lb to 210 lb. Etiologies for ___ most likely congestive nephropathy, as Cr improved with diuresis. Patient has been maintaining fluid balance on Torsemide 40 mg daily dose. # CAD: History of CAD s/p DES to ___ ___, last angiogram ___ showing mild to moderate disease. We continued home aspirin, atorvastatin, metoprolol. Patient not on clopidogrel due to hx of GI bleed (admitted for melena on ___. # Hypertension: Continued home amlodipine. Stopped losartan given ___. # Type 2 diabetes mellitus: Patient managed on ISS while inpatient and restarted on home medications at discharge. # Overactive Bladder: Held home Myrbetriq at home as non-formulary. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 7.5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Cyanocobalamin 1000 mcg PO DAILY 5. Fish Oil (Omega 3) 1000 mg PO DAILY 6. Losartan Potassium 100 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Acetaminophen 1000 mg PO Q8H 9. biotin 10,000 mcg oral DAILY 10. ___ (cranberry extract) 405 mg oral DAILY 11. GlipiZIDE XL 10 mg PO DAILY 12. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY 13. SITagliptin 100 mg oral DAILY 14. Lidocaine 5% Patch 1 PTCH TD QPM 15. Metoprolol Succinate XL 100 mg PO DAILY 16. Torsemide 40 mg PO DAILY 17. mirabegron 50 mg oral DAILY 18. Tizanidine 2 mg PO QHS:PRN Muscle spasm 19. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 3. amLODIPine 7.5 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. biotin 10,000 mcg oral DAILY 7. ___ (cranberry extract) 405 mg oral DAILY 8. Cyanocobalamin 1000 mcg PO DAILY 9. Fish Oil (Omega 3) 1000 mg PO DAILY 10. GlipiZIDE XL 10 mg PO DAILY 11. Lidocaine 5% Patch 1 PTCH TD QPM 12. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY 13. Metoprolol Succinate XL 100 mg PO DAILY 14. mirabegron 50 mg oral DAILY 15. Multivitamins 1 TAB PO DAILY 16. SITagliptin 100 mg oral DAILY 17. Tizanidine 2 mg PO QHS:PRN Muscle spasm 18. Torsemide 40 mg PO DAILY 19. HELD- Losartan Potassium 100 mg PO DAILY This medication was held. Do not restart Losartan Potassium until speaking to your doctor. 20.Outpatient Lab Work Please draw Chem7 + Mg, Phosph, Calcium on ___ and send results to pcp ___., MD - Fax: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: -Acute on chronic left ventricular diastolic heart failure -Prior aortic stenosis now status post transcatheter aortic valve replacement -Acute kidney injury -Type 2 diabetes mellitus with -Stage 3 chronic kidney disease -Coronary artery disease with prior stenting -Hypertension -Hyperlipidemia -Overactive bladder -Obstructive sleep apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms ___, It was a pleasure taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because of your weight gain and increase in kidney number. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - You were found to have volume overload and given medications to remove fluid from your body and improve your shortness of breath. - Your losartan was held during the hospital stay because of your kidney function. Do not restart it until you speak to your doctor. WHAT SHOULD I DO WHEN I GO HOME? - You should continue to take your medications as prescribed including Torsemide 40mg daily. Do NOT restart losartan until you speak to your doctor. - You should attend the appointments listed below. - Please return to the hospital if you have severe chest pain, worsening shortness of breath, or loss of consciousness. - Please weigh yourself everyday. Call your primary care doctor if your weight goes up more than 3 pounds in one day or 7 pounds in one week. We wish you the best! Your ___ Care Team Followup Instructions: ___
10305005-DS-9	10,305,005	25,262,011	DS	9	2173-04-30 00:00:00	2173-05-05 23:30:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Naprosyn / lisinopril Attending: ___. Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a ___ with PMH T2DM, HTN, HLD who presents with SOB for ___ weeks. She states that she has had progressive difficulty breathing for the past couple of ___, exacerbated by exertion and relieved by rest. Today she visited her PCP where she had a chest ___ (negative) and a ___ taken. ___ was elevated and she was told to come to the ED. . In the ED, initial VS were 99.0 83 182/64 20 92%.Labs showed lytes within normal limits, and normal CBC with neutrophilic predominance. BNP was 566, ___ 889. She was given ASA 325mg x1. ECG showed SR, NANI, no ST changes. Given elevated ___, pt had CTA, which showed no PE. Plan was for 2 sets and stress this am. However, given desat with ambulation, decision was made to admit to medicine. VS prior to transfer ___ FPO, 159/54, 69, 18, 93% 2LNC. . Upon transfer to the floor, VS - Temp F, BP142/72 , HR61 , R18 , ___ 94% 2LNC. Past Medical History: PMH: DMII HTN Gallstone Pancreatisit (___) OA PSH: ERCP ___ Appendectomy Right breast lumpectomy Bilateral Knee Replacements Social History: ___ Family History: Mother and father with T2DM Physical Exam: Physical Exam on Admission: VS - Temp F, BP142/72 , HR61 , R18 , ___ 94% 2LNC GENERAL - ___ obese woman in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no visible JVD, large fatty neck, no carotid bruits LUNGS - CTA bilat, no rh/wh, bibasilar rales, good air movement, resp unlabored, no accessory muscle use HEART - PMI ___, RRR, ___ systolic murumur heard best at the RUSB but also throughout the precordium, nl ___ ABDOMEN - NABS, soft/TTP in the RUQ/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs ___ grossly intact Physical Exam on Discharge: Afebrile, Improved exercise tolerance, oxygen sats 93% on room air with ambulation Pertinent Results: Lab Results on Admission: ___ 02:45PM BLOOD ___ ___ Plt ___ ___ 02:45PM BLOOD ___ ___ ___ 12:00AM BLOOD ___ ___ ___ 12:00AM BLOOD ___ ___ ___ 12:00AM BLOOD cTropnT-<0.01 ___ ___ 08:05AM BLOOD cTropnT-<0.01 ___ 05:45PM BLOOD cTropnT-<0.01 ___ 07:50AM BLOOD ___ ___ 02:45PM BLOOD ___ ___ 05:50PM BLOOD ___ ___ Base ___ INTUBA ___ 10:45AM BLOOD ___ ___ Base ___ INTUBA Radiology: Studies: CTA: IMPRESSION: 1. No pulmonary embolism or acute aortic syndrome. 2. No focal consolidation or pleural effusions. 3. Multiple thyroid nodules, some calcified. Dedicated thyroid ultrasound is recommended for further characterization. 4. 4 mm pulmonary nodule in the right upper lobe. If the patient has no smoking history or other risk factors for malignancy, no followup is needed. However, if patient is a smoker or with risk factors, followup chest CT in 12 months is recommended to evaluate for interval change. 5. Evidence of probable moderate small airways disease. 6. Mild distal esophageal wall thickening. Recommend correlation with endoscopy. Studies: ___ ECG: Sinus rhythm. Left atrial abnormality. Compared to the previous tracing of ___ the rate has slowed. Otherwise, no diagnostic interim change. ___ CXR: IMPRESSION: No acute cardiopulmonary process. ___ TTE: IMPRESSION: Biatrial enlargement. Normal left ventricular cavity size and wall thickness with preserved global biventricular systolic function. Mild aortic stenosis by transaortic valvular gradient, although valve leaflets appear to open fairly well and may be more consistent with minimal aortic stenosis. Mildly dilated ascending aorta and aortic arch. Mild mitral regurgitation. Normal pulmonary artery systolic pressure. ___ ECG: Normal sinus rhythm. Normal tracing. No difference compared to the previous tracing of ___. Microbiology: ___ 5:23 pm URINE Source: ___. *FINAL REPORT ___ URINE CULTURE (Final ___: <10,000 organisms/ml. Lab Results on Discharge: ___:10AM BLOOD ___ ___ Plt ___ ___ 08:05AM BLOOD ___ ___ 09:10AM BLOOD ___ ___ ___ 08:05AM BLOOD ___ ___ 09:10AM BLOOD ___ ___ 10:38AM BLOOD ___ B ___ 10:38AM BLOOD ___ ___ ___ ___ 08:05AM BLOOD ___ ___ 08:05AM BLOOD ___ Brief Hospital Course: Primary Reason for Hospitalization: Patient is a ___ female with past medical history significant for diabetes, hypertension, and hyperlipidemia who presented with 3 weeks of worsening shortness of breath and wheezing when supine and dyspnea on exertion particularly severe last night. She was found on CT to have findings consistent with small airway disease and was treated with inhaled and systemic steroids and inhaled bronchodilators. She was discharged with improved exercise tolerance and improved oxygen saturation on ambulation. . ACUTE CARE: . 1. Small airway disease: Patient presented with DOE, wheezing and paroxysmal nocturnal dyspnea. CT showed no pulmonary embolism, no pleural effusion, and no pulmonary edema, but was consistant with small airway disease. She initially had ambulatory oxygen saturation to the mid 80's on room air with ambulation and occasional dips at rest as well. This process of small airway inflammation is possibly from asthma vs. hot tub lung vs. other environmental irritant vs. viral bronchitis. With a rapid taper of oral corticosteroids and treatment with inhaled corticosteroids and bronchodilators, patient's symptoms improved and she had oxygen sats to low 90's on room air with ambulation. She was discharged with pulmonary followup with a suspicion of underlying OSA vs pulmonary hypertension as well. . CHRONIC CARE: . 1. Hypertension: Patient was continued on her home BP meds with moderately ___ pressures. . 2. Hypercholesteremia: Patient was continued on home Lipitor. . 3. Type II Diabetes: Oral hypoglycemics were held on admission but ___ over hospital course. Glycemic control was managed with insulin sliding scale. Patient's blood sugars were initially difficult to control while on oral corticosteroid therapy but were improving on discharge. She was instructed to monitor sugars at home and call her doctor if they were over 400 at home. . TRANSITIONAL CARE: 1. CODE: FULL 2. CONTACT:Patient and her husband 3. PENDING STUDIES: 4. ___: - PCP - recommend thyroid u/s to assess for nodules seen on CT scan - may need f/u of pulmonary nodule with repeat CT scan in 12 months Medications on Admission: ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth once a day ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 Tablet(s) by mouth once a day LOSARTAN - 25 mg Tablet - 1 Tablet(s) by mouth once a day METFORMIN - 500 mg Tablet Extended Rel 24 hr - 4 Tab(s) by mouth once a day OXYBUTYNIN CHLORIDE - 5 mg Tablet Extended Rel 24 hr - 1 Tab(s) by mouth once a day PIOGLITAZONE [ACTOS] - 30 mg Tablet - 1 Tablet(s) by mouth once a day SITAGLIPTIN [JANUVIA] - 100 mg Tablet - 1 Tablet(s) by mouth once a day Medications - OTC ASPIRIN - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth once a day Discharge Medications: 1. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. metformin 500 mg Tablet Sig: Four (4) Tablet PO once a day. 5. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day. 6. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO once a day. 7. sitagliptin 100 mg Tablet Sig: One (1) Tablet PO once a day. 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. prednisone 10 mg Tablet Sig: see below Tablet PO once a day for 2 days: please take 2 tablets ___, then 1 tablet ___ . Disp:3 Tablet(s) Refills:0 10. ___ mcg/dose Disk with Device Sig: One (1) puff Inhalation BID (2 times a day). Disp:1 discus Refills:2 11. guaifenesin 100 mg/5 mL Syrup Sig: ___ MLs PO Q6H (every 6 hours) as needed for cough. Disp:500 ML(s) Refills:0 12. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: ___ Puffs Inhalation Q6H (every 6 hours) as needed for wheeze, shortness of breath. Disp:1 inhaler Refills:2 13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: ___ Puffs Inhalation Q4H (every 4 hours) as needed for wheezing, shortness of breath. Disp:1 inhaler Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: 1. Shortness of breath, hypoxia 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 this admission. You were admitted for shortness of breath. Your oxygen levels were found to be low. Your cardiac enzymes and EKG were reassuring that this was unrelated to your heart. A CAT scan of your chest showed no clot or pneumonia. We checked an echocardiogram, which showed no major change in your heart function from prior. We gave you diuretics to take extra fluid off of your lungs. We had the pulmonary doctors ___, and based on our assessment with them of your physical exam and CT findings, we feel that you have bronchitis, either from an environmental irritant, allergen, or related to a viral infection that will clear. We think you may have a component of sleep apnea and recommend that you have a sleep study done as an outpatient. The following medications were changed during this admission: 1. START Albuterol ___ puffs inhaled every four hours as needed for shortness of breath or wheeze 2. START Atrovent ___ puffs inhaled every 6 hours as needed for shortness of breath or wheeze 3. START Advair 1 puff inhaled twice daily 4. START prednisone 10mg tabs. Take 2 pills tomorrow morning, and one pill the day after. Following this, stop taking prednisone. Please continue the other medications you were on prior to this admission. Please monitor your blood sugars for the next few days as you ___ your home meds diabetes medications and taper down your prednisone. These should normalize your blood sugars over the next few days. We recommend you consider eventually stopping Actos as this medication may be dangerous in the setting of volume overload. Please discuss this at your upcoming appointment. On the CAT scan we saw small thyroid nodules, for which we would recommend you have thyroid ultrasound as an outpatient. You also had a very small 4mm nodule in your lung, for which you may require a repeat CAT scan in 12 months. There was also some thickening of the esophagus, for which you may require an endoscopy in the future. Please discuss all of these needed ___ imaging with your doctor as an outpatient. Followup Instructions: ___
10305105-DS-4	10,305,105	23,821,889	DS	4	2168-01-17 00:00:00	2168-01-17 20:55:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Nsaids / Bactrim DS Attending: ___. Chief Complaint: Pneumonia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a lovely ___ woman with a pmhx. significant for CVID, bronchiectasis, GERD, and frequent pneumonias (one requiring MICU stay and pressors) who is admitted with fevers, chills, nausea, and CXR concerning for right upper lobe pneumonia. Ms. ___ was in her usual state of health until ___ of last week when she developed a scratchy throat. Called her allergist who prescribed a Zpack. Patient initially felt better but over the course of the weekend continued having chills, nausea, and vomiting. She felt quite ill on morning of admission and decided to present to ED for further evaluation. In the ED, initial vitals were: 101.4 92 170/74 26 96% RA. A CXR showed a right upper lobe infiltrate. Patient was given vanc, cefepime, zofran, and tylenol. Upon admission to the floor, vitals are: 99.6, 80, 20, 118/60, SPO2 of 94% on 3L. Patient is feeling better, though on oxygen and with raspy voice. Patient denies chest pain, shortness of breath, abdominal pain, constipation, diarrhea, dysuria. A 12-point review of systems is otherwise negative. Past Medical History: --Asthma --Bronchiectasis --Chronic rhinitis --Chronic variable immunodeficiency --Depression --Gallbaldder polyps --GERD --High cholesterol --Kidney stones --OA --Osteoporosis --S/p TAH/BSO --Colonic adenoma --Hemorrhoids Social History: ___ Family History: No family history of immune deficiency. Physical Exam: ADMISSION EXAM: VS: 99.6, 80, 20, 118/60 GENERAL: Well appearing, no acute distress, wearing oxygen CHEST: Diffuse rhonchi througout, scattered wheezes, "machine like" sounds CARDIAC: RRR, no murmurs, rubs or gallops ABDOMEN: +BS, soft, non-tender, non-distended EXTREMITIES: No edema bilaterally SKIN: Warm and dry, not diaphoretic NEURO: CN II-XII grossly intact, moving all four extremities Pertinent Results: ___ 11:51AM LACTATE-1.5 ___ 11:30AM GLUCOSE-181* UREA N-15 CREAT-0.7 SODIUM-135 POTASSIUM-3.1* CHLORIDE-103 TOTAL CO2-21* ANION GAP-14 ___ 11:30AM estGFR-Using this ___ 11:30AM URINE HOURS-RANDOM ___ 11:30AM URINE UCG-NEGATIVE ___ 11:30AM WBC-4.2 RBC-3.87* HGB-12.5 HCT-35.0* MCV-91 MCH-32.3* MCHC-35.6* RDW-12.8 ___ 11:30AM NEUTS-89.2* LYMPHS-7.4* MONOS-3.0 EOS-0.2 BASOS-0.2 ___ 11:30AM PLT COUNT-171 ___ 11:30AM URINE COLOR-LtAmb APPEAR-Hazy SP ___ ___ 11:30AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG ___ 11:30AM URINE RBC-2 WBC-8* BACTERIA-FEW YEAST-NONE EPI-<1 ___ 11:30AM URINE HYALINE-2* ___ 11:30AM URINE MUCOUS-MANY Brief Hospital Course: This is a ___ woman with a medical history significant for CVID, bronchiectasis who is admitted with fever, cough and CXR consistent with pneumonia. # PNEUMONIA: She was started on broad spectrum antibiotics with vancomycin, cefepime, and azithromycin. Her fevers resolved, her oxygen saturation improved (95% with ambulation at the time of discharge), and her symptoms were slowly improving at the time of discharge. Blood culture was no growth. Sputum culture grew respiratory flora. She was seen by the pulmonary service. She was transitioned to cefpodoxime and levofloxacin and will complete a 14 day total course (11 more days after discharge). . #BRONCHIECTASIS: She was seen by the pulmonary service. She was given a flutter (acapella) valve for respiratory physical therapy. She was continued on albuterol nebulizer and incentive spirometry. #CVID: Her immunoglobulins were checked and results communicated to her immunologist. She was continued on IVIG Qweekly. # DEPRESSION: She was continued on celexa # GERD: She was continue omeprazole and ranitadine # COMMUNICATION: Patient and husband ___, ___ Home, ___ # CODE STATUS: Full (confirmed) . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Shorntess of breath 2. Azithromycin 250 mg PO Q24H 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Citalopram 20 mg PO DAILY 5. Evista NF (raloxifene) 60 mg Oral QD 6. Ranitidine 300 mg PO HS 7. traZODONE 50 mg PO HS:PRN Insomnia 8. Acetaminophen 500 mg PO Q6H:PRN Pain 9. Calcium Carbonate 500 mg PO Q6H 10. Vitamin D 800 UNIT PO DAILY 11. Guaifenesin ER 1200 mg PO Q12H 12. Omeprazole 20 mg PO DAILY 13. Probiotic NF (lactobacillus rhamnosus GG) 10 billion cell Oral QD Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN Pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Shorntess of breath 3. Calcium Carbonate 500 mg PO Q6H 4. Citalopram 20 mg PO DAILY 5. Evista NF (raloxifene) 60 mg Oral QD 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 7. Guaifenesin ER 1200 mg PO Q12H 8. Omeprazole 20 mg PO DAILY 9. traZODONE 50 mg PO HS:PRN Insomnia 10. Vitamin D 800 UNIT PO DAILY 11. Probiotic NF (lactobacillus rhamnosus GG) 10 billion cell Oral QD 12. Ranitidine 300 mg PO HS 13. Levofloxacin 750 mg PO DAILY RX levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #11 Tablet Refills:0 14. Cefpodoxime Proxetil 200 mg PO Q12H RX cefpodoxime 200 mg 1 tablet(s) by mouth Q12 Disp #22 Tablet Refills:0 15. Ondansetron 4 mg PO Q8H:PRN nausea Discharge Disposition: Home Discharge Diagnosis: Pneumonia Bronchiectasis 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 on this admission. You came to the hospital with a pneumonia. We treated you with antibiotics and your symptoms improved. You will need to You were seen by the pulmonary doctors who recommended using a flutter valve to help your lungs clear the secretions. Followup Instructions: ___
10305105-DS-5	10,305,105	24,662,948	DS	5	2171-03-08 00:00:00	2171-03-08 18:06:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Nsaids / Bactrim DS Attending: ___. Chief Complaint: Pneumonia Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old Female with asthma and bronchiectasis who presents with probable pneumonia. The patient states her symptoms began 10 days prior to admission with sinus congestion and rhinorrhea and was started on augmentin and prednisone. She had some initial relief with the 30mg prednisone but then worsened once tapered to 20mg, with deeper cough, fevers and dyspnea. She states the cough has some green phlegmy production. She notes her baseline PEF is 400-450. She follows with ___ for pulmonary. She has never been intubated or been admitted to the ICU solely for asthma. She has been admitted to ICU for sepsis due to her CVID. In the ___ ED her initial vials were 100, 118, 152/76, 20, 99%. AN x-ray was performed with a retrocardiac opacity. As she works as a PACU nurse this is being treated as HCAP and she was started on vancomycin and zosyn. Her PEF was 300 on exam in the ED. Past Medical History: --Asthma --Bronchiectasis --Chronic rhinitis --Chronic variable immunodeficiency (CVID) --Depression --Gallbaldder polyps --GERD --High cholesterol --Kidney stones --OA --Osteoporosis --S/p TAH/BSO --Colonic adenoma --Hemorrhoids Social History: ___ Family History: Relative Status Age Problem Comments Mother ___ ___ PULMONARY EMBOLISM post-op Father ___ ___ DIABETES MELLITUS CORONARY ARTERY DISEASE CONGESTIVE HEART FAILURE Physical Exam: PHYSICAL EXAM on admission: VSS: 98.1, 118/58, 72, 18, 97% GEN: NAD Pain: ___ HEENT: EOMI, MMM, - OP Lesions PUL: Coarse rhonchi B/L, bronchial sounds COR: RRR, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: - CCE NEURO: CAOx3, Non-Focal Physical exam on discharge: Vitals: AVSS Gen: NAD, lying in bed Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, no edema Resp: normal effort, no accessory muscle use; good air movement, bronchial breathsounds bilaterally, few scattered rhonchi, but no longer much in the way of wheezes. Overall much better. GI: soft, NT, ND, BS+ MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Psych: Full range of affect. Very pleasant. GU: No foley Pertinent Results: Labs on admission: ___ 03:20AM BLOOD WBC-12.4# RBC-4.11 Hgb-12.7 Hct-36.7 MCV-89 MCH-30.9 MCHC-34.6 RDW-12.1 RDWSD-39.0 Plt ___ ___ 03:20AM BLOOD Neuts-81.6 Lymphs-13.0* Monos-4.7* Eos-0.1* Baso-0.2 Im ___ AbsNeut-10.11* AbsLymp-1.61 AbsMono-0.58 AbsEos-0.01* AbsBaso-0.03 ___ 03:20AM BLOOD Glucose-108* UreaN-16 Creat-0.7 Na-138 K-3.6 Cl-103 HCO3-22 AnGap-17 ___ 03:38AM BLOOD Lactate-1.8 ___ 02:40AM URINE Color-Straw Appear-Clear Sp ___ ___ 02:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG Imaging studies: CXR on admission: Retrocardiac opacity concerning for pneumonia. Labs on discharge: ___ 07:23AM BLOOD WBC-8.4 RBC-3.66* Hgb-11.3 Hct-33.1* MCV-90 MCH-30.9 MCHC-34.1 RDW-12.3 RDWSD-40.5 Plt ___ ___ 07:23AM BLOOD ___ PTT-33.2 ___ ___ 07:23AM BLOOD Glucose-135* UreaN-8 Creat-0.7 Na-138 K-3.6 Cl-105 HCO3-24 AnGap-13 Brief Hospital Course: This is a ___ with mild asthma, bronchiectasis, CVID on IVIG (had lots of severe resp tract infections prior to diagnosis), who presents with cough and dyspnea along with fevers/chills. She was found to have infiltrate on CXR and along with systemic symptoms and leukocytosis she was appropriately diagnosed with pneumonia (along with classic bronchiectasis type flare with wheezing, rhonchi, etc). Given some HCAP risk factors, she was started on broad spectrum agents vanc/cefepime/azithro along with increased dose steroids, nebulizers, and airway clearance. She did remarkably well and very rapidly improved with above treatments; leukocytosis resolved, cough and lung exam much improved. We discussed antibiotic de-escalation, which is always a difficult question in these patients. Reviewing microbiology, she has really never had a resistant organism in spite of her risk factors. Given her rapid improvement and absence of micro, she and I agreed to a trial of de-escalation, and she was transitioned to Levaquin. She has now continued to do very well on PO Levaquin. She will be discharged with a course of Levaquin for pneumonia, a slightly extended steroid taper from her original prescription, her home inhaler regimen, and additional duonebs as needed for wheezing during her period of recovery. # Sepsis due to # Pneumonia leading to # Mild flare of bronchiectasis and consequently # Acute respiratory failure: As above. - Steroid taper - Levaquin # CVID: Received IVIG recently. - F/u with Dr ___ after DC # Anxiety, mild: - Continue Ativan PRN # PPX: Heparin # Disposition: Home # Code status: Full code # Billing: >30 minutes spent coordinating discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 3. PredniSONE 20 mg PO DAILY Tapered dose - DOWN 4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 5. TraZODone 50 mg PO QHS:PRN insomnia 6. Lorazepam 0.5 mg PO DAILY:PRN anziety 7. Ranitidine 300 mg PO QHS 8. raloxifene 60 mg oral DAILY 9. Omeprazole 20 mg PO DAILY 10. Qvar (beclomethasone dipropionate) 40 mcg/actuation inhalation BID Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 2. Lorazepam 0.5 mg PO DAILY:PRN anziety 3. Omeprazole 20 mg PO DAILY 4. PredniSONE 30 mg PO DAILY RX prednisone 10 mg 3 tablet(s) by mouth daily Disp #18 Tablet Refills:0 5. raloxifene 60 mg oral DAILY 6. Ranitidine 300 mg PO QHS 7. TraZODone 50 mg PO QHS:PRN insomnia 8. Levofloxacin 750 mg PO Q24H Duration: 5 Days RX levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #5 Tablet Refills:0 9. Benzonatate 100 mg PO TID RX benzonatate 100 mg 1 capsule(s) by mouth three times daily Disp #30 Capsule Refills:0 10. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 11. Qvar (beclomethasone dipropionate) 40 mcg/actuation INHALATION BID 12. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of breath, wheezing RX ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 neb INH every 6 hours as needed Disp #30 Ampule Refills:0 Discharge Disposition: Home Discharge Diagnosis: Acute respiratory failure and sepsis Pneumonia Bronchiectasis and asthma CVID GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with fevers, chills, cough, and shortness of breath and found to have a pneumonia along with a flare of your asthma/bronchiectasis. You were treated with antibiotics, nebulizers, steroids, and inhalers, and you improved very quickly. You are being discharged on a course of Levaquin to treat pneumonia, along with a slightly longer steroid taper than originally prescribed by Dr ___. Please follow-up with your immunologist and PCP. Followup Instructions: ___
10305245-DS-11	10,305,245	21,127,077	DS	11	2112-10-26 00:00:00	2112-10-29 09:05:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fevers, weakness, sore throat Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ ___ woman without remarkable past medical history who presented on ___ with ~2 days of neck stiffness and 1 day of fevers and generalized weakness and numbness. This history was primarily obtained by neurology consult and with the assistance of the husband as a ___. She has a history of lower back and neck pain and muscle spasms for years. However, in the ___ days prior to admission, she developed a significant worsening of her typical neck pain, which did not improve with a heating pad. On the day of presentation (___), she woke at 6am to use the bathroom. At this time, her throat and tonsils were hurting. She then went back to sleep and her husband left for work. Around 9am, she woke up for the day. At this time, she felt hot and developed a subjective fever. She also noticed that she could not walk in a stable manner due to weakness in her legs. She did not fall. She attributed this to her back pain and neck stiffness. At the same time, she developed numbness that started in her lower back and spread to her feet. At 12pm, she noticed that her hands were now numb and feeling weak. At this time, she called her neighbor who brought her to ___. She felt fatigue and malaise. She denied any urinary or bowel incontinence, recent tick or bug bites, rashes, or recent travel outside the country (she was in ___ ___ years ago). She has not been south of ___ recently. She has no history of herpetic lesions, TB, or HIV. She did have honey from ___ for her sore throat on the AM of presentation. At ___, she was found to be febrile to 102.7 with BP 95/69, RR 18, pulse 99 and O2 sats 100%. General exam notable for dry mucous membranes, nuchal rigidity, and erythematous posterior pharynx. Her neurological exam was notable for "flaccid weakness of the lower extremities, when asked to move her feet there is twitching of her toes but she is unable to dorsi or plantar flex the legs, when each leg is actively raised it drops immediately. [...] I do see some quadricep contraction. [...] Straight leg raise causes radicular pain in the low back. ___ grip strength at hands bilaterally." Cranial nerves, sensation and reflexes were intact and rectal tone was normal. Labs revealed a leukocytosis (14.6) with left shift. CXR, MRI C/L spine +/- were unremarkable. MRI brain +/- showed non-specific T2/FLAIR white matter hyperintensities. Pt was given CTX 1g and then transferred to ___ for further management. At the time of neurology assessment in the ED on the evening of ___, she reported that her symptoms of numbness have resolved. She reports ongoing weakness that has been stable since the early afternoon. She also reports a holocephalic dull headache and blurry vision. Her husband reported that she looked improved; he also stated that she was "mumbling" previously and was now speaking more clearly. She reported persistent neck stiffness and back pain. She denied any shortness of breath or diplopia. She has never had similar symptoms prior, including during an acute illness. In the ED, initial vitals were: T: 98.4 HR: 79 BP: 105/58 RR: 14 Sp02: 100% RA Labs showed initial WBC of 13.4, anemia with HgB 10.6 (Baseline: unknown), CRP 99.5, LFTs wnl, electrolytes wnl (Cr 0.6) Lactate 0.6, mild academia on VBG to 7.32, Urine show negative UCG and some ketones. On examination by the neurology attending, an LP, ___ MRI was recommended and the patient was found to have cervical adenopathy and pus noted on her tonsils. A CT neck was recommended. LP, clear fluid, 1/1/2/3.5cc tubes. Opening pressure 17.5 @ 0300 MRI brain showed small scattered nonspecific T2 white matter foci. CT neck showed peritonsillar abscess, MRI ___ was within normal limits. Received ___ 21:43 IV CefTRIAXone 2 gm ___ 22:00 IVF 1000 mL NS 1000 mL ___ 22:20 IV Acyclovir 700 mg ___ 22:20 IV Morphine Sulfate 2 mg ___ 23:06 IV Vancomycin 1000 mg ___ 23:56 IV DiphenhydrAMINE 25 mg ___ 05:30 IVF 1000 mL NS 1000 mL ___ 07:16 PO Acetaminophen 1000 mg ___ 08:18 IVF 1000 mL LR 1000 mL ___ 08:18 IV Ondansetron 4 mg ___ 11:28 IV CeftriaXONE 2 gm ___ 13:00 IV Vancomycin 1000 mg ___ 14:33 IV Morphine Sulfate 2 mg ___ 15:35 IV Ampicillin-Sulbactam 3 g ___ 15:35 IV Dexamethasone 8 mg Neuro and ENT were consulted. Neuro consult is described above. ENT recommended no immediate drainage, but continued treatment with antibiotics. Decision was made to admit to medicine for further management. On arrival to the floor, patient reports ongoing generalized weakness, persistent dull headache, unchanged throat pain, ongoing neck pain and stiffness. She denies chest pain, dyspnea, cough, abdominal pain, dysuria. She endorses constipation, which is chronic for her. Denies diarrhea. Her most recent travel was to ___ 1 week ago. She feels that she has regained some strength compared to the day prior. Denies ongoing numbness. Past Medical History: Lower back and neck pain for years Post-partum depression Per husband, no history of TB or HIV. Social History: ___ Family History: No family history of neurologic disease or auto-immune disease. Mother with pre-diabetes. Father with arthritis. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vital Signs: 97.2 PO ___ 18 100 RA General: Ill-appearing, pale, speaks in soft voice, no stridor, no drooling HEENT: Dry mucous membranes, patient unable to open mouth wide enough for posterior oropharynx examination secondary to pain, sclerae anicteric Neck: +meningismus, +Brudzinski's and +Kernig's, + painful cervical lymphadenopathy R>L ___: Regular rate Pulmonary: CTAB, no wheezes or rhonchi Abdomen: Soft, NT, ND Extremities: Warm, no edema Skin: No rashes or lesions Neuro: CN II-XII intact, though unable to evaluate cranial nerve IX/X secondary to patients inability to open mouth in setting of pain. Strength ___ in the upper extremities with sensation to light touch intact. Patient able to move toes bilaterally, though unable to raise either leg against gravity, which she attributes to low back pain. Sensation to light touch intact in the lower extremities bilaterally. Downgoing Babinksi bilaterally. DISCHARGE PHYSICAL EXAM: ======================== Vital Signs: 98.3 96/55 64 17 100 RA General: AOx3, speaks in soft voice, no stridor, no drooling HEENT: Dry mucous membranes, uvula midline, erythematous pharynx, sclera anicteric, no stridor Neck: Mild bilateral LAD <1cm, mildly painful to palpation ___: Regular rate and rhythm Pulmonary: CTAB, no wheezes or rhonchi Abdomen: Soft, NT, ND Extremities: Warm, no edema Skin: No rashes or lesions Neuro: Strength intact in the UE and ___ with sensation to light touch intact. Pertinent Results: ADMISSION LABS: =============== ___ 08:00PM BLOOD WBC-13.4* RBC-3.46* Hgb-10.6* Hct-32.2* MCV-93 MCH-30.6 MCHC-32.9 RDW-13.2 RDWSD-44.1 Plt ___ ___ 08:00PM BLOOD Neuts-83.2* Lymphs-10.3* Monos-5.6 Eos-0.1* Baso-0.3 Im ___ AbsNeut-11.12* AbsLymp-1.38 AbsMono-0.75 AbsEos-0.02* AbsBaso-0.04 ___ 08:00PM BLOOD Plt ___ ___ 08:00PM BLOOD ___ PTT-28.2 ___ ___ 08:00PM BLOOD Glucose-75 UreaN-5* Creat-0.6 Na-137 K-3.7 Cl-107 HCO3-16* AnGap-18 ___ 08:00PM BLOOD ALT-10 AST-18 AlkPhos-55 TotBili-0.2 ___ 08:00PM BLOOD Lipase-24 ___ 08:00PM BLOOD Albumin-3.5 Calcium-7.9* Phos-3.1 Mg-1.8 ___ 08:00PM BLOOD CRP-99.5* ___ 09:48PM BLOOD ___ pO2-38* pCO2-38 pH-7.32* calTCO2-20* Base XS--5 ___ 08:12PM BLOOD Lactate-0.6 ___ 09:48PM BLOOD O2 Sat-70 PERTINENT LABS: =============== ___ 08:00PM BLOOD ALT-10 AST-18 AlkPhos-55 TotBili-0.2 ___ 08:00PM BLOOD Lipase-24 ___ 06:14AM BLOOD calTIBC-235* Hapto-247* Ferritn-91 TRF-181* ___ 06:55AM BLOOD TSH-0.64 ___ 06:55AM BLOOD ANCA-Negative ___ 06:55AM BLOOD ___ dsDNA-Negative ___ 08:00PM BLOOD CRP-99.5* ___ 06:55AM BLOOD HIV Ab-Negative ___ 06:55AM BLOOD RO & LA-Negative ___ 06:55AM BLOOD ANGIOTENSIN 1 - CONVERTING ___ ___ 06:55AM BLOOD ACETYLCHOLINE RECEPTOR ANTIBODY-Negative ___ 08:00PM BLOOD SED RATE-34 CSF STUDIES: ============ ___ 03:00AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-0 ___ ___ 03:00AM CEREBROSPINAL FLUID (CSF) TotProt-33 Glucose-61 ___ 03:34PM CEREBROSPINAL FLUID (CSF) MULTIPLE SCLEROSIS (MS) PROFILE-No oligoclonal bands ___ 03:00AM CEREBROSPINAL FLUID (CSF) VARICELLA DNA (PCR)-NEGATIVE ___ 03:00AM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-NEGATIVE ___ 03:00AM CEREBROSPINAL FLUID (CSF) ___ VIRUS, QUAL TO QUANT, PCR-PND PERTINENT STUDIES/IMAGING: ========================== ___ CT NECK W/ CONTRAST: 1. Bilateral peritonsillar inflammation associated with tonsilliths, possibly early phlegmon, and a discrete 5 mm right peritonsillar abscess. 2. Right upper lobe early consolidation or aspiration. ___ MR ___ and W/O CONTRAST: IMPRESSION: Normal MRI of the thoracic spine. ___ MR CERVICAL SPINE W/O CONTRAST ___ OPINION: 1. No abnormal signal or enhancement within the cervical and lumbar spinal cord. 2. Normal MRI of the cervical spine. 3. Mild degenerative discogenic disease at L5-S1, which causes mild bilateral neural foraminal stenosis. No spinal canal stenosis. CXR (OSH): NAD MRI head +/- (OSH, ___: No acute infarct or abnormal enhancement. No epidural fluid collections. Scattered nonspecific T2 white matter foci. These finding may be due to demyelination, prior infectious or inflammatory etiologies, vasculitis, postmigraine changes or be idiopathic. MRI C/L spine +/- (OSH, ___: Minimal degenerative changes. No epidural fluid collections, abscesses or abnormal enhancement. MICRO: ====== ___ 6:55 am Blood (EBV) CHEM # ___. FINAL REPORT ___ ___ VIRUS VCA-IgG AB (Final ___: POSITIVE BY EIA. ___ VIRUS EBNA IgG AB (Final ___: POSITIVE BY EIA. ___ VIRUS VCA-IgM AB (Final ___: NEGATIVE <1:10 BY IFA. INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION. In most populations, 90% of adults have been infected at sometime with EBV and will have measurable VCA IgG and EBNA antibodies. Antibodies to EBNA develop ___ weeks after primary infection and remain present for life. Presence of VCA IgM antibodies indicates recent primary infection. ___ 6:55 am Blood (CMV AB) CHEM # ___. FINAL REPORT ___ CMV IgG ANTIBODY (Final ___: POSITIVE FOR CMV IgG ANTIBODY BY EIA. 27 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final ___: NEGATIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: INFECTION AT UNDETERMINED TIME. A positive IgG result generally indicates past exposure. Infection with CMV once contracted remains latent and may reactivate when immunity is compromised. Greatly elevated serum protein with IgG levels ___ mg/dl may cause interference with CMV IgM results. If current infection is suspected, submit follow-up serum in ___ weeks. ___ 10:00 am THROAT FOR STREP FINAL REPORT ___ GRAM STAIN- R/O THRUSH (Final ___: NO ___ ORGANISMS SEEN. NEGATIVE FOR YEAST. R/O Beta Strep Group A (Final ___: NO BETA STREPTOCOCCUS GROUP A FOUND. ___ 3:00 am CSF;SPINAL FLUID Source: LP. Enterovirus Culture (Preliminary): No Enterovirus isolated. ___ 3:00 am CSF;SPINAL FLUID Source: LP # 3. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ___ 8:00 pm SEROLOGY/BLOOD POURED OFF FROM ___. FINAL REPORT ___ ___ SEROLOGY (Final ___: NO ANTIBODY TO B. BURG___ DETECTED BY EIA. Reference Range: No antibody detected. Negative results do not rule out B. burgdorferi infection. Patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody. Patients with clinical history and/or symptoms suggestive of ___ disease should be retested in ___ weeks. ___ BLOOD CULTURE x2: NEGATIVE DISCHARGE LABS: =============== ___ 06:14AM BLOOD WBC-8.1 RBC-3.40* Hgb-10.3* Hct-31.1* MCV-92 MCH-30.3 MCHC-33.1 RDW-13.5 RDWSD-44.6 Plt ___ ___ 06:14AM BLOOD Plt ___ ___ 06:14AM BLOOD Glucose-83 UreaN-5* Creat-0.4 Na-141 K-4.1 Cl-105 HCO3-27 AnGap-13 ___ 06:14AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.1 Iron-55 Brief Hospital Course: ___ is a ___ year old woman who presents with neck stiffness, fevers, generalized weakness (near quadriplegia) and numbness. Brain imaging showed small non-enhancing white matter lesions, spine imaging wnl, with normal LP. CT showed very small peritonsilar abscess and tonsillitis and she was started on Unasyn. Her neurological exam normalized over time. Her CSF studies showed were mostly pending at discharge, but HSV was negative. She was treated with Unasyn and Switched to Amoxicillin for a 10 day course. # Neurological Findings: Initially concern for meningitis given stiff neck. She received brief treatment for meningitis. However, CSF was bland and meningitis coverage was discontinued. MRI of the C-T spine without acute findings. MRI brain with scattered nonspecific T2 white matter foci, which may be due to demyelination, prior infectious or inflammatory etiologies, vasculitis, postmigraine changes or be idiopathic. She was evaluated by neurology in the ED though the etiology of her findings remains unclear. Per neuro, resolving weakness in the setting of fever may be due to radiologically isolated syndrome. She will be seen in neurology clinic as outpatient. HIV negative. ___, ESR, CRP, Quant ___, Sjogren, ANCA, ESR, SLE antibodies, ACE, ACHR, MS panel ___ bands) were all negative. # Tonsillitis with small right peritonsillar abscess: Patient presented with sore throat and neck pain as well as painful cervical adenopathy. Patient reports long history of tonsillitis. Initially treated for meningitis coverage, found to have pus in tonsils on closer examination. CT Neck on ___ shows bilateral peritonsillar inflammation associated with tonsilliths, possibly early phlegmon, and a discrete 5 mm right peritonsillar abscess. On exam, patient is breathing comfortably, with no stridor and uvula midline. Per ENT, there is no discrete drainable collection at this time given size and position. She was treated with Unasyn while inpatient with a plan for oral amoxicillin for 10 day course (D1: ___. Right tonsil culture did not grow GAS. She will follow-up with ENT. # Fever: resolved. The etiology is most likely secondary to tonsillitis. CSF not consistent with meningitis as above. CT neck with evidence of RUL consolidation, though clinically and per history she does not have signs/symptoms of pneumonia. UA bland. Abdominal exam benign. She was treated as above. # Neck Stiffness: Initially concerning for meningitis, though as noted above CSF is not consistent. She has chronic neck pain at baseline. Multiple CSF studies are pending. Conservative treatment was done for neck pain including Tylenol and tramadol. # Dizziness: resolved. Patient noted dizziness, lightheadedness, with dull headache. Per patient, presentation consistent with symptoms when her diastolic BP at home <50. Concern for pre-syncope and orthostatic hypotension given history of hypotension and dizziness. Patient states she is baseline hypotensive, with undetermined etiology. Her orthostatics were negative and her dizziness resolved with eating (initially NPO). #Anemia: Patient presented with normocytic anemia at 10.6. Her iron studies significant for low reticulocyte index. A poor bone marrow response who be evaluated further. Transitional Issues: [ ] F/u pending CSF studies [ ] Anemia: inadequate bone marrow response with RI of 0.7, ferritin wnl, iron wnl--may need further work-up to evaluate inadequate bone marrow response. [ ] 10 day course of Antibiotics (Unasyn switched to Amoxicillin) Last day: ___ [ ] PCP to refer for ENT Follow-up [ ] PCP to refer for Neurology follow-up # CODE: Full # CONTACT: Husband ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. FLUoxetine 20 mg PO DAILY 2. Cyclobenzaprine 10 mg PO TID:PRN neck stiffness Discharge Medications: 1. FLUoxetine 20 mg PO DAILY 2. Cyclobenzaprine 10 mg PO TID:PRN neck stiffness 3. Amoxicillin 500 mg PO Q12H RX amoxicillin 500 mg 1 capsule(s) by mouth Q12 Disp #13 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: Tonsillitis Parethesias Transient Quadriplegia Secondary: Chronic Low Back Pain, Neck Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You came to the hospital for a sore throat, fever, weakness and some numbness. We determined that this was not due to meningitis or a primary problem with the brain or the spinal cord. We found that your tonsils were inflamed and that you had a very small pocket of infection near your right tonsil. We treated you with antibiotics and you improved. Neurology recommended follow-up as an outpatient since your neurological findings resolved. The ear, nose, throat doctors recommended follow-up in ___ weeks. You should follow-up with your primary care physician and they ___ refer you to the ear-nose-throat doctor as well as the neurologist. It was a pleasure taking care of you, -Your ___ Team Followup Instructions: ___
10305245-DS-12	10,305,245	23,016,743	DS	12	2112-11-08 00:00:00	2112-11-08 20:31:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: weakness, fatigue, fever, nausea, diarrhea, and worsening abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ with minimal PMH with recent admission for ___ abcess who presents with generalized weakness, fatigue, fever, nausea, and worsening abdominal pain associated with myalgias. Per the husband (translated in ___, the patient had a full day yesterday, during which she did all her ADLs and felt generally well. She had diffuse lower quadrant pain, that seemed to have subsided with ___ bouts of watery diarrhea. This AM she felt increasingly weak and had trouble getting out of bed. She has not been able to eat anything, and has worsening nausea, but no emesis. She had T 100 in the ED, and has felt feverish today. She has no sick contacts, and has only traveled to ___. Patient was recently discharged from ___ on ___ following a similar presentation on ___. That admission she was treated for tonsillitis and RP abcess (though was not large enough to drain that admission and was to f/u with ENT as an outpatient.) After discharge, patient completed a 10 day course of abx and finished her Augmentin on ___. Today, exam and interview conducted with her husband acting as ___ in ED as she is ___ speaking only. All symptoms started when the patient woke up this AM. She initially had numbness in all of her extremities, however this has improved on arrival to the ED. Her main symptoms now are diffuse subjective weakness and fatigue. She has no sore throat or neck pain. During the last admission (___), the patient presented with neck stiffness, fevers, generalized weakness (near quadriplegia) and numbness. Brain imaging showed small non-enhancing white matter lesions, spine imaging wnl, with normal LP. CT showed very small peritonsilar abscess and tonsillitis and she was started on Unasyn. Her neurological exam normalized over time. She had LP, concern for meningitis, though CSF studies were negative for MS, VZV, HSV 1 and 2, and EBV. She was treated with Unasyn and switched to Amoxicillin for a ___uring her last admission, all of the following testing was negative: HIV, Lyme, ___, ESR, Quant ___, Sjogren, ANCA, ESR, SLE antibodies, ACE, ACHR, MS panel ___ bands), CMV, EBV, varicella. CRP was sig elevated, though non-specific. In the ED, initial vital signs were: 100.0 96 92/56 16 96% RA Exam notable for Labs were notable for WBC 22.2 neutrophil predominant, H/H 10.5/31.8 Patient was given Tylenol 1 g, 1 L NS On Transfer Vitals were: T 98.6 BP 88/42 P 80 R 18 SatO2 100/RA Past Medical History: Lower back and neck pain for years Post-partum depression Per husband, no history of TB Social History: ___ Family History: No family history of neurologic disease or auto-immune disease. Mother with pre-diabetes. Father with arthritis. Physical Exam: PHYSICAL EXAM on ADMISSION: Vitals: Tm 98.6 BP 88/42 P 80 R 18 SatO2 100/RA General: pale, ill-appearing young woman in pain HEENT: ___, anicteric sclera, dry mucosa Lymph: deferred CV: RR, no murmurs, rubs, or gallops Lungs: CTAB Abdomen: thin, soft, guarding, tender to palpation over lower quadrants and periumbilical, exquisitely tender over RLQ, positive Rovsing Ext: no edema or cyanosis Neuro: AOx3, rest of neuro exam deferred Skin: no rashes PHYSICAL EXAM on DISCHARGE: Vitals: Tc 98.2 BP 97/65 HR 66 RR 16 SaO2 98% on RA General: In no acute distress, ambulating around the room HEENT: PERRL, anicteric sclera CV: RRR, no murmurs, rubs, or gallops Lungs: CTAB Abdomen: Soft, nondistended, mildly tender diffusely, hyperactive bowel sounds, no guarding or rebound. Ext: no edema or cyanosis Neuro: AOx3, CN ___ intact, ___ strength in all extremities Pertinent Results: Labs on ADMISSION: ___ 01:31PM BLOOD WBC-22.2# RBC-3.40 Hgb-10.5* Hct-31.8* MCV-94 MCH-30.9 MCHC-33.0 RDW-13.1 RDWSD-44.3 Plt ___ ___ 01:31PM BLOOD Neuts-91.5* Lymphs-5.2* Monos-1.8* Eos-0.1* Baso-0.3 Im ___ AbsNeut-20.35# AbsLymp-1.16 AbsMono-0.39 AbsEos-0.02* AbsBaso-0.06 ___ 08:05PM BLOOD Neuts-90* Bands-2 Lymphs-6* Monos-2* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-24.01* AbsLymp-1.57 AbsMono-0.52 AbsEos-0.00* AbsBaso-0.00* ___ 08:05PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 01:31PM BLOOD Plt ___ ___ 08:05PM BLOOD ___ PTT-24.8* ___ ___ 08:05PM BLOOD Plt Smr-NORMAL Plt ___ ___ 01:31PM BLOOD Glucose-87 UreaN-8 Creat-0.7 Na-138 K-3.6 Cl-104 HCO3-23 AnGap-15 ___ 08:05PM BLOOD Glucose-87 UreaN-7 Creat-0.6 Na-139 K-3.9 Cl-107 HCO3-20* AnGap-16 ___ 01:31PM BLOOD ALT-22 AST-20 AlkPhos-60 TotBili-0.7 ___ 08:05PM BLOOD ALT-21 AST-17 AlkPhos-57 TotBili-0.6 ___ 01:31PM BLOOD Lipase-27 ___ 01:31PM BLOOD Albumin-4.1 ___ 08:05PM BLOOD Calcium-8.3* Phos-3.0 Mg-1.5* ___ 08:24PM BLOOD ___ pO2-53* pCO2-40 pH-7.33* calTCO2-22 Base XS--4 Comment-GREEN TOP ___ 01:32PM BLOOD Lactate-1.4 LABS on DISCHARGE: ___ 07:53AM BLOOD WBC-6.9 RBC-2.96* Hgb-8.9* Hct-27.3* MCV-92 MCH-30.1 MCHC-32.6 RDW-13.6 RDWSD-45.8 Plt ___ ___ 07:53AM BLOOD Plt ___ ___ 07:53AM BLOOD Glucose-88 UreaN-4* Creat-0.5 Na-139 K-3.6 Cl-104 HCO3-24 AnGap-15 ___ 07:53AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.7 OTHER PERTINENT LABS: ___ 08:10AM BLOOD calTIBC-221* Hapto-213* Ferritn-130 TRF-170* ___ 08:10AM BLOOD Cortsol-22.4* Blood cultures (___) pending MICROBIOLOGY/STUDIES: - Stool cultures: ___ 12:53 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. C. difficile DNA amplification assay (Final ___: Reported to and read back by ___ ___ ___ 9AM. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). FECAL CULTURE (Preliminary): CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Preliminary): FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Preliminary): Norovirus negative Brief Hospital Course: ___ with PMH of neck stiffness, fevers, generalized weakness, and numbness, found to have ___ abscess during recent admission (___), s/p 10-day course of amoxicillin, with an extensive recent work-up that was negative for an infectious, inflammatory, or neurological etiology, who presented with weakness, fatigue, fever, nausea, worsening abdominal pain and runny diarrhea concerning for acute appendicitis vs ovarian torsion/ruptured cyst vs colitis/ileitis, with CT showing no inflamed appendix and a thickened descending colon concerning for infectious colitis, found to be C. diff positive. ACTIVE ISSUES: # C Diff colitis: CDiff positive on ___. Improved on PO vancomycin; leukocytosis and fever resolved. The patient had lower quadrant abdominal pain on ___, followed by ___ bouts of watery diarrhea, with subsiding pain afterward. She had nausea, increasing abdominal pain, and fever on ___, found to have WBC of 22 increasing to 26.1. CT abdomen/pelvis did not show an inflamed appendix, but a thickened descending colon concerning for infectious colitis in the setting of recent course of amoxicillin for 10 days. No immediate intervention by Surgery. Norovirus negative. Discharged on PO Vancomycin 125 Q6H, plan for ___nemia: Stable. Patient presented with normocytic anemia H/H 10.___.8. Her iron studies during last admission were significant for low reticulocyte index. A poor bone marrow needs to be further evaluated. During this admission, repeat retic was 1.3, iron 11, TIBC 221 (L), ferritin 130 (wnl), TRF 170 (L), which appears to suggest at mixed iron deficiency anemia and anemia of chronic disease. Follow-up as an outpatient to further work-up anemia. CHRONIC ISSUES: # Post-Partum Depression: Mood improved. Unclear Psychiatric history at this point. Per ___ interpreter, the patient was recently admitted to the ___ for a psychiatric issue. TSH 0.64 (wnl). RANSITIONAL ISSUES: - Follow up with PCP (___) - Recommend further discussion with and monitoring by PCP regarding the patient's intermittent numbness on her hands. - Last day of PO vancomycin on ___ - Please f/u pending blood cultures # Code: FULL # Emergency Contact: ___, husband, Phone: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. FLUoxetine 20 mg PO DAILY 2. Cyclobenzaprine 10 mg PO TID:PRN neck pain Discharge Medications: 1. FLUoxetine 20 mg PO DAILY 2. Cyclobenzaprine 10 mg PO TID:PRN neck pain 3. Vancomycin Oral Liquid ___ mg PO Q6H Last day on ___. RX vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours Disp #47 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: Colitis Secondary: ___ abscess post-partum depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___. You were admitted because you had worsening weakness, abdominal pain, diarrhea, and fever. Further work up showed that you did not have appendicitis (swelling of the appendix), but you do appear to have an infection in your colon. Your stool was sent to the lab we found that you have a bacterial infection of your stool called C. diff. You will required treatment of your infection with an antibiotic called vancomycin. Please continue to take this antibiotic for 14 days (last day ___. Please follow up with your primary care doctor ___ below). We wish you the best, Your ___ team Followup Instructions: ___
10305417-DS-15	10,305,417	28,146,124	DS	15	2178-06-07 00:00:00	2178-06-07 15:35:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / latex / nuts / shrimp / Barium Iodide Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with previous history of pancreatitis, C. difficile colitis presents with two days of epigastric pain. She states that the pain is located in the epigastric area and radiates to the back. It is worse when sitting forward. She has been nauseous but has not vomited. She reports diarrhea for the last two days, about 8 watery stools per day, with no blood or mucus. The day preceding the pain, she at cold cereal and a fried meat pie, fully cooked. There are no fevers, but she has had some chills. Only recent travel has been to ___. She is dogsitting currently one dog. No one is currently sick around her. In the ED, initial vitals were 98.2 88 124/87 16 99%RA. She received 1 liter NS. Labs showed no abnormality except for mildly elevated lipase at 66. She received morphine 5 mg IV x 2, acetaminophen 325 mg x 1, ondansetron 2 mg x 1, and hyoscyamine 0.125 mg x 1. UA was unremarkable. Vitals on transfer were 98.0 78 121/85 16 100%RA. Currently, patient reports ___ abdominal pain, with no nausea. Review of sytems: (+) Per HPI (-) Denies fever, 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. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Ten point review of systems is otherwise negative. Past Medical History: PAST MEDICAL HISTORY: Peptic ulcer disease Kidney stones h/o Helicobacter pylori Migraines Fibromyalgia Allergic rhinitis Vitamin D deficiency Social History: ___ Family History: Mother LUNG CANCER ___ STOMACH CANCER MGM BREAST CANCER Physical Exam: ADMISSION EXAM: Vitals: T: 98.0 BP: 122/64 P: 68 R: 20 O2: 100%RA GEN: Alert, oriented to name, place and situation. Fatigued appearing but comfortable, no acute signs of distress. HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric, o/p clear, MMM. Neck: Supple, no JVD Lymph nodes: No cervical, supraclavicular LAD. CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. RESP: Good air movement bilaterally, no rhonchi or wheezing. ABD: Soft, moderately tender in epigastric area, no rebound or guarding, non-distended, + bowel sounds. EXTR: No lower leg edema, no clubbing or cyanosis DERM: No active rash. Neuro: non-focal. PSYCH: Appropriate and calm. DISCHARGE EXAM: VS: T 97.8 BP 110/70 P 76 R 18 Sat 96%RA GEN: Alert, oriented to name, place and situation. Fatigued appearing but comfortable, no acute signs of distress. HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric, o/p clear, MMM. Neck: Supple, no JVD, no thyromegaly. Lymph nodes: No cervical, supraclavicular or axillary LAD. CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. RESP: Good air movement bilaterally, no rhonchi or wheezing. ABD: Soft, mildly tender in epigastric area, non-distended, + bowel sounds. EXTR: No lower leg edema, no clubbing or cyanosis DERM: No active rash. Neuro: Cranial nerves ___ grossly intact, muscle strength ___ in all major muscle groups, sensation to light touch intact, non-focal. PSYCH: Appropriate and calm. Pertinent Results: ADMISSION LABS -------------- ___ 05:45PM BLOOD WBC-6.0 RBC-4.22 Hgb-13.6 Hct-38.8 MCV-92 MCH-32.1* MCHC-35.0 RDW-12.7 Plt ___ ___ 05:45PM BLOOD Glucose-98 UreaN-12 Creat-0.7 Na-141 K-4.1 Cl-108 HCO3-24 AnGap-13 ___ 07:20AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.5 ___ 06:02PM BLOOD Lactate-1.4 DISCHARGE LABS -------------- ___ 07:20AM BLOOD WBC-5.0 RBC-4.22 Hgb-13.4 Hct-38.8 MCV-92 MCH-31.7 MCHC-34.4 RDW-12.7 Plt ___ ___ 07:20AM BLOOD Glucose-93 UreaN-12 Creat-0.7 Na-141 K-4.4 Cl-106 HCO3-24 AnGap-15 ___ 07:20AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.5 IMAGING ------- CT abdomen/pelvis ___: No acute pathology in the abdomen or pelvis. MICROBIOLOGY ------------ Urine culture ___: no growth Blood culture ___: pending Brief Hospital Course: ___ year old female with previous history of pancreatitis, C. difficile colitis presents with two days of epigastric pain. ACTIVE ISSUES ------------- # Abdominal pain: associated with diarrhea and nausea. Has history of pancreatitis and C. difficile colitis. Lipase mildly elevated at 66. Patient had no recent sick contacts. Labs were otherwise unremarkable. No suspicious travel was reported. There was no blood in the stools, and the patient reported ___ loose stools daily for a few days before admission. UA was unremarkable, and urine culture was negative. H. pylori breath test was recently negative as an outpatient. CT abdomen/pelvis was unremarkable. Diet was advanced to a full diet. Her home dicyclomine dose was increased with improvement in her pain. Her home acetaminophen, cyclobenzaprine, simethicone and amitriptyline were continued. C. diff PCR was ordered, but patient did not have a bowel movement during admission, so it was considered that recurrent C. difficile was unlikely. Home omeprazole and ranitidine was continued. Etiology was likely viral gastroenteritis or irritable bowel syndrome related to previous gastroenteritis episodes. She will follow up with Gastroenterology and her PCP upon discharge. INACTIVE ISSUES --------------- # Fibromyalgia: pain medications were administered as above, as well as home cyclobenzaprine. # Vitamin D deficiency: patient was continued on her home calcium/Vitamin D TRANSITIONS OF CARE ------------------- # Follow-up: patient will follow up with her gastroenterologist and her PCP. There is a pending blood culture at discharge, which will be followed up. # Code status: Full code, confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen ___ mg PO Q6H:PRN fever/pain 2. Calcium Carbonate 500 mg PO QID:PRN indigestion 3. Omeprazole 40 mg PO BID 4. Ranitidine 300 mg PO DAILY 5. Simethicone 40-80 mg PO QID:PRN Bloating 6. Vitamin D 400 UNIT PO DAILY 7. DiCYCLOmine 10 mg PO TID 8. Cyclobenzaprine 5 mg PO TID 9. Amitriptyline 25 mg PO HS Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN fever/pain 2. Amitriptyline 25 mg PO HS 3. Calcium Carbonate 500 mg PO QID:PRN indigestion 4. Cyclobenzaprine 5 mg PO TID 5. DiCYCLOmine 20 mg PO TID RX dicyclomine 20 mg 1 tablet(s) by mouth three times a day Disp #42 Tablet Refills:*0 6. Omeprazole 40 mg PO BID 7. Ranitidine 300 mg PO DAILY 8. Simethicone 40-80 mg PO QID:PRN Bloating 9. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Viral gastroenteritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at the ___. You came for further evaluation of abdominal pain. Further studies failed to uncover a cause for your pain, though it is likely this is either related to viral gastroenteritis, or irritable bowel syndrome related to your previous abdominal infection. You are now eating a regular diet with improved pain, and will be returning home. It is important that you continue to take your medications as prescribed and follow up with the appointments listed below. Good luck! Followup Instructions: ___
10305417-DS-17	10,305,417	20,504,563	DS	17	2179-01-24 00:00:00	2179-01-24 18:53:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / latex / nuts / shrimp / Barium Iodide Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMH significant for h/o multiple hernia repairs, nephrolithiasis and PID s/p abx treatement who presents with abdominal pain for 2 days. The pain is localized to the umbilican region but also radiates to her lower abdomen. The pain is constant, but waxes and wanes. She describes it as sharp. The patient describes subjective chills, nausea, NBNB vomiting, and diarrhea. The diarrhea started as loose but today became watery. She estimates over >20 BMs today. She also complains of stool incontinance. She reports bright red blood with wiping. She reports this is similar when she had C. diff, and possibly pelvic inflammatory disease. She is only sexually active with her husband. She denies any recent antibiotic use and no new medications. Of note, she was recently admitted from ___ with abdominal pain across the lower abdomen. She underwent transvaginal and renal US w/o clear explanation for the pain. A GYN exam was performed demonstrating yellow discharge, but no cervical motion tenderness. Her pain improved on opiates. She was also continued on doxycycline (total 10 day course) that was prescribed at ___ ED for presumed pelvic inflammatory disease. She was discharged with a small amount of opiates for severe pain with follow-up with her PCP. In the ED, initial vitals were: T98.2 P72 BP145/116 RR22 RA96%. Pelvic exam did not reveal any cervical motion tenderness. Labs were significant for normal LFTs, lipase, WBC. Pelvic ultrasound was obtained, which showed no evidence of a pelvic abscess, but did show an increased size of a now 4.8 cm right ovarian thin-walled cyst on prelim read. RUQ ultrasound was also obtained and was normal. Surgery was consulted, who felt that there were no surgical issue identified. VS upon transfer are: T98.4 P67 BP135/95 RR14 99% RA. On the floor, patient continued to complain of severe abdominal pain, mostly localized to her epigastric area. She had also vomitied nonbloody, nonbilious emesis. Review of systems: (+) Per HPI (-) Denies headache, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies constipation. No dysuria. Past Medical History: H/o C diff secondary to antibiotics, diagnosed on colonoscopy H/o acute pancreatitis H/o H. pylori s/p antibiotics H/o nephrocalcinosis H/o PID s/p treatment with doxycycline H/o viral gastroenteritis Chronic right shoulder pain ___ injury S/p hernia repair Abnormal pap smear s/p LEEP Vitamin D deficiency Asthma Social History: ___ Family History: Mother: ___ infarction, lung cancer. MGM: Ovarian cancer. GF: Stomach cancer Physical Exam: ON ADMISSION: ==================================== Vitals: T98.0 BP133/94 P69 RR22 100%RA ___: Appears uncomfortable, fatigued, no acute distress. HEENT: Scleral anicteric, moist mucous membranes, oropharynx clear. Neck: Supple, no cervical lymphadenopathy. CV: Regular rate and rhythm, normal S1, S2. No S3, S4. No murmurs. Lungs: Clear to auscultation bilaterally. Back: + Rt CVA tenderness. Abdomen: Hyperactive bowel sounds, soft, nondistended. Tender to palpation in the epigastric area with voluntary guarding. No rebound tenderness. No hernia palpated. GU: Deferred. Ext: Warm and well perfused. Pulses 2+. No peripheral edema. Neuro: Grossly intact. Skin: No rashes or ecchymosis. ON DISCHARGE: ====================================== Vitals:T98.1 BP135/97 P64 RR20 98RA ___: Appears comfortable, pleasant, no acute distress. HEENT: Scleral anicteric, moist mucous membranes, oropharynx clear. Neck: Supple, no cervical lymphadenopathy. CV: Regular rate and rhythm, normal S1, S2. No S3, S4. No murmurs. Lungs: Clear to auscultation bilaterally. Back: + Rt CVA tenderness. Abdomen: Normoactive bowel sounds. Soft, nondistended, tender to palpation in the epigastric area with voluntary guarding. No rebound tenderness. GU: Deferred. Ext: Warm and well perfused. Pulses 2+. No peripheral edema. Neuro: Grossly intact. Skin: No rashes or ecchymosis. Pertinent Results: ON ADMISSION: =================================== ___ 12:45PM BLOOD WBC-6.3 RBC-4.17* Hgb-13.4 Hct-38.8 MCV-93 MCH-32.2* MCHC-34.6 RDW-12.6 Plt ___ ___ 12:45PM BLOOD Neuts-66.9 ___ Monos-3.7 Eos-2.5 Baso-0.8 ___ 12:45PM BLOOD Glucose-92 UreaN-15 Creat-0.6 Na-138 K-3.9 Cl-106 HCO3-23 AnGap-13 ___ 12:45PM BLOOD ALT-17 AST-24 AlkPhos-49 TotBili-0.2 ON DISCHARGE: ==================================== ___ 06:15AM BLOOD WBC-5.2 RBC-4.02* Hgb-12.5 Hct-38.0 MCV-95 MCH-31.1 MCHC-32.8 RDW-13.1 Plt ___ ___ 06:15AM BLOOD Glucose-79 UreaN-11 Creat-0.6 Na-137 K-4.0 Cl-107 HCO3-24 AnGap-10 ___ 06:15AM BLOOD Calcium-8.1* Phos-2.7 Mg-2.0 URINE: ==================================== ___ 02:30PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 02:30PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 02:30PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-10 MICROBIOLOGY: ==================================== Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by PANTHER System, APTIMA COMBO 2 Assay. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae by PANTHER System, APTIMA COMBO 2 Assay. C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). STUDIES: ==================================== PELVIC US( ___ 1. No evidence of a pelvic abscess. 2. Increased size of a now 4.8 cm right ovarian thin-walled cyst. No imaging follow up is required given this patient's premenopausal status. RUQ US (___) The liver is normal in echotexture and echogenicity. No focal liver lesions are identified. There is no intra or extrahepatic biliary duct dilatation, with the common duct measuring 2 mm. The portal vein is patent, with normal hepatopetal flow. The gallbladder is unremarkable. The pancreas is within normal limits. The right kidney measures 11.1 cm and the left kidney measures 11.8 cm. The kidneys are grossly normal in appearance. The spleen is normal in size, measuring 8.9 cm. The abdominal aorta is normal in caliber. Limited assessment of the IVC is unremarkable. There is no free fluid in the abdomen. IMPRESSION: Normal abdominal ultrasound Brief Hospital Course: ___ with PMH significant for h/o Clostridium difficile, pelvic inflammatory disease, h/o pancreatitis, who presents with 2 days of abdominal pain. # Viral gastroenteritis: The patient's presenting symptoms of abdomianl pain associated with nausea, vomiting, and diarrhea were consistent with the diagnosis of viral gastroenteritis. Differential diagnosis included Clostridium difficile and pelvic inflammatory disease. C difficile was negatie. Pelvic inflammatory disease was considered as the patient described similar pain with her previous diagnosis of PID. However pelvic exam in the ED did not reveal any cervical motion tenderness. Chlamydia and gonorrhea vaginal swabs later returned negative. The patient was treated with IV fluids and managed symptomatically with oxycodone and zofran. Her symptoms improved on day 2 of hospitalization, and she was able to tolerate PO without any difficulty. # Hypertension: The patient's diastolic blood pressure was consistently >90mmHg. She denied any headaches, chest pain, and shortness of breath. Consider monitoring once her acute illness resolves. # Chronic pain: The patient only complained of right shoulder pain secondary to fall. She was continued on her home medications of amitryptiline, cyclobenzarine, and lyrica. # GERD: Asymptomatic. She was continued on omeprazole and ranitidine. TRANSITIONAL ISSUES: - Diastolic blood pressure >90 during hospitalization. Please monitor when acute illness resolves. - Follow up other stool studies. - Consider discontinuing omeprazole to reduce risk of recurrent C difficile. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Pregabalin 50 mg PO BID 3. Pregabalin 100 mg PO HS 4. Simethicone 40-80 mg PO QID:PRN gas, bloating 5. DiCYCLOmine 20 mg PO TID 6. Ibuprofen 600 mg PO Q6H:PRN pain/cramping 7. Cyclobenzaprine 5 mg PO TID 8. Ranitidine 300 mg PO HS 9. Omeprazole 40 mg PO BID 10. albuterol sulfate 90 mcg/actuation inhalation Q4-6H SOB 11. Amitriptyline 100 mg PO HS Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Amitriptyline 100 mg PO HS 3. Cyclobenzaprine 5 mg PO TID 4. Omeprazole 40 mg PO BID 5. Pregabalin 50 mg PO BID 6. Pregabalin 100 mg PO HS 7. Ranitidine 300 mg PO HS 8. Simethicone 40-80 mg PO QID:PRN gas, bloating 9. albuterol sulfate 90 mcg/actuation INHALATION Q4-6H SOB 10. DiCYCLOmine 20 mg PO TID 11. Ibuprofen 600 mg PO Q6H:PRN pain/cramping 12. Ondansetron 8 mg PO Q8H:PRN nausea RX ondansetron 4 mg ___ tablet(s) by mouth every eight (8) hours Disp #10 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Viral gastroenteritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at ___ ___. As you recall, you were admitted for nausea, vomiting, abdominal pain, and diarrhea. Your labs and imaging were all normal. Your stool studies were negative for Clostridium difficile. We believe your symptoms are due to a viral infection, which is treated with supportive management. We gave you IV fluids and medications for pain and nausea. Please see below for medication changes and follow up appointments. We are glad you are feeling better and we wish you the best! Followup Instructions: ___
10305417-DS-18	10,305,417	21,170,834	DS	18	2179-12-22 00:00:00	2179-12-24 20:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / latex / nuts / shrimp / Barium Iodide Attending: ___. Chief Complaint: Abdominal pain, nausea/vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman with a past medical history significant for migraine headaches, functional dyspepsia, constipation-predominant IBS, gastritis, and C. diff colitis who presents with 7 days of LLQ abdominal pain. She was seen at the ___ on ___ for similar symptoms. CT A/P showed no acute process and she was discharged on empiric C. diff treatment, though no stool sample was sent. TVUS on ___ revealed a 1.5 follicular cyst on the left ovary. She was seen by her PCP on the day of presentation, and antibiotics were stopped as her diarrhea had subsided. After returning home, patient developed acute worsening of her LLQ pain and had one episode of large volume black "tarry" stool. She also reports intermittent nausea and NBNB vomiting. She reports chills and lightheadedness on standing. She also reports heavy menses, for which her PCP prescribed medroxyprogesterone (she did not start it). She denies fever, chest pain, or dyspnea. She was referred to the ___ by her PCP. In the ___, initial VS were: T 99 HR 90 P ___ RR 22 SaO2 95%. Exam was notable for tenderness to palpation in LUQ and epigastrium, guaiac negative. CBC and chem 7 unremarkable (H/H 13.7/38.8, baseline Hgb ___. UA revealed trace blood, otherwise unremarkable, LFTs normal other than mildly elevated AST 45 (though hemolyzed). Patient received morphine, oxycodone, zofran, pantoprazole, and dicyclomine. On the floor, patient continues ___ LLQ pain. She also reports a severe headache consistent with her migraines. Past Medical History: H/o C diff secondary to antibiotics, diagnosed on colonoscopy H/o acute pancreatitis H/o H. pylori s/p antibiotics H/o nephrocalcinosis H/o PID s/p treatment with doxycycline H/o viral gastroenteritis Chronic right shoulder pain ___ injury S/p hernia repair S/p appendectomy Abnormal pap smear s/p LEEP Vitamin D deficiency Asthma Social History: ___ Family History: Mother: ___ infarction, lung cancer. MGM: Ovarian cancer. GF: Stomach cancer Physical Exam: ADMISSION EXAM: ================ Vital Signs: T 98.4, HR 68, BP 134/91, RR 18, SaO2 100% RA General: Alert, oriented, appears uncomfortable at times but 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: +BS, soft, mildly distended, tender to palpation in periumbilical region and LLQ, +voluntary guarding, no rebound, no organomegaly GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Grossly intact, moving all extremities with purpose DISCHARGE EXAM: ================ Vital Signs: T 98.1, HR 66, BP 100/64, RR 20, SaO2 97% RA General: Alert, oriented, appears uncomfortable at times but 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: +BS, soft, mildly distended, mild LLQ tenderness to palpation without rebound or guarding, no organomegaly GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Grossly intact, moving all extremities with purpose Pertinent Results: ADMISSION LABS: ================ ___ 12:02AM BLOOD WBC-9.2# RBC-4.62 Hgb-14.8 Hct-40.7 MCV-88 MCH-32.0 MCHC-36.3* RDW-13.0 Plt ___ ___ 12:02AM BLOOD Neuts-70.5* ___ Monos-4.3 Eos-1.7 Baso-0.4 ___ 12:02AM BLOOD ___ PTT-29.3 ___ ___ 12:02AM BLOOD Glucose-112* UreaN-20 Creat-0.8 Na-138 K-4.9 Cl-105 HCO3-25 AnGap-13 ___ 12:02AM BLOOD ALT-37 AST-45* AlkPhos-68 TotBili-0.1 ___ 12:02AM BLOOD Lipase-45 ___ 12:02AM BLOOD Albumin-4.3 ___ 12:09AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.8 INTERIM LABS: ============== ___ 12:21AM BLOOD Lactate-1.0 ___ 12:09AM BLOOD cTropnT-<0.01 DISCHARGE LABS: ================ ___ 08:00AM BLOOD WBC-4.2 RBC-4.11* Hgb-13.1 Hct-36.3 MCV-89 MCH-31.8 MCHC-36.0* RDW-13.5 Plt ___ ___ 08:00AM BLOOD Glucose-90 UreaN-15 Creat-0.7 Na-141 K-4.2 Cl-107 HCO3-26 AnGap-12 ___ 08:00AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0 IMAGING: ========= CT Abdomen/Pelvis (___): 1. Thickening of the bowel wall in the descending and sigmoid colon is likely due in part to underdistention, although a mild colitis is not excluded. 2. 1.6 cm left paraovarian or exophytic ovarian cyst. 3. No evidence of tubo-ovarian abscess or hydrosalpinx. Pelvic Ultrasound (___): 1. Unremarkable pelvic ultrasound. 2. Stable appearing anechoic cyst in left ovary, consistent with normal follicular activity. KUB (___): Gas is seen in nondilated loops of both small and large bowel. There is no evidence of obstruction or free intraperitoneal air. A few pelvic phleboliths are re- demonstrated. There is stool within the right colon and rectum. MICROBIOLOGY: ============== Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by PANTHER System, APTIMA COMBO 2 Assay. Validated for use on Urine Samples by the ___ Microbiology Laboratory. Performance characteristics on urine samples were found to be equivalent to those of FDA- approved TIGRIS APTIMA COMBO 2 and/or COBAS Amplicor methods. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae by ___ System, APTIMA COMBO 2 Assay. Validated for use on Urine Samples by the ___ Microbiology Laboratory. Performance characteristics on urine samples were found to be equivalent to those of FDA- approved TIGRIS APTIMA COMBO 2 and/or COBAS Amplicor methods. URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Brief Hospital Course: Ms. ___ is a ___ woman with a past medical history significant for migraine headaches, functional dyspepsia, constipation-predominant IBS, gastritis, and C. diff colitis who presented with 7 days of LLQ abdominal pain. # Abdominal pain: Patient reported 7 days of LLQ pain, acutely worsened prior to admission, and associated with intermittent nausea/vomiting and diarrhea. Basic labs, including LFTs and lipase, were normal. Urine HCG was negative. Imaging included KUB (which was negative for obstruction), pelvic ultrasound (which showed no evidence of ovarian torsion or pelvic pathology), and CT A/P (which showed some bowel wall thickening likely secondary to underdistension). Due to concern for cervical motion tenderness on exam, she was briefly on ceftriaxone and doxycycline for PID, but these were discontinued prior to discharge. After discharge, urine GC/CT returned negative. Patient's pain was controlled with oxycodone and her nausea was controlled with Phenergan (per patient, Zofran ineffective). Home amitriptyline, dicyclomine, and pregabalin were continued. Patient had a few episodes of diarrhea but resolved before C. diff assay could be sent. # Melena: Patient reported an episode of black tarry stool on the evening prior to admission concerning for melena. H/H was normal (14.8/40.7 on admission) and remained stable. Patient was guaiac negative x 2. Home pantoprazole and ranitidine were continued. Patient did not have any recurrent melena. # Hypotension: Patient had an episode of hypotension (SBP dropped from 115 to 80) associated with bradycardia to ___. This was likely secondary to hypovolemia and/or increased vagal tone. Her blood pressure improved with IV fluids and remained stable thereafter. TRANSITIONAL ISSUES: ===================== None Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. ALPRAZolam 0.5 mg PO BID:PRN anxiety 3. Amitriptyline 50 mg PO QHS 4. DiCYCLOmine 20 mg PO TID 5. linaclotide 290 mcg oral DAILY 6. Meclizine 12.5 mg PO DAILY:PRN dizziness 7. MedroxyPROGESTERone Acetate 10 mg PO BID 8. OxycoDONE (Immediate Release) 5 mg PO QHS:PRN pain 9. Pantoprazole 40 mg PO Q12H 10. Pregabalin 150 mg PO BID 11. Ranitidine 300 mg PO QHS 12. Tizanidine 4 mg PO QHS Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. ALPRAZolam 0.5 mg PO BID:PRN anxiety 3. Amitriptyline 50 mg PO QHS 4. DiCYCLOmine 20 mg PO TID 5. Meclizine 12.5 mg PO DAILY:PRN dizziness 6. OxycoDONE (Immediate Release) 5 mg PO QHS:PRN pain 7. Pantoprazole 40 mg PO Q12H 8. Pregabalin 150 mg PO BID 9. Ranitidine 300 mg PO QHS 10. Tizanidine 4 mg PO QHS 11. linaclotide 290 mcg oral DAILY 12. MedroxyPROGESTERone Acetate 10 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: =================== Abdominal pain SECONDARY DIAGNOSES: ===================== Migraine headaches Irritable bowel syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you during your hospitalization at ___. You were admitted for abdominal pain and nausea/vomiting. Your labs were reassuring and multiple imaging studies, including a CT scan and a pelvic ultrasound, did not identify anything concerning. Due to concern for a pelvic infection, you were briefly treated with antibiotics. These were discontinued on discharge. Your pain and nausea were controlled with medications. You had an episode of black stool prior to admission concerning for possible bleeding, but your blood counts remained stable. We wish you good health! Sincerely, Your ___ Team Followup Instructions: ___
10305488-DS-7	10,305,488	26,986,783	DS	7	2112-05-07 00:00:00	2112-05-07 20:21:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: ___ h/o COPD (dependent on O2 on 2L), gout, recently dx dilated cardiomyopathy (EF 30%)and recent diagnosis of paroxysmal afib, newly on warfarin, transferred from ___ with CHF and question of NSTEMI. Patient complains of increasing DOE, "chest fluttering", leg swelling, cough, and PND over the past month. Denies any chest pain, nausea, diaphoresis, abdominal pain, lightheadedness, falls. Also over the past month he has been requiring oxygen while minimally active at home (Has COPD - usually only uses O2 when sleeping, at rest, or traveling outside of home). His PCP recently stopped his amlodipine and started him on lasix for the ___ swelling. Due to pesistent sx he had an echocardiogram performed at ___ on ___ which showed 30% EF (diffuse hypokinesis). Patient further states that in the past two weeks he was started on chronic anticoagulation with warfarin (5mg daily) for paroxysmal atrial fibrillation. He was referred to a cardiologist at ___ who saw him yesterday and felt he was volume overloaded so sent him to the ___. Patient decided to go home instead and go to the ER the next day. He presented to the ___ today. At ___, trop 0.8, EKG showed Afib with RVR and possible left bundle branch block (no record of prior EKGs at ___ but there may be one present at PCP ___. DUe to concern for NSTEMI, patient was transferred to ___ for further work-up. While at ___, he was started on heparin gtt, asa 325mg, plavix 300mg, metoprolol 25mg. In the ___ here, initial vitals were 97.2 96 168/106 20 90% 3L. Labs and imaging significant for A fib with RVR, HR 120s. EKG showed LBBB (unknown if new), BNP 1800. Patient was given lasix 20mg IV, metop 5mg IV x2, heparin gtt 1450 U. Pt admitted to cardiology service for acute systolic heart failure and ?NSTEMI. Vitals on transfer were 98.9 ___ 22 92% . On arrival to the floor VS were noted to be comfortable. Feels more SOB than he baseline (needs O2 to get to bathroom currently). Denies current CP, nausea, diaphoresis. REVIEW OF SYSTEMS On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: - Afib - Dilated cardiomyopathy (EF of 30%) diffuse hypokinesis. - COPD (on home O2) - Gout - HLD Social History: ___ Family History: Brother had heart issues and died suddenly in his ___. Grandfather died of a heart attack in his ___. No fam Hx DM, Stroke. Physical Exam: VS- Afebrile, HR 119, BP 150/78, RR 16, Sat 89% on 5L Wt 123kg GENERAL- NAD. Pleasant. Oriented x3. Mood, affect appropriate. HEENT- NCAT. Sclera anicteric. PERRL, EOMI. NECK- Supple with JVP of to earlobe sitting up CARDIAC- PMI located in ___ intercostal space, midclavicular line. IRIR rate that is fast, normal S1, S2. No m/r/g. No S3 or S4. LUNGS- crackles at bases (L>R), clear upper lungs with slightly increased expiratory phase and to accessory muscle use ABDOMEN- Soft, distended ___ to habitus. No HSM or tenderness. EXTREMITIES- 2+ pitting edema to mid-shins bilaterally, WWP SKIN- No stasis dermatitis, ulcers, scars. Skin abrasion in center chest PULSES- Right: DP 2+ ___ 2+ Left: DP 2+ ___ 2+ DISCHARGE EXAM VS: 98.9 BP 115/70 HR 103 RR 23 O2 88%4LNC Wt 115kg GENERAL- NAD. Pleasant. Oriented x3. Mood, affect appropriate. HEENT- NCAT. Sclera anicteric. PERRL, EOMI. NECK- Supple with JVP 12cm CARDIAC- Irregular, normal S1, S2. No m/r/g. No S3 or S4. LUNGS- crackles at bases (R>L), clear upper lungs. ABDOMEN- Soft, distended ___ to habitus. No HSM or tenderness. EXTREMITIES- 2+ pitting edema to mid-shins bilaterally, WWP SKIN- No stasis dermatitis, ulcers, scars. Skin abrasion in center chest PULSES- Right: DP 2+ ___ 2+ Left: DP 2+ ___ 2+ Pertinent Results: ___ 06:16AM BLOOD WBC-6.4 RBC-4.02* Hgb-13.9* Hct-41.3 MCV-103* MCH-34.6* MCHC-33.7 RDW-14.0 Plt ___ ___ 10:04PM BLOOD Glucose-109* UreaN-26* Creat-1.2 Na-142 K-3.9 Cl-103 HCO3-27 AnGap-16 ___ 04:56PM BLOOD ___ PTT-40.9* ___ ___ 04:56PM BLOOD proBNP-1835* ___ 07:42PM BLOOD cTropnT-0.10* ___ 10:04PM BLOOD CK-MB-6 cTropnT-0.11* ___ 06:16AM BLOOD CK-MB-5 cTropnT-0.11* Lipids: ___ 04:56PM BLOOD Triglyc-76 HDL-30 CHOL/HD-4.2 LDLcalc-81 Other Studies: ___ 06:16AM BLOOD TSH-3.8 ___ 06:16AM BLOOD VitB12-396 ___ 12:58PM BLOOD Folate-10.8 ___ 12:45PM BLOOD Ferritn-221 REPORTS EKG ___ Baseline artifact. The underlying rhythm is probably atrial fibrillation, although it is difficult to be certain. Left bundle-branch block. Low QRS voltges in the limb leads. No previous tracing available for comparison. CXR ___ Mild congestive heart failure with possible trace bilateral pleural effusions. Right Heart CATH ___ Hemodynamic Measurements (mmHg) Baseline SiteSysDiasEndMeanA WaveV WaveHR RA ___ ___ ___ ___ ___ ___ AO ___ ___ Findings ESTIMATED blood loss: <40 cc Hemodynamics (see above): 1-Moderately elevated left and right-sided filling pressures 2-Severely elevated pulmonary arterial blood pressure 3-Normal (lower range) cardiac output and cardiac index 4-Normal systemic arterial BP 5-No step-up or step-down in O2 saturation on shunt run Left Heart Cath ___ Coronary angiography: right dominant LMCA: Calcified, patent LAD: Calcified with 40-50% proximal beyond the takeoff- of a large diagonal branch. Overall, preserved vessel with mild luminal irregularities LCX: Large vessel giving a large OM branch RI: Smaller vessel without significant disease, which has 80% focal (napkin ring) lesion just beyond its origin. The AV groove circumflex is small and diffusely diseased. RCA: Difficult to engage with upward takeoff (Shepherd's crook) with severe diffuse calcific serial stenoses in the mid segment tapering to subtotal occlusion in one spot and 90% in another. The rest of the diseased segment is 70%. Left heart cath ___ Radiation Dosage Effective Equivalent Dose Index (mGy)___.40 Total Fluoro Time (minutes)57.6 Findings ESTIMATED blood loss: <70 cc Hemodynamics (see above): Normal systemic arterial BP Coronary angiography: right dominant LMCA, LAD, and LCX: Not imaged - see cath report ___ RCA: Severe diffuse calcific disease with severe sequential stenoses Interventional details Long ___ sheath into R CFA and short ___ sheath into R CFV under US and fluoroscopy guidance. Pacer wire positioned and capture confirmed (set at 80/2.5). Crossed with the Rota Floppy wire with ease. We then performed rotational atherectomy utilizing a 1.25 burr and performing three passes (160 kRPM x35, 55, 55 seconds) followed by two runs at 170 kRPM (35 and 25 seconds). At this point, it became apparent that the rotablator burr coupling had become disconnected and the device was then exchanged for a new 1.25 mm burr with three additional passes performed at 160 kRPM (55, 30, 30 sec). The patient tolerated the rotablation well without chest pain or hemodynamic compromise but did require intermittent temporary back-up pacing. Upon removal of the initial defective burr, we noted the shaft would not advance in response to the manual rotor advancer (both extracorporeal and in ___. Therefore, we will return the first set to the manufacturer. Upon repositioning the wire from the Marginal branch into the distal RCA, a nonflow-limiting dissection in the mid RCA at the origin of the (very large) AM branch. Eventually, we crossed into the distal RCA with a ChoICE Floppy wire and exchange over a 1.25 mm balloon (required a couple low pressure inflation to advance beyond the calcified and dissected bifurcation) for a ChoICE ___ Extra Support wire. We then performed additional dilatations with 2.0 balloon (to the dissected area) at 14 ATM. At this point, and given satisfactory result and improved flow throughout the RCA system, along with the radiation dose (due to patient's body habits and procedure length), we opted to terminate the procedure and evaluate the need to bring him back in 4 weeks. Meanwhile, I will see him in 1 month in follow up. The R CAF sheath was then removed and Perclose device utilized to close the arteriotomy site with adequate hemostasis. The patient left the cath lab free from angina and in stable condition. Views utilized during the procedure include ___ and ___. Briefly, ___ was used. Assessment & Recommendations 1.Successful rotational atherectomy of the proximal-mid RCA with 1.25 mm burr 2.Successful POBA of the distal RCA with 1.25, 1.5 and 2.0 balloons. 3.Nonflow-limited dissection in the distal RCA 4.Successful closure of the RCF arteriotomy with ___ Perclose with adequate hemostasis 5.ASA 325 mg daily and Clopidogrel 75 mg daily 6.Likely return to the lab in few weeks after dissection heals ___ with Dr ___ (see me in 4 weeks for post-procedure check) 8.Images discussed with Drs. ___ ___ LABS ___ 07:54AM BLOOD WBC-6.8 RBC-4.12* Hgb-14.7 Hct-42.2 MCV-103* MCH-35.6* MCHC-34.7 RDW-14.5 Plt ___ ___ 07:54AM BLOOD ___ PTT-51.9* ___ ___ 07:54AM BLOOD Glucose-164* UreaN-30* Creat-1.2 Na-139 K-4.2 Cl-102 HCO3-24 AnGap-17 ___ 06:16AM BLOOD ALT-23 AST-27 LD(LDH)-237 CK(CPK)-65 AlkPhos-97 TotBili-1.3 Brief Hospital Course: # Toponinemia: Elevated troponin at OSH of 0.8 and then 0.10->0.11->0.11 here with MB 6->5->4. EKG shows known LBBB. This is likely demand ischemia in the setting of Afib with RVR and wall stress from volume overload from heart failure. The patient underwent cardiac cath to assess cause of his cardiomyopathy, which showed severe 2 vessel disease with 90% RCA and 80% OM and highly calcified coronaries. The coronaries were difficult to engage, so the patient was brought back to the cath lab for rotational arterectomy. During the procedure, the rotablator burr coupling malfunctioned and was exchanged. Upon repositioning the wire from the marginal branch into the distal RCA, a nonflow-limiting dissection in the mid RCA at the origin of the AM branch was noted. The dissected area was dilated, and converted TIMI II to TIMI III flow. No stent was placed, and because of the radiation exposure, completion was deferred for 4 weeks. The patient tolerated the procedures well. He is discharged on aspirin 325, Plavix, atorva 80mg, metoprolol, and Irbesartan. He will have a stress perfusion scan before followup with Dr. ___ in 4 weeks. #Acute on chronic systolic heart failure: ___ records indicate EF 30% with diffuse dilated heart. His CAD makes the source most likely ischemic vs. tachycardia-induced from Afib. He was volume overloaded on admission and was effectively diuresed 8kg to a dry weight close to 115kg. Right heart cath showed mean PCWP 19mm Hg and PA systolic of 75 c/w left heart failure and chronic lung disease. The patient's oxygen requirement improved in house, satting 88% on RA on the day of discharge. However, he desatted to 80% while walking on 4LNC. He showed no labored breathing. He will followup with Dr. ___ in 2 weeks. His home diuretic was changed from 20mg lasix to 40mg torsemide. # A fib with RVR: Recent diagnosis, he was only on warfarin for a week prior to admission. His CHADS2 = 1. He was in Afib on admission, but converted to sinus on HD1. He went back into Afib on HD3, but this responded to metoprolol succinate 150mg and initiation of amiodarone 200mg TID. He converted back to normal sinus and remained NS during the 24 hours prior to discharge. His warfarin was held for the procedures and he was maintained on a heparin gtt. Warfarin was restarted two days prior to discaharge. # COPD: Secondary to 45 pack year smoking, PFT's from clinic showed FEV1/FVC 69, but DLCO of 9. The patient was maintained on his home nebs and albuterol. He was also started on amiodarone. While he has poor lung parenchymal reserve, his respiratory status is likely better served in the short term by improving his rhythm and atrial kick than it is at risk by amiodarone toxicity. However, this issue needs to be revisited over the coming weeks. TRANSITIONAL ISSUES: STARTED: -Torsemide 40mg -Plavix 75mg -ASA 325mg -Amiodarone 200mg TID for 7 days, BID for 9 days before followup with Dr. ___ ___: Atorvatastin is now 80mg daily Metoprolol succinate is now ___ daily Amiodarone toxicity with COPD must be reevaluated. Patient requires stress perfusion scan which is scheduled. Patient requires followup chem7 since he required daily K repletion in house on IV lasix. Patient requires INR management by PCP, confirmed with ___ ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Tartrate 50 mg PO BID 2. irbesartan NF 300 mg Oral QD 3. Atorvastatin 10 mg PO DAILY 4. Allopurinol ___ mg PO DAILY 5. Tiotropium Bromide 1 CAP IH DAILY 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 7. Omeprazole 10 mg PO DAILY 8. Warfarin 5 mg PO DAILY16 9. Furosemide 20 mg PO DAILY 10. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB 2. Atorvastatin 80 mg PO DAILY RX atorvastatin 80 mg 1 tablet(s) by mouth once daily Disp #30 Tablet Refills:0 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Tiotropium Bromide 1 CAP IH DAILY 5. Warfarin 5 mg PO DAILY16 6. Amiodarone 200 mg PO TID RX amiodarone 200 mg 1 tablet(s) by mouth three times daily Disp #60 Tablet Refills:0 7. Aspirin 325 mg PO DAILY RX aspirin 325 mg 1 tablet(s) by mouth once daily Disp #30 Tablet Refills:0 8. Clopidogrel 75 mg PO DAILY RX clopidogrel 75 mg 1 tablet(s) by mouth once daily Disp #30 Tablet Refills:0 9. Metoprolol Succinate XL 150 mg PO DAILY RX metoprolol succinate 100 mg 1 tablet(s) by mouth once daily Disp #30 Tablet Refills:0 RX metoprolol succinate 50 mg 1 tablet(s) by mouth once daily Disp #30 Tablet Refills:0 10. Torsemide 40 mg PO DAILY RX torsemide 20 mg 2 tablet(s) by mouth once daily Disp #60 Tablet Refills:0 11. Allopurinol ___ mg PO DAILY 12. irbesartan NF* 300 mg ORAL QD 13. Omeprazole 10 mg PO DAILY 14. Outpatient Lab Work Please obtain chem 7 on ___ and fax results to Dr. ___ at ___ 15. Outpatient Lab Work Please obtain INR on ___ and fax results to ___ at ___ Discharge Disposition: Home Discharge Diagnosis: Coronary artery disease Atrial fibrillation Systolic heart failure Chronic obstructive pulmonary disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure participating in your care at ___ ___. You were admitted with shortness of breath that was complicated by your atrial fibrillation. While you were here, the vessels supplying your heart were imaged and found to have some narrowing. One of these vessels was dilated and the flow was noted to improve. However, the procedure took a long time and it was determined that it was best to reduce your radiation exposure by postponing the placement of a stent. You are now taking aspirin and clopidogrel, which you must take every day. Do not stop taking aspirin or clopidogrel unless told to do so by your cardiologist. It is important that you weigh yourself every day. If your weight increases by more than 3 pounds, call your doctor. Also, avoid extra salt and canned foods, and please restrict your fluid intake to less than 2 liters daily. Finally, take your torsemide every day as directed. You will need to obtain a study of your heart called a stress perfusion scan. This appoinment has been arranged for you. You will need to have a blood draw at Dr. ___ this ___ to check your INR and blood chemistries. Followup Instructions: ___
10306714-DS-20	10,306,714	25,701,912	DS	20	2166-04-16 00:00:00	2166-04-16 21:46:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left leg, arm, and face numbness Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. ___ is a ___ yo man with history of multiple vascular risk factors and recent MI who presents with 10 minute episode of L hemibody numbness, for which Neurology is consulted. He woke up feeling well this morning and approximately noon, while standing still performing standing meditation, he noted acute onset of left leg numbness, followed by left arm numbness, followed by left face tingling. He describes the numbness, which was most prominent in the left leg, as "as if it was asleep", "I felt like I could not control it", denies pins/needles, denies weakness but states that if he placed more weight on the leg he may have fallen. This is associated with lightheadedness, not vertigo, and no palpitations. He was able to speak and comprehend speech, and had no other focal neurologic symptoms. The area of numbness in his left arm was more prominent along theulnar aspect of the lower arm. Past Medical History: MI ___ s/p stent on ASA and prasugrel 2 months of postnasal drip ADHD ED Social History: ___ Family History: No family history of migraine or seizures. Physical Exam: ADMISSION EXAM Vitals: T: 98.0 HR: 79 BP: 124/92 RR: 16 SaO2: 98% RA General: Awake, cooperative, NAD. HEENT: no scleral icterus, MMM, no oropharyngeal lesions. Pulmonary: Breathing comfortably, no tachypnea nor increased WOB Cardiac: Skin warm, well-perfused. Abdomen: soft, ND Extremities: Symmetric, no edema. Neurologic Examination: - Mental status: Awake, alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Speech is fluent with normal grammar and syntax. No paraphasic errors. Naming intact to low frequency words. Repetition intact. Comprehension intact to complex, cross-body commands. Normal prosody. Able to register 3 objects and recall ___ at 5 minutes. No apraxia. -Cranial Nerves: PERRL 3->2.5. VFF to confrontation. EOMI without nystagmus. Facial sensation intact to light touch. Face symmetric at rest and with activation. Hearing intact to conversation. Palate elevates symmetrically. ___ strength in trapezii bilaterally. Tongue protrudes in midline and moves briskly to each side. No dysarthria - Motor: Normal bulk and tone. No drift. No tremor nor asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 -DTRs: Bi Tri ___ Pat Ach Pec jerk Crossed Abductors L 2 2 2 2 2 R 2 2 2 2 2 Plantar response was flexor bilaterally. -Sensory: Proprioception intact BUE. Intact to LT, PP throughout. Proprioception intac to small excursions bilateral great toes. - Coordination: No dysmetria with finger to nose testing bilaterally. - Gait: deferred ============================================== DISCHARGE EXAM Vitals: T: 98.6 BP: 124/79 HR: 68 RR: 16 SaO2: 96% RA General: awake, cooperative, NAD HEENT: NC/AT, no scleral icterus noted Pulmonary: breathing comfortably, no tachypnea or increased WOB Cardiac: skin warm, well-perfused Extremities: symmetric, no edema Neurologic: -Mental Status: Alert, oriented x 3. Attentive, able to name days of week backward without difficulty. Language is fluent with intact repetition and comprehension. Able to follow both midline and appendicular commands. -Cranial Nerves: EOMI without nystagmus. Facial sensation intact to light touch. Face symmetric at rest and with activation. Hearing intact to finger rub bilaterally. Palate elevates symmetrically. ___ strength in trapezii bilaterally. Tongue protrudes in midline. -Motor: Normal bulk throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 R 5 ___ ___ 5 5 5 5 -Sensory: Intact to LT and PP throughout. No extinction to DSS. -DTRs: ___. -Coordination: No dysmetria or action tremor on FNF bilaterally. Pertinent Results: HEMATOLOGY ___ 05:50AM BLOOD WBC-7.3 RBC-5.00 Hgb-15.6 Hct-46.8 MCV-94 MCH-31.2 MCHC-33.3 RDW-12.8 RDWSD-43.3 Plt ___ ___ 05:50AM BLOOD ___ PTT-27.5 ___ ___ 05:50AM BLOOD Glucose-92 UreaN-17 Creat-1.2 Na-143 K-5.3* Cl-100 HCO3-26 AnGap-17* ___ 05:50AM BLOOD ALT-23 AST-25 AlkPhos-55 TotBili-0.4 ___ 08:00PM BLOOD cTropnT-<0.01 ___ 01:40PM BLOOD cTropnT-<0.01 ___ 05:50AM BLOOD Albumin-4.2 Calcium-9.5 Phos-5.2* Mg-2.3 Cholest-119 ___ 05:50AM BLOOD %HbA1c-5.5 eAG-111 ___ 05:50AM BLOOD Triglyc-155* HDL-42 CHOL/HD-2.8 LDLcalc-46 ___ 05:50AM BLOOD TSH-6.0* ___ 01:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG URINE ___ 02:36PM URINE Color-Straw Appear-Clear Sp ___ ___ 02:36PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 02:36PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-POS* oxycodn-NEG mthdone-NEG IMAGING CT HEAD W/O CONTRAST No acute intracranial process. CTA HEAD ___ C & RECONS; CTA NECK ___ & RECONS 1. Patent intracranial and neck vasculature without evidence for occlusion, dissection, or aneurysm. 2. Mild calcifications within the bilateral common carotid bulbs and cavernous segments of the bilateral internal carotid arteries, without flow limiting stenosis. TTE No specific echocardiographic evidence of cardiac source of embolus noted. Brief Hospital Course: 1. Transient ischemic attack: On repeat interview, patient described symptomatology as poor motor control of the left leg, followed by a 'cold sensation' in the ulnar aspect of the left forearm, followed by paresthesias of the left side of the face, progressing over the course of a few minutes and resolving within about 10 minutes. CT and MR imaging of head and neck did not reveal acute infarct, hemorrhage, or dissection as the etiology of patient's symptoms. Echocardiogram did not reveal PFO or thrombus. Due to likely TIA, prasugrel was switched to clopidogrel in coordination with patient's outpatient cardiologist, due to boxed warning on prasugrel in patients with a history of TIA or stroke. Of incidental note, patient had an episode of severe subscapular muscle spasm on the right side prior to discharge; EKG and troponins were reassuring, and symptoms did not recur. Transitional issues: 1. Patient has been previously noted to have borderline hyperkalemia, which had resolved by time of discharge; if persistent, consider switching antihypertensive agent from lisinopril. Medications on Admission: 1. Aspirin 81 mg PO DAILY 2. Prasugrel 10 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. dextroamphetamine-amphetamine 15 mg oral QHS 5. Vyvanse (lisdexamfetamine) 60 mg oral DAILY 6. Lisinopril 5 mg PO DAILY 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 9. melatonin 3 mg oral QHS Discharge Medications: 1. Clopidogrel 75 mg PO DAILY RX clopidogrel 75 mg 1 (One) tablet(s) by mouth once a day Disp #30 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. dextroamphetamine-amphetamine 15 mg oral QHS 5. Lisinopril 5 mg PO DAILY 6. melatonin 3 mg oral QHS 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 9. Vyvanse (lisdexamfetamine) 60 mg oral DAILY 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: Dear Mr. ___, You were admitted to ___ due to an episode of abnormal sensation in your left leg, face, and arm. CT and MRI scans of your head and neck did not show signs of a stroke, bleed, or vessel tear as the cause of your symptoms, so it was likely that your symptoms were due to a transient ischemic attack (TIA). As a result of this episode, one of your medications (prasugrel) was switched to a related medication ( ) on the advice of your cardiologist. Your other medications otherwise remained the same. Please follow up with your primary care provider within one week of discharge. It was a pleasure taking care of you at ___. Sincerely, Neurology at ___ Followup Instructions: ___
10306862-DS-5	10,306,862	24,876,120	DS	5	2150-06-28 00:00:00	2150-06-28 18:11:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: acetaminophen / butalbital / codeine / levofloxacin / meperidine / oxycodone / tramadol Attending: ___ Chief Complaint: Abnormal imaging, dizziness Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMH HTN, HLD, DM, migraines who presents with 5 days of vertigo and was noted to have "critical stenosis" on outside CTA. She states that she starting having room spinning vertigo when moving from side to side in bed about 5 days ago. She continued to have symptoms intermittently over the past few days, which occurred at any time, but mostly during moving. They typically last seconds to minutes and then resolve. Her symptoms are not position dependent to the best that I can ascertain. She denies any blurry or double vision. She endorses photophobia, and when looking into bright lights everything looks bright afterwards transiently. She denies seeing darkness, dark spots, sharp edges or lines. She also reports dysphagia to water, which has been ongoing for years. She states her gait has been unsteady for the past few months and she "feels like she's drunk" when she's walking, but does not drift to one side or the other. Yesterday, in addition to her vertigo, she had nausea and vomiting, which brought her to the ED. At ___, she was found to have a positive ___ maneuver. CTA supposedly showed critical stenosis so she was transferred to ___. In terms of her migraine history, she was never formally diagnosed to her knowledge, but reports daily, unilateral, throbbing headaches with photophobia that started in ___. She was started on VPA 250mg qHS, which helped tremendously. She states that she takes half a pill a day now, but her most recent bottle is from ___. She says she has a more recent bottle at home with ___ instructions, but her other pill bottles have all been filled within the last month. Here she reports some occipital pain on palpation, but denies any headache. She had back/chest pain for which she went to the ED a few days ago and they did a CTA chest which was negative for acute pathology. She was discharged on cyclobenzaprine, but she denies taking any. Past Medical History: HTN, HLD, DM, Migraines Social History: ___ Family History: Non contributory Physical Exam: ADMISSION PHYSICAL EXAM ======================== -Vitals: T: 97.8 BP: 112/64 HR: 66 SR RR: 18 SaO2: 99%RA -General: Awake, cooperative, NAD, appears older than stated age. -HEENT: NC/AT. No scleral icterus noted. MMM. No lesions noted in oropharynx. -Neck: resists to passive movement. No occipital ridge tenderness, no trapezius tenderness, tightness -Back: Tender to palpation on spinous process entire length of spine with increased tenderness in thoracic spine -Cardiac: RRR. Well perfused. -Pulmonary: Breathing comfortably on room air. -Abdomen: Soft, NT/ND. -Extremities: No cyanosis, clubbing, or edema bilaterally. -Skin: No rashes or other lesions noted. NEUROLOGIC EXAM: -Mental Status: Alert, oriented x 3. Per nephew, no errors in language, no dysarthria -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch, temperature although reports alternating side of increased intensity of gross touch, temp (no consistency). VII: No facial droop, facial musculature symmetric. VIII: Hearing grossly intact to speech. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline and equal strength bilaterally. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 R 5 ___ ___ 5 5 5 5 -Sensory: No deficits to light touch, cold sensation, pinprick, vibration, or proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor. No dysmetria on FNF or HKS. Pass pointing to right on right FTN with eyes closed and pass pointing to left on left FTN with eyes closed. Finger tap slow but normal cadence. Difficult to head impulse test, ___ due to patient resistance and lack of cooperation. Dizziness elicited when roll to R>L and resolves when lies flat within ___ -Gait: deferred DISCHARGE PHYSICAL EXAM ======================== Unchanged. No nystagmus. No cerebellar signs. No weakness. Steady gait. Pertinent Results: LABS ===== ___ 05:45AM BLOOD WBC-7.7 RBC-4.39 Hgb-11.6 Hct-36.2 MCV-83 MCH-26.4 MCHC-32.0 RDW-13.2 RDWSD-39.4 Plt ___ ___ 05:45AM BLOOD Neuts-57.5 ___ Monos-6.3 Eos-4.1 Baso-0.6 Im ___ AbsNeut-4.43 AbsLymp-2.41 AbsMono-0.49 AbsEos-0.32 AbsBaso-0.05 ___ 05:45AM BLOOD ___ PTT-28.1 ___ ___ 05:45AM BLOOD Glucose-153* UreaN-18 Creat-0.7 Na-143 K-4.5 Cl-106 HCO3-25 AnGap-12 ___ 05:45AM BLOOD ALT-16 AST-18 LD(LDH)-160 CK(CPK)-65 AlkPhos-80 TotBili-0.2 ___ 05:45AM BLOOD GGT-28 ___ 05:45AM BLOOD TotProt-7.4 Albumin-4.4 Globuln-3.0 Cholest-147 ___ 05:45AM BLOOD %HbA1c-8.0* eAG-183* ___ 05:45AM BLOOD Triglyc-85 HDL-56 CHOL/HD-2.6 LDLcalc-74 ___ 05:45AM BLOOD TSH-4.0 ___ 05:45AM BLOOD CRP-1.4 ___ 03:38AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG IMAGING ======= MRI BRAIN W/O CONTRAST : No evidence of mass, hemorrhage or infarction. CAROTID DOPPLERS: <40% stenosis L ICA, 0% stenosis R ICA ECHO: EF 60%, normal chamber size, good function, normal valves Brief Hospital Course: Ms. ___ was admitted to the Neurology Stroke Service after transfer due to symptoms of vertigo and CTA showing bilateral ICA stenosis (R>L) and left vertebral artery stenosis. Brain MRI showed no evidence of infarct. She does have evidence of calcification of these vessels however therefore stroke risk factors were assessed: Hb A1c 8%, LDL 74, TSH 4, TTE normal, telemetry for 24h showed no evidence of arrythmia. Vascular surgery evaluated her and recommended carotid dopplers which showed minimal stenosis (R ICA <40%, L ICA 0%). Overall, her history of episodic vertigo associated with photophobia and headache sounds most consistent with vestibular migraine. There was inconsistent association with head position and ___ intermittently positive therefore BPPV would also be on the differential. For either condition, ___ rehabilitation would be beneficial. ___ evaluated her inpatient and agreed with this recommendation. She was discharged on Aspirin for stroke prevention and Reglan PRN for vertigo. We recommend PCP follow up for episodic vertigo. TRANSITIONAL ISSUES [ ] F/U WITH VASCULAR SURGER [ ] BETTER DIABETES CONTROL [ ] LDL 74, CONTINUE SIMVASTATIN 20MG, ADJUST IF NEEDED PER PCP [ ] CONSIDER MIGRAINE PROPHYLACTIC TREATMENT Medications on Admission: The Preadmission Medication list is accurate and complete. 1. HydrALAZINE 5 mg PO QAM 2. Simvastatin 20 mg PO QPM 3. glimepiride 6 mg oral QAM 4. alogliptin 25 mg oral DAILY 5. Invokana (canagliflozin) 100 mg oral DAILY 6. Cyclobenzaprine 10 mg PO TID:PRN muscle soreness 7. Divalproex (DELayed Release) 125 mg PO DAILY 8. Omeprazole 40 mg PO DAILY:PRN acid reflux 9. Lidocaine 5% Patch 1 PTCH TD QAM 10. Ferrous Sulfate 325 mg PO DAILY 11. Vitamin D ___ UNIT PO DAILY 12. HydrALAZINE 10 mg PO QPM 13. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild Discharge Medications: 1. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 2. Metoclopramide 10 mg PO Q8H:PRN vertigo RX metoclopramide HCl 5 mg 1 tab by mouth three times per day Disp #5 Tablet Refills:0 3. alogliptin 25 mg oral DAILY 4. Cyclobenzaprine 10 mg PO TID:PRN muscle soreness 5. Divalproex (DELayed Release) 125 mg PO DAILY 6. Ferrous Sulfate 325 mg PO DAILY 7. glimepiride 6 mg oral QAM 8. HydrALAZINE 10 mg PO QPM 9. HydrALAZINE 5 mg PO QAM 10. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild 11. Invokana (canagliflozin) 100 mg oral DAILY 12. Lidocaine 5% Patch 1 PTCH TD QAM 13. Omeprazole 40 mg PO DAILY:PRN acid reflux 14. Simvastatin 20 mg PO QPM 15. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Vestibular migraine Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the Neurology Service due to symptoms of dizziness or rooms spinning which we call "vertigo". You did not have a stroke and your stroke work-up which included echo and labs were normal. Your diabetes needs to be better controlled. Your vessel imaging was reviewed and shows you have calcifications that put you at risk for stroke and we recommend Aspirin 81mg to prevent stroke. You were given Reglan for headache and dizziness and you will be discharged with these to take AS NEEDED for vertigo or headache. 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: ___
10306862-DS-6	10,306,862	26,903,699	DS	6	2151-03-27 00:00:00	2151-03-28 14:19:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: butalbital / codeine / levofloxacin / meperidine / oxycodone / tramadol / Levaquin Attending: ___ Major Surgical or Invasive Procedure: None attach Pertinent Results: DISCHARGE PHYSICAL EXAM: ======================== VITALS: ___ 0739 Temp: 98.2 PO BP: 130/80 R Sitting HR: 81 RR: 16 O2 sat: 97% O2 delivery: Ra GENERAL: Alert and interactive. In no acute distress. CARDIAC: Regular rhythm, normal rate. No murmurs. RESP: Clear to auscultation bilaterally. ABDOMEN: Normal bowels sounds, soft, non distended, mildly tender to deep palpation in left lower quadrant. BACK: No CVA tenderness. MSK: No edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. No rash. NEURO: AOx3. speech fluent, face symmetric, moving all 4 extremities purposefully. ADMISSION LABS: =============== ___ 12:15PM BLOOD WBC-8.5 RBC-4.03 Hgb-10.8* Hct-34.9 MCV-87 MCH-26.8 MCHC-30.9* RDW-13.1 RDWSD-41.0 Plt ___ ___ 12:15PM BLOOD Neuts-70.3 ___ Monos-4.9* Eos-0.9* Baso-0.4 Im ___ AbsNeut-5.97 AbsLymp-1.96 AbsMono-0.42 AbsEos-0.08 AbsBaso-0.03 ___ 12:15PM BLOOD Glucose-299* UreaN-13 Creat-0.6 Na-140 K-4.9 Cl-100 HCO3-30 AnGap-10 ___ 07:50AM BLOOD Calcium-9.6 Phos-4.1 Mg-2.1 Iron-96 ___ 07:50AM BLOOD calTIBC-324 VitB12-991* Folate->20 Ferritn-140 TRF-249 PERTINENT DISCHARGE LABS: ========================= ___ 06:38AM BLOOD WBC-8.9 RBC-4.26 Hgb-11.4 Hct-36.6 MCV-86 MCH-26.8 MCHC-31.1* RDW-13.0 RDWSD-40.1 Plt ___ ___ 06:38AM BLOOD Plt ___ ___ 06:38AM BLOOD Glucose-139* UreaN-17 Creat-0.7 Na-143 K-4.6 Cl-99 HCO3-27 AnGap-17 ___ 06:38AM BLOOD Calcium-9.8 Phos-4.5 Mg-2.2 MICRO: ====== ___ 11:45 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. IMAGES: ======= CT ABD & PELVIS WITH CONTRAST ___: 1. An irregular peripheral hypodensity is demonstrated within the spleen, likely a splenic infarction. 2. No other findings to explain symptoms. No evidence of colonic diverticulosis or acute diverticulitis. PELVIS, NON-OBSTETRIC ___: Nonvisualization of the uterus and bilateral ovaries. TTE ___: IMPRESSION: Suboptimal image quality. Possible mitral valve mass (? fibroelastoma vs redundant leaflet tissue; but cannot exclude vegetation) Compared with the prior TTE (images reviewed) of ___, the findings are similar. The mitral valve mass was present previously, although may be larger on the present study. TEE ___: No masses or vegetations are seen on the aortic valve, there is a filamentous echodensity traversing the LVOT in the ___nd clip 29 that is most likley an aberrant chordae tendinae attached to the aortc valve and is in the same area as the abnormality seen on the TTE. IMPRESSION: No discrete vegetation or abscess seen (see comment on aberrant chordae above). No valvular pathology or pathologic flow identified. Normal global left ventricular systolic function. Compared with the prior TTE (images reviewed) of ___ , mobile echodensity correlates with abberant chordae tendinae. Brief Hospital Course: BRIEF HOSPITAL COURSE: ====================== Ms. ___ is a ___ year old female who presented to the ED for evaluation of abdominal pain and bright red blood per rectum and was found to have incidental splenic infarct. LLQ and suprapubic pain persisted for several days with preserved ability to maintain PO. Isolated episode of BRBPR at home 3d prior to admission with subsequently normal BM. CT A/P without acute intraabdominal process that would explain LLQ pain, however did find incidental wedge-shaped splenic infarct c/f arterial embolism. Protein C, protein S, LAC, B2-microglobulin, anticardiolipin sent. Vascular medicine consulted for concern for possible mesenteric ischemia and felt infarct likely old and no strong reason to initiate AC at this time. Monitored on tele without any e/o Afib, sent home on Zio patch for further monitoring. TTE with possible mass on mitral valve. TEE with aberrant chordae tendinae attached to the aortic valve and no evidence of mass on mitral valve. Abdominal pain of unclear etiology, could consider IBS, colonic pathology, or as a dx of exclusion related to prior diagnosis of somatization disorder. Urine GC/CT/trich neg. Pelvic u/s neg. Eating well throughout. Her episode at home of isolated BRBPR with stable Hgb should be followed up with o/p colonoscopy. She was also re-started on metoclopramide for recurrence of vestibular migraine. TRANSITIONAL ISSUES: ==================== PCP: []discontinued hydralazine and began lisinopril for HTN given history of diabetes []discharged on zio patch to monitor for Afib []please schedule patient for colonoscopy for isolated episode of lower GI bleeding and given LLQ pain []consider abdominal arterial US if abdominal pain persists []please clarify discrepancies in medication list as PACT med rec notes that patient is not taking paroxetine and clonazepam, while she does endorse taking them []poor DM control with A1c 9%, patient offered to start insulin on discharge and declined, please consider uptitration of oral diabetic agents or re-address insulin use for better glycemic control []restarted previous metoclopramide for vestibular migraines []complaining of malodorous vaginal discharge which can be followed up as outpatient []f/u APLS labs - pending (beta2glycoprotein, cardiolipin, lupus, prot C/s, drvvt-s) ENT/Neurology: []restarted previous metoclopramide for vestibular migraines MEDICATIONS: New meds: -Metoclopramide 5mg TID -Lisinopril 5mg daily Stopped meds: -Hydralazine Relevant discharge data: Hgb: 11.4 #CODE: Full confirmed #CONTACT: Ms. ___ ___ ACUTE ISSUES: ============= #Splenic infarction: Wedge shape peripheral lesion concerning for splenic infarct. Likely unrelated to abdominal pain. Last had ECHO in ___, no vegetation. No history of Afib and no events on tele. Vascular medicine consulted and felt no strong reason for anticoagulation. No known personal or family history of clotting. Protein C, protein S, LAC, B2-microglobulin, anticardiolipin pending at discharge. TTE with possible mass on mitral valve. TEE with aberrant chordae tendinae attached to the aortic valve and no evidence of mass on mitral valve. Will discharge with Zio patch and follow up to rule out paroxysmal atrial fibrillation. #Left lower quadrant abdominal pain: Patient presented with left lower quadrant abdominal pain for 3 days that has improved, without further BRPBR, diarrhea or n/v. CT scan without diverticula or explanation for pain, but did note incidental splenic infarct, which was not felt likely to explain her LLQ pain. Pelvic u/s without cause and urine GC/CT/trich neg. Given spontaneous BRBPR along with splenic infarct, concern for thromboembolic events and possible mesenteric ischemia as above, but given how well she looked and her benign clinical course, this was deemed very unlikely. Pain managed with Tylenol and warm packs. Can consider outpatient abdominal arterial ultrasound if pain persists. Can consider IBS, other intramural colonic pathology. Finally, while patient has a chart diagnosis of somatization disorder, supratentorial etiology of abdominal pain is a diagnosis of exclusion. #GI bleed: Hgb remained stable. Patient with isolated episode of GI bleed 4 days prior to presentation. No BRBPR since, however guaiac positive. Likely internal hemorrhoids. However given patient's history as above, possible she has mesenteric atherosclerosis leading to ischemia of bowel and subsequent abdominal pain and GI bleed per above, though this was thought less likely. Reports last colonoscopy less then ___ years normal except for 1 polyp. No hemorrhoids on exam. No diverticulosis seen on CT A/P. Unlikely fissure. Will likely need colonoscopy as outpatient. #DMII: A1c of 9.0%, likely will require new home regimen. On home alogliptin 25 mg daily + glimepiride 6 mg oral QAM which were held as inpatient due to nonformulary. Managed on insulin as inpatient. ___ consulted while inpatient and recommend starting glargine 16U qHS, decrease glimepiride to 2mg qAM and continuing alogliptin 25mg daily, but patient declined to make change to home regimen and preferred not to start insulin on discharge. #Vaginal discharge: Whitish discharge with foul odor has been occurring for many years per patient, without pain. Likely BV. Urine GC/CT/Trich neg. Possibly vaginal candidiasis. Recommend follow up as outpatient. #Diarrhea, resolved: Acute onset diarrhea once during hospitalization. Most consistent with aggressive bowel regimen, as resolved with decreasing bowel regimen. #Anemia, resolved: #History of pernicious anemia: Anemia could be ___ GI bleed vs pernicious anemia. MCV normocytic so less likely from Pernicious Anemia. Guaiac positive in ED. B12, folate, iron studies wnl. #Nausea, resolved: Patient developed nausea in the ED that improved with zofran. Denies inability to tolerate PO. Remained asymptomatic. #Hypertension: On Hydralazine 10mg daily. ___ benefit from transition to more conventional anti-hypertensive. She has good renal function and DM. Switched from hydralazine to lisinopril 5mg daily. CHRONIC ISSUES: =============== #Depression/Anxiety: Continue home Divalproex and Paroxetine #Primary Prevention: Continued home aspirin 81mg daily. #Vertigo: Restarted on previous metoclopramide 5mg TID for recurrence of symptoms >30 minutes spent on patient care and coordination on day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ferrous Sulfate 325 mg PO DAILY 2. Omeprazole 40 mg PO DAILY:PRN acid reflux 3. Simvastatin 20 mg PO QPM 4. Vitamin D ___ UNIT PO DAILY 5. Aspirin 81 mg PO DAILY 6. alogliptin 25 mg oral DAILY 7. Divalproex (DELayed Release) 250 mg PO DAILY 8. glimepiride 6 mg oral QAM 9. HydrALAZINE 10 mg PO DAILY 10. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild 11. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 12. Simethicone 80 mg PO QID:PRN gas Discharge Medications: 1. Lisinopril 5 mg PO DAILY 2. Metoclopramide 5 mg PO TID 3. alogliptin 25 mg oral DAILY 4. Aspirin 81 mg PO DAILY 5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 6. ClonazePAM 0.25 mg PO DAILY:PRN anxiety 7. Divalproex (DELayed Release) 250 mg PO DAILY 8. Ferrous Sulfate 325 mg PO DAILY 9. glimepiride 6 mg oral QAM 10. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild 11. Omeprazole 40 mg PO DAILY:PRN acid reflux 12. PARoxetine 10 mg PO QHS 13. Simethicone 80 mg PO QID:PRN gas 14. Simvastatin 20 mg PO QPM 15. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: ================== Abdominal pain Secondary diagnoses: ==================== Anemia Diabetes mellitus Depression Hypertension Hyperlipidemia Somatization disorder Vestibular migraine Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? -You were admitted for abdominal pain and nausea. What was done for me while I was in the hospital? -You had some imaging of your abdomen which did not show a cause of your abdominal pain. -The imaging of your abdomen did show an area of your spleen that had lack of blood flow. -You were seen by vascular medicine who were reassured by your exam and imaging and recommend workup as an outpatient -You had an ultrasound of your heart which did not show any clots. What should I do when I leave the hospital? -Take all of your medications as prescribed (listed below). -Follow up with your doctors as listed below. -___ medical attention if you have new or concerning symptoms listed below. Sincerely, Your ___ Care Team Followup Instructions: ___
10307428-DS-3	10,307,428	28,440,720	DS	3	2124-10-07 00:00:00	2124-10-07 16:28:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R tib plateau and shaft fractures Major Surgical or Invasive Procedure: R tib plateau ORIF and IMN History of Present Illness: Patient is a ___ yo male previoulsy healthy, presenting with tibial plateau fracture after fall from tree. Injury occurred at At this time, the patient is complaining of pain a right knee region. He denies any head strike or LOC. Denies any headache, vision changes, nausea, or vomiting. He denies any neck or back pain. In the ED, initial vitals were 98.6 80 117/76 14 98%. Per the ED, the patient's exam did not show evidence of neurovascular symptoms. Past Medical History: none Social History: ___ Family History: noncontributory Physical Exam: AFVSS NAD RLE: wwp compartments soft in ___ unlocked ___ SILT s/s/sp/dp/t Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have R tib plateau and shaft fractures and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for R tib plateau ORIF, tibial nail, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patients home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is touch down weight bearing in unlocked blesoe in the right lower extremity, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC QHS Start: Today - ___, First Dose: Next Routine Administration Time RX enoxaparin 40 mg/0.4 mL 1 syringe at bedtime Disp #14 Syringe Refills:0 4. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain RX oxycodone [Oxecta] 5 mg ___ tablet(s) by mouth q3hrs Disp #80 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: R tib plateau and shaft fxs Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks WOUND CARE: - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. ACTIVITY AND WEIGHT BEARING: TDWB RLE, ___ unlocked Danger Signs: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Followup Instructions: ___
10307543-DS-17	10,307,543	27,678,227	DS	17	2186-09-25 00:00:00	2186-09-25 23:36:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Levetiracetam / Latex Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Blood Transfusion History of Present Illness: ___ with recurrent stage IIIA cervical cancer who was admitted from clinic with vaginal bleeding and abdominal pain. Per prior notes, she was diagnosed with recurrent cervical cancer on ___ and had planned to started chemotherapy, but then she went to ___ and used herbal medicine while in ___, for about three months. She returned to the ___ rencetly has continued to have small amounts of vaginal spotting/bleeding and lower abdominal pain for at least 1 month. The pain at its worst is ___, prompting her to use Advil. No diarrhea, perhaps mild constipation, last BM this AM. She was sent to the ED for further evaluation. In the ED, she received 5 mg of IV Morphine for pain control, IVF, and Flagyl. After the morphine, her pain is at ___, but has mild dizziness with the morphine. She is eating a regular diet, ROS is positive for urinary frequency, but no sharp pain or burning with urination. She is also having chets pain at rest, for the last month. Past Medical History: PAST MEDICAL HISTORY: 1. Atypical meningioma, s/p resection ___ ___ MD) 2. Brief seizure disorder, given Keppra, developed rash. Not taking AED at this time. Purportedly to undergo radiation therapy, but did not undergo therapy. 3. Chronic eczematous process involving thighs, chronic hyperpigmented shins bilaterally, seen by dermatology in past. 4. G6P4 - 2 Ab 5. Cervical Cancer - Stage IIIa; dx ___ 6. Thyroid Cancer Social History: ___ Family History: FAMILY HISTORY: Father - lung cancer, smoker Mother - no known medical issues She has 5 sisters, 1 brother. She has 4 children. Physical Exam: PHYSICAL EXAM: T: 89.82 HR: 78 BP: 106/64 RR: 20 O2: 100% HEENT: Anicteric sclerae. Oropharynx moist without exudate or lesions. Lungs are clear to auscultation bilaterally. Cardiovascular exam is regular rate and rhythm, normal S1, S2, no rubs, no murmurs, or gallops. Abdomen: Positive bowel sounds, soft, nondistended, mild TTP in pelvis. No hepatosplenomegaly could be appreciated. Extremities: No clubbing, cyanosis, or edema. Right fifth finger contracture. Rectal exam was deferred. Cranial nerves II through XII are grossly intact. No obvious skin lesions. Pertinent Results: ___ 12:30PM ___ PTT-31.3 ___ ___ 12:30PM PLT COUNT-591* ___ 12:30PM NEUTS-76.1* LYMPHS-15.3* MONOS-4.0 EOS-4.4* BASOS-0.2 ___ 12:30PM WBC-13.1# RBC-2.78 HGB-7.7# HCT-25.1 MCV-90 MCH-27.7 MCHC-30.8* RDW-15.3 ___ 12:30PM ALBUMIN-2.8* CALCIUM-8.0* PHOSPHATE-3.5 MAGNESIUM-2.0 ___ 12:30PM ALT(SGPT)-11 AST(SGOT)-15 ALK PHOS-59 TOT BILI-0.2 ___ 03:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD ___ 03:30PM URINE RBC-77* WBC-14* BACTERIA-FEW YEAST-NONE EPI-<1 CT TORSO IMPRESSION: 1. Heterogeneously-enhancing irregular 7.8-cm cervical mass, enlarged since ___, causing new fluid-filled dilation of the endometrial canal,suggesting cervical stenosis. Small low-density free pelvic fluid tracks superiorly along the right paracolic gutter. 2. 12 x 10 mm left upper lobe lobulated pulmonary nodule, previously 9 mm, and now with new central cavitation, compatible with metastatic disease. No new pulmonary nodule. 3. Heterogeneous right thyroid mass, similar to prior, and compatible with known thyroid cancer. Brief Hospital Course: Patient was transfused 1 unit of PRBC with good response. She was seen by GYN and felt to have slow, chronic vaginal bleed. Pelvic exam showed fungating mass. CT Torso done this admission showed progression of cervical cancer mass as well as lung mass. Patient does have history of 2 primary cancers, cervical and thyroid. Pain was controlled with oxycodone. Bowel regimen was provided. Patient was also started on 3 day course for possible UTI with Bactrim suggested on urinalysis. Transition Issues: 1. Follow up management of cervical cancer 2. Follow up management of thyroid cancer. Likely cervical cancer therapy will take priority given she is having abdominal pain and vaginal bleeding. Medications on Admission: advil 200 mg po q 6h prn Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:11 2. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth every ___ hours Disp #60 Tablet Refills:0 3. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX Miralax 17 gram/dose 17 gram by mouth once a day Disp #1 Bottle Refills:5 4. Senna 1 TAB PO BID:PRN constipation RX senna 8.6 mg 2 tablets by mouth at bedtime Disp #60 Tablet Refills:11 5. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days RX Bactrim DS 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #6 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Abdominal pain Vaginal Bleeding Cervical Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent.But has back pain. Discharge Instructions: You were admitted for concern of vaginal bleeding and progression of cancer. You were found to have a low blood level, but you received a transfusion of blood and your blood level is much better. You also have pain that is related to the cancer. We will make appointments for you to see Dr ___ another oncologist with you very soon. For pain, you will use oxycodone. For constipation, you will be given a stool softener, a gentle laxative, and a liquid called Miralax that you take once a day (for ___ days) until your bowel movements are more regular. Followup Instructions: ___
10307543-DS-19	10,307,543	22,965,129	DS	19	2186-12-27 00:00:00	2186-12-27 15:49:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Levetiracetam / Latex Attending: ___ ___ Complaint: Lower GI bleed, pelvic pain Major Surgical or Invasive Procedure: None. History of Present Illness: This is a ___ woman with a pmhx. significant for stage IIIA (T3, N0 Mx) high-grade cervical cancer, papillary thyroid cancer, seizure disorder, and atypical meningioma who is admitted from the ED with fever, lower GI bleed, and UTI. Patient has been undergoing active treatment for cervical cancer with Taxol/carboplatin with C4 on ___. Ms. ___ has been having trouble with GI bleeding (in the setting of constipation and straining as per outpatient notes), and has been supported conservatively with blood transfusions. No history of EGD or colonsocopy in our system. Ms. ___ states the for the last weekshe has noticed increased blood in her stool. Also endorses fevers, chills, and abdominal pain. In the ED, initial vitals were: 102.0 109 105/65 16 100% ra. Hgb was 9.4 and u/a was consistent with UTI. Patient received 3L of NS and 1 gram of ceftriaxone. CT abdomen/pelvis showed: "thickening of the rectum and sigmoid colon with extension to possibly the mid-descending colon raise suspicion for a proctocolitis due to an infectious or inflammatory process. Heterogenous irregular cervical mass appears stable in size but there is more hypodense material endometrial canal suggesting either outlet obstruction by the mass or possibly involvement of the region by the mass. Left upper lobe nodule has decreased in size." Vitals on admission were: 98.3, 67, 92/55, 15, 100% ra. Past Medical History: 1. Atypical meningioma, s/p resection ___ ___ MD) 2. Brief seizure disorder, given Keppra, developed rash. Not taking AED at this time. Purportedly to undergo radiation therapy, but did not undergo therapy. 3. Chronic eczematous process involving thighs, chronic hyperpigmented shins bilaterally, seen by dermatology in past. 4. G6P4 - 2 Ab 5. Cervical Cancer - Stage IIIa; dx ___ mets and progression in ___- -cycle #1 ___ ___. 6. Thyroid Cancer-no treatment Social History: ___ Family History: Father: lung cancer, smoker. Mother: no known medical issues. She has 5 sisters, 1 brother. She has 4 children. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.3, 67, 92/55, 15, 100% RA GENERAL: Alert, oriented, pleasant no acute distress HEENT: Mucous membranes moist CHEST: CTA bilaterally, no wheezes, rales, or rhonchi CARDIAC: RRR, no MRG ABDOMEN: +BS, slightly tender, non-distended EXTREMITIES: Dry skin, no edema bilaterally DISCHARGE EXAM: Tmax: 37.2 °C (99 °F), Tcurrent: 36.6 °C (97.9 °F), HR: 61 (60 - 93) bpm BP: 102/69(77) {93/53(65) - 126/93(98)} mmHg RR: 13 (11 - 22) insp/min SpO2: 99% GENERAL: Alert, oriented, NAD HEENT: MMM CHEST: CTA bilaterally, no wheezes, rales, or rhonchi CARDIAC: RRR, S1 S2, no MRG ABDOMEN: +BS, soft, suprapubic mass is mildly tender, non-distended, hepatic edge palpable, no cvat EXTREMITIES: Dry skin, no edema bilaterally Pertinent Results: ADMISSION LABS: ___ 12:20PM URINE COLOR-Yellow APPEAR-Cloudy SP ___ ___ 12:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG ___ 12:20PM URINE RBC-36* WBC->182* BACTERIA-MOD YEAST-NONE EPI-0 ___ 12:20PM URINE MUCOUS-MOD ___ 11:26AM ___ COMMENTS-ADDED TO G ___ 11:26AM LACTATE-1.7 ___ 10:45AM GLUCOSE-183* UREA N-14 CREAT-0.5 SODIUM-132* POTASSIUM-3.2* CHLORIDE-97 TOTAL CO2-24 ANION GAP-14 ___ 10:45AM estGFR-Using this ___ 10:45AM ALT(SGPT)-21 AST(SGOT)-19 LD(LDH)-170 ALK PHOS-113* TOT BILI-0.7 ___ 10:45AM ALBUMIN-3.0* ___ 10:45AM WBC-6.3 RBC-3.09* HGB-9.4* HCT-29.0* MCV-94 MCH-30.3 MCHC-32.3 RDW-16.1* ___ 10:45AM NEUTS-92.7* LYMPHS-5.7* MONOS-1.4* EOS-0.1 BASOS-0.2 ___ 10:45AM PLT COUNT-298 ___ 10:45AM ___ PTT-30.7 ___ STUDIES: ___ CT Chest Abd Pelvis IMPRESSION: 1. Proctocolitis, which may be due to an infectious or inflammatory process. 2. Heterogenous irregular cervical mass appears relatively similar, compatible with known carcinoma. Increased hypodense material in the endometrial canal with peripheral irregular enhancement is suggestive of increased endometrial fluid due to cervical obstruction by the mass with endometritis, but neoplastic involvement of the endometrium may also be present. Air within the cervix and vagina is unchanged from the prior studies; while no communication is seen between the vagina and rectum, if there is concern for a rectovaginal fistula, this can better be assessed with rectal contrast. 3. Interval decrease in size of the left upper lobe nodule. 4. Heterogeneous hypodense area within the right lobe of the thyroid gland, consistent with the patient's known thyroid carcinoma. 5. Mild dilatation of the ureters without frank hydronephrosis, likely due to mass effect upon the distal ureters by the cervical tumor. ___ KUB FINDINGS: There is retained contrast within the large bowel. There is no dilated bowel. There is no free air or pneumatosis. IMPRESSION: No gas abnormality. MICROBIOLOGY ___ MRSA SCREEN MRSA SCREEN-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ URINE CULTURE-FINAL INPATIENT ___ BLOOD CULTURE -PENDING ___ BLOOD CULTURE- PENDING DISCHARGE LABS ___ 03:59AM BLOOD WBC-2.4* RBC-3.43* Hgb-10.5* Hct-30.2* MCV-88 MCH-30.7 MCHC-34.9 RDW-16.9* Plt ___ ___ 03:59AM BLOOD Glucose-111* UreaN-10 Creat-0.5 Na-136 K-3.7 Cl-104 HCO3-23 AnGap-13 ___ 03:59AM BLOOD Calcium-7.8* Phos-2.5* Mg-1.3* ___ 04:51AM BLOOD Lactate-1.3 Brief Hospital Course: This is a ___ woman with a history of cervical cancer stage IIIA (T3, N0 Mx), papillary thyroid cancer, atypical meningioma, and anemia who is admitted with fever, lower GI bleed, and likely UTI. ACTIVE ISSUES: 1. LOWER GI BLEED: Patient received IVF and an active type, screen and crossmatch was maintained. She had a CT scan demonstrating colitis. Given recent chemotherapy, chemotherapy-induced colitis was high in our differential. We also considered infectious colitis and patient was started on antibiotics. She was afebrile in the ICU and not passing stool, so an infectious etiology was felt to be less likely and Zosyn was discontinued on ___. Ischemic bowel was unlikely given lactate is within normal limits and patient does not appear systemically ill. On ___, patient received 2 units pRBC for a HCT of 21, with HCT increasing appropriately to 29 on the morning of ___. While in the FICU, patient passed small blood clots through her rectum but did not have frank hematochezia or melena. Patient was called out of the FICU on ___ but a floor bed was not available. On ___ she was stable for discharge home. 2. UTI: Patient with evidence of UTI on u/a on admission. Asymptomatic. She was initially treated with antibiotics. However, urine studies were felt to represent fecal contamination and her imaging was concerning for possible fistula. Antibiotics were discontinued on ___ and patient remained afebrile. 3. CERVICAL CANCER: Patient currently undergoing chemotherapy with taxol and carboplatin. Her outpatient oncologist was contacted who felt colitis could be secondary to chemotherapy and chemotherapy was not given in house. Patient will follow up with oncology as outpatient. 4. HYPOTENSION: Patient was initially transferred to the FICU with an SBP in the 80's in spite of aggressive fluid resuscitation and concern for sepsis. Upon further investigation, patient's baseline outpatient SBP is 80's-100. She denied symptoms of orthostatic hypotension. CHRONIC ISSUES: 1. THYROID CANCER: No treatment at this time. 2. PAIN: Patient was continued on oxycodone and oxycontin. Ibuprofen was held in the setting of GI bleed. TRANSITIONAL ISSUES - Avoid NSAIDS - Determine future chemo regimen Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dexamethasone 2 mg PO DAILY 2. Lorazepam 0.5-1 mg PO Q6H:PRN Anxiety or insomnia Please hold for oversedation or RR <10. 3. Ondansetron 8 mg PO Q8H:PRN Nausea 4. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN Pain Please hold for oversedation or RR <10. 5. Oxycodone SR (OxyconTIN) 30 mg PO QAM Please hold for oversedation or RR <10. 6. Oxycodone SR (OxyconTIN) 20 mg PO QPM Please hold for oversedation or RR <10. 7. Prochlorperazine 10 mg PO Q8H:PRN Nausea 8. Docusate Sodium 100 mg PO BID 9. Senna 1 TAB PO BID:PRN Constipation 10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation 11. Ibuprofen 400 mg PO Q8H:PRN Pain Discharge Medications: 1. Dexamethasone 2 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Lorazepam 0.5-1 mg PO Q6H:PRN Anxiety or insomnia Please hold for oversedation or RR <10. 4. Ondansetron 8 mg PO Q8H:PRN Nausea 5. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN Pain Please hold for oversedation or RR <10. 6. Oxycodone SR (OxyconTIN) 30 mg PO QAM Please hold for oversedation or RR <10. 7. Oxycodone SR (OxyconTIN) 20 mg PO QPM Please hold for oversedation or RR <10. 8. Prochlorperazine 10 mg PO Q8H:PRN Nausea 9. Senna 1 TAB PO BID:PRN Constipation 10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation Discharge Disposition: Home Discharge Diagnosis: Lower GI bleed Hypotension Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at ___. You were admitted for low blood pressure and blood in your stool. You had a blood transfusion which improved your blood pressure and your anemia. A CT scan showed inflammation of your colon which is most likely due to your chemotherapy. You also complained of tongue pain, which is also likely due to your chemotherapy. We have prescribed a lidocaine mouth rinse to help with the pain. In the future, please avoid over the counter non-steroidal anti-inflammatory medications (NSAIDs), as they may cause worse bleeding in your GI tract. This means you should NOT take ibuprofen (advil, motrin), aspirin, or naproxen. It is OK to take Tylenol. Please continue to follow up with your Oncologist for care of your cervical cancer. Followup Instructions: ___
10307649-DS-4	10,307,649	21,668,679	DS	4	2184-10-25 00:00:00	2184-10-25 22:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Transaminitis Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with history of exercise induced asthma, allergic rhinitis, dysmenorrhea/endometriosis who was referred in from her PCP with elevated transaminases following a large accidental ingestion of tylenol to treat pain related to presumed gastritis, found to have ALT 12,775, AST 21,365 in the outpatient setting. Ms. ___ notes that she developed acute onset abdominal pain on ___ associated with right upper quadrant/mid-epigastric pain, nausea, and green colored diarrhea. She spent the ___ weekend in a cabin in ___. During that time she ate potato/chicken salad. She notes there were times where the potato/chicken salad was in a cooler and would be transferred in and out of the cooler throughout the day. She denies any tick bites, mosquito bites, or ingestion of any mushrooms. She felt well throughout the weekend but developed sudden right upper quadrant/epigastric pain on ___. She developed nausea, green colored diarrhea (no melena or hematochezia), fevers, chills, night sweats and myalgias. She denied any joints pains. These persisted on ___. To treat the symptoms, she took Pepto-Bismol, TUMS, and ranitidine. Since the symptoms persisted she presented to her PCP ___ ___. She was diagnosed with acute gastritis and prescribed omeprazole 40 mg BID, Ondansetron ___ mg every 6 hours for nausea and Tylenol prn for discomfort. She took 5 tablets of Tylenol (dose unknown) on ___ and 3 tablets of Tylenol (dose unknown) on ___. Her sister claims, however, that when investigating a previously new bottle of 150 Tylenol pills, there were only 100 or so remaining. During the follow-up visit, LFT's were sent which were noted to be elevated with AST 12,775 and AST 21,365. Given the elevated transaminases she was referred to the Emergency Department. In the ED: Labs were notable for WBC 2.5, H/H13.8/37.5, platelets 89. ___ 17.6, PTT 30.9. INR 1.6. Chemistry panel showed Na 133, Potassium 4.3, Chloride 100, HCO3 24, Creatinine 1.5 (baseline 0.7) glucose 130. ALT was 7,080, AST 6,391, Alk Phos 89, Total Bilirubin 8.3. Toxicology testing was negative for aspirin, ethanol, benzodiazepine, barbiturates, tricyclics. Acetaminophen was positive for acetaminophen with a level of 12. Urine toxicology was negative for benzodiazepines, barbiturates, opiates, cocaine, acetaminophen, methadone. Lactate was 2.6. UA showed 14 WBC, 4 RBC. Blood cultures x 2 pending. RUQ US performed which showed "1. echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded. 2. Thickened gallbladder wall, likely related to a liver dysfunction, chronic entities such xanthogranulomatous cholecystitis while much less likely cannot be excluded, follow up ultrasound is recommended in 6 weeks to re-evaluate." Toxicology consulted. recommended admission with 21 hour NAC protocol. Received the loading dose in the ED (150 mg/kg over 60 minutes). Recommended 4 hour infusion at 12.5 mg/kg/hour followed up 16 hour infusion of 6.25 mg/kg/hour. Received acetylcysteine, in ED but concern for patient developing tachycardia so patient received famotidine, and diphenhydramine. Patient also received 1 L normal saline. On the floor, patient noted her abdominal discomfort had improved following initial treatment. Past Medical History: -Exercise induced asthma -Allergic rhinitis -Dysmenorrhea/endometriosis -Alcohol misuse Social History: ___ Family History: -Breast cancer in family -History of alcohol abuse -No primary liver diseases. Physical Exam: =============== ADMISSION EXAM =============== VS: 98.7, 129/81, 102, 16, 100% on RA. General: Pleasant affect, laying in bed, does not appear in any acute distress. HEENT: Icteric sclera, dry mucous membranes. Neck: Neck supple, no elevated JVD. CV: RRR, S1 and S2 present, no murmurs, rubs or gallops. Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi. Abdomen: soft abdomen, minimal tenderness in right upper quadrant/epigastric region, no rebound or guarding, normoactive bowel sounds. Ext: No lower extremity edema. Neuro: No asterixis. Skin: Urticaria like lesions on the back and chest. =============== DISCHARGE EXAM =============== VS: 97.6 PO 117/96 72 17 99RA GEN: ambulating well, NAD, AAOx3, pleasant, conversational HEENT: NCAT, MMM NECK: No JVD CV: RR, S1+S2, NMRG RESP: CTABL, no w/r/r GI: nondistended. normal bs. nontender w/o rebound/guarding. no asterixis. GU: Deferred EXT: WWP, no edema NEURO: CN II-XII grossly intact, MAE Pertinent Results: ============== ADMISSION LABS =============== ___ 10:50PM BLOOD Plt Ct-89* ___ 02:56AM BLOOD ___ PTT-30.9 ___ ___ 10:50PM BLOOD WBC-2.5# RBC-4.20 Hgb-13.8 Hct-37.5 MCV-89 MCH-32.9 MCHC-36.8 RDW-11.9 RDWSD-37.8 Plt Ct-89* ___ 10:50PM BLOOD Neuts-64.5 ___ Monos-8.1 Eos-2.0 Baso-0.8 Im ___ AbsNeut-1.60# AbsLymp-0.60* AbsMono-0.20 AbsEos-0.05 AbsBaso-0.02 ___ 10:50PM BLOOD Glucose-130* UreaN-12 Creat-1.5* Na-133 K-4.3 Cl-100 HCO3-24 AnGap-13 ___ 10:50PM BLOOD ALT-7080* AST-6391* AlkPhos-89 TotBili-8.3* ___ 10:50PM BLOOD Albumin-4.1 Calcium-8.5 Phos-2.2* Mg-2.3 ___ 10:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-12 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 08:50PM BLOOD Acetmnp-NEG ___ 01:03AM BLOOD Lactate-2.6* =============== KEY INTERIM LABS =============== ___ 10:55AM BLOOD ALT-4900* AST-2920* AlkPhos-69 TotBili-9.3* ___ 08:50PM BLOOD ALT-3997* AST-1827* AlkPhos-70 TotBili-9.6* ___ 05:50AM BLOOD ALT-3194* AST-1074* AlkPhos-67 TotBili-8.9* ================= IMAGING ================= RUQ U/S ___: 1. 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. 2. Thickened gallbladder wall, likely related to a liver dysfunction, chronic entities such xanthogranulomatous cholecystitis while much less likely cannot be excluded, followup ultrasound is recommended in 6 weeks to re-evaluate. Brief Hospital Course: ACUTE ISSUES: # Transaminitis: Patient presented with significantly elevated transaminitis with ALT 12,775, AST 21,365 as outpatient. Most likely possibility was acetaminophen toxicity in the setting of the patient deliriously overusing acetaminophen during viral illness, given that her sister reported 50 missing acetaminophen pills in a 2 day span. Other considerations include acute viral hepatitis and autoimmune hepatitis for which a full workup was sent. CMV/EBV and sexually transmitted infection studies were also sent. Her transaminitis downtrended consistently during the course of her admission to the time of discharge. Patient was treated with NAC protocol. She was discharged with instructions to follow-up in outpatient clinic for repeat LFTs. Results showed HBsAg negative, HBsAb positive, HBcAb negative, IgM HBc negative, HAV Ab positive, although IgM HAV negative. # Thrombocytopenia/Leukopenia: Patient presented with WBC and plt counts well below baseline. Thought to be secondary to underlying viral illness, with CMV/EBV studies sent. Appeared to be resolving at time of discharge. # Coagulopathy: Patient had elevated INR of 1.6 on admission. Etiology may be secondary to malnutrition versus worsening hepatic dysfunction. She was given vitamin K 10mg IV and INR was downtrending to 1.2 at time of discharge. # Alcohol Abuse: Drinks up to 15 drinks per week. She acknowledged having difficulty with her alcohol consumption in the past. Was kept on multivitamin, folic acid, thiamine during admission. Outpatient follow-up was discussed. ___ Issues: -Patient will need follow-up appointment with primary care to assess clinical status and serum chem 7, CBC, ___, INR, ALT, AST, Tbili, Alk phos within a week of discharge. -Liver US demonstrated thickened gallbladder wall, likely related to a liver dysfunction, chronic entities such xanthogranulomatous cholecystitis while much less likely cannot be excluded, followup ultrasound is recommended in 6 weeks to re-evaluate. - f/u results of Hep E, ___ Ab, RPR, CMV/EBV viral load, blood cultures. - Please obtain repeat UA as an outpatient given evidence of hematuria during hospitalization. - Please discuss alcohol abstinence as an outpatient. - Code Status: Full Code (confirmed) - Contact Information: ___ (sister): ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pseudoephedrine 30 mg PO Q6H:PRN allergic rhinitis 2. Amphetamine-Dextroamphetamine XR 20 mg PO 3X/WEEK PRN inattention Discharge Medications: 1. Amphetamine-Dextroamphetamine XR 20 mg PO 3X/WEEK PRN inattention 2. Pseudoephedrine 30 mg PO Q6H:PRN allergic rhinitis Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================== - Medication induced hepatic injury SECONDARY DIAGNOSIS =================== -Exercise induced asthma -Allergic rhinitis -Dysmenorrhea/endometriosis -Alcohol misuse 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 to the hospital after you were found at your outpatient clinic to have evidence of liver injury following Tylenol use for a likely "stomach bug." In the emergency room you received blood work that followed the injury to your liver and also ruled out other causes of injury. It became clear from the story we obtained that the most likely cause of the injury to the liver was from the amount of Tylenol that was taken. We understand this was accidental. Tylenol can be toxic in large amounts, so it is very important to adhere to the maximum dose guidelines on the side of the bottle. Please also attempt to abstain from alcohol as this can lead to worsening of your liver function. Please note that you underwent an ultrasound of your liver during this hospitalization. Results indicated "thickened gallbladder wall, likely related to a liver dysfunction, chronic entities such xanthogranulomatous cholecystitis while much less likely cannot be excluded." Please follow up with your primary care physician. PLEASE OBTAIN A REPEAT ULTRASOUND IN 6 WEEKS to re-evaluate your gallbladder. You were also noted to have a small amount of blood in your urine. Please follow up with your primary care physician to get ___ repeat urine sample to assess for resolution of the blood within the urine. When you get home you should follow-up with your primary care doctor in order to have repeat blood tests drawn to assess your liver. It was a pleasure taking care of you during your hospitalization! We wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___
10307793-DS-9	10,307,793	20,274,888	DS	9	2197-09-16 00:00:00	2197-09-17 13:17:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: IV Dye, Iodine Containing Contrast Media Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: 1. Exploratory laparotomy, lysis of adhesions. 2. Primary repair of ventral hernia. History of Present Illness: ___ w/ h/o ventral hernia who presents with abdominal pain. She had sharp abdominal pain that started around 10 am on ___, mostly in the lower abdomen. It worsened throughout the day, and she had 2 episodes of emesis. She has continued to pass gas today and her last BM was yesterday night. She presented to the ED for further evaluation. Past Medical History: Past Medical History: Hypothyroidism Past Surgical History: laparoscopic cholecystectomy ___, thyroidectomy ___, tibial fracture repair ___ Social History: ___ Family History: NC Physical Exam: VS: Tmax=99.5, Tc= 98.4, HR=58, BP=142/72, RR=18, SaO2= 100%3L Gen: NAD. A&Ox3. HEENT: Anicteric. Tacky mucosal membranes. Neck: No JVD. No LAD. No TM. CV: RRR. Pulm: CTAB. Abd: Soft. NT. ND. +BS. Ext: Warm and well perfused. No peripheral edema. Neuro: Motor and sensation grossly intact. Pertinent Results: ___ 03:25PM GLUCOSE-94 UREA N-8 CREAT-0.9 SODIUM-140 POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-23 ANION GAP-13 ___ 03:25PM WBC-6.3 RBC-4.73 HGB-14.2 HCT-44.6 MCV-94 MCH-30.1 MCHC-31.9 RDW-14.2 ___ 03:25PM NEUTS-70.8* ___ MONOS-2.5 EOS-0.6 BASOS-1.2 CT Abd/Pelvis w/o Contrast: 1. Incarcerated small bowel within a ventral hernia inferior to the umbilicus with proximal small bowel obstruction. 2. Additional ventral wall defects, similar to the prior exam, one of which contains non-incarcerated transverse colon. Brief Hospital Course: The patient was admitted to the Acute Care Surgery Service for evaluation and treatment of an incarcerated ventral hernia. The patient underwent an exploratory laparotomy, lysis of adhesions, and primary repair of a ventral hernia, which went well without complication. Neuro: The patient received tramadol, tylenol, and oxycodone with good effect and adequate pain control. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection of which there were none. Endocrine: The patient's blood sugar was monitored routinely throughout her stay Hematology: The patient's complete blood count was examined, no transfusions were required Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; she 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. Medications on Admission: Synthroid ___ mcg Discharge Disposition: Home Discharge Diagnosis: Incarcerated Ventral Hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory Independent. Discharge Instructions: You were admitted to the acute care surgery service for an incarcerated ventral hernia that was repaired operatively. 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 wheeze. 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 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 concerning symptoms. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 20 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. 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. 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: ___
10308232-DS-18	10,308,232	24,703,054	DS	18	2156-04-30 00:00:00	2156-04-30 12:35:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Hyponatremia Major Surgical or Invasive Procedure: ___: endoscopic endonasal resection of suprasellar mass History of Present Illness: ___ year old female recently s/p endoscopic endonasal resection of suprasellar mass with Dr. ___ on ___ re-presented with hyponatremia. Past Medical History: HTN HLD T2DM Chronic cough COPD dysphonia arthritis R hip replacement ___ L hip replacement ___ Social History: ___ Family History: Mother: Died of breast cancer age ___. Mother's sisters with various forms of cancer. Father: No cancer history. Physical Exam: PHYSICAL EXAM: T: 97.5 BP: 136/90 HR:55 R:16 O2Sats: 100% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL. EOMs: intact without nystagmus Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Dysphonic. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally EXAM ON DISCHARGE: A&Ox3, PERRL, EOMI, No drift, MAE ___. Brief Hospital Course: ___ year old female recently s/p endoscopic endonasal resection of suprasellar mass with Dr. ___ on ___ re-presented with hyponatremia. # Hyponatremia/DI The patient presented with a serum sodium down to 115. She was started on hypertonic saline 3%. Once the patient's serum sodium reached 128, the 3% was stopped. Her serum sodium continued to improve and stabilize. She was started on hydrocortisone ___ dosing, and eventually her 2L water restriction was lifted and the patient was allowed to drink to thirst. She maintained appropriate mentation, and therefore Endocrine performed water deprivation testing to further investigate etiology of hyponatremia. The water deprivation test r/o DI and she was cleared for discharge from an endocrine perspective on ___. # Physical Therapy ___ evaluated the patient and determined the patient was safe for discharge home. ___ offered home services, but the patient declined. On ___ the patient was discharged home in stable conditions. All discharge instruction and follow up were given prior to discharge. Medications on Admission: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. PredniSONE 5 mg PO QAM 5. Senna 17.2 mg PO QHS constipation 6. amLODIPine 5 mg PO DAILY 7. Atorvastatin 40 mg PO QPM 8. Levothyroxine Sodium 50 mcg PO QAM 9. Lisinopril 20 mg PO BID 10. Magnesium Oxide 400 mg PO DAILY 11. MetFORMIN XR (Glucophage XR) 500 mg PO QPM 12. Omeprazole 20 mg PO EVERY OTHER DAY 13. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID 3. Hydrocortisone 40 mg PO QAM 4. Hydrocortisone 20 mg PO QPM RX hydrocortisone 20 mg 1 tablet(s) by mouth Q ___ and 2 tabs Q AM Disp #60 Tablet Refills:*0 5. Senna 17.2 mg PO HS 6. amLODIPine 5 mg PO DAILY 7. Atorvastatin 40 mg PO QPM 8. Levothyroxine Sodium 50 mcg PO DAILY 9. Lisinopril 5 mg PO BID 10. Magnesium Oxide 400 mg PO DAILY 11. Omeprazole 20 mg PO EVERY OTHER DAY Discharge Disposition: Home Discharge Diagnosis: Hyponatremia s/p endoscopic endonasal resection of suprasellar mass on ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ¨Take your pain medicine as prescribed. ¨Exercise should be limited to walking; no lifting, straining, or excessive bending. ¨Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ¨Clearance to drive and return to work will be addressed at your post-operative office visit. ¨If you have been discharged on hydrocortisone, take it daily as prescribed. ¨If you are required to take hydrocortisone, an oral steroid, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as this medication can cause stomach irritation. Hydrocortisone should also be taken with a glass of milk or with a meal. CALL YOUR DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ¨New onset of tremors or seizures. ¨Any confusion or change in mental status. ¨Any numbness, tingling, weakness in your extremities. ¨Pain or headache that is continually increasing, or not relieved by pain medication. ¨Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ¨It is normal for feel nasal fullness for a few days after surgery, but if you begin to experience drainage or salty taste at the back of your throat, that resembles a dripping sensation, or persistent, clear fluid that drains from your nose that was not present when you were sent home, please call. ¨Fever greater than or equal to 101° F. ¨If you notice your urine output to be increasing, and/or excessive, and you are unable to quench your thirst, please call your endocrinologist. Followup Instructions: ___
10308906-DS-19	10,308,906	29,952,378	DS	19	2166-07-04 00:00:00	2166-07-04 18:08:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: heparin Attending: ___. Chief Complaint: Confusion Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: Ms. ___ is a ___ woman with history notable for seizure disorder reportedly complicated by medication non-adherence, alcohol use disorder (complicated by cirrhosis), and multiple additional substance use disorders (including benzodiazepines, heroin, and cocaine) transferred from ___ due to concern for stroke. She reportedly was with her boyfriend today when she began slumping over while in the care, and then started to "behave strangely". She was apparently last seen normal 30 minutes prior to arrival at ___, which occurred at ___ today. Her boyfriend apparently mentioned that she has not been taking her anti seizure medicines for several days, but he was not at ___, and is not here currently, to verify this. She was noted to be answering all questions non-sensically. NIHSS was scored at 13, though break down is not documented. Fingerstick glucose was 99. Telestroke was activated; for the stroke fellow/attending she was found to have an NIHSS of 6 (1 questions, 2 commands, 1 R arm drift, 2 aphasia). There were possibly some oral automatisms as well as decreased movement of the right side, but this seemed to fluctuate. CT head did not show any acute intracranial process. Due to the possibility of seizure and rapidly resolving deficits, tPA was not given. She was given Levetiracetam 1500mg IV, Lroazepam 1mg IV, and transferred to ___. She was previously admitted at ___ in ___ after presenting to an outside hospital with confusion and possibly also a 5 minute episode of convulsion. The following is gleaned from that admission: With respect to her seizure history, Ms. ___ reports onset of seizures around age ___, for which she was placed on phenytoin that she subsequently self-discontinued "after a few years." She does not recall follow-up with a neurologist, and is unable to recall her typical seizure frequency or prior admissions for seizures. She recalls her seizures being described as generalized convulsions, and denies any preceding sensory or motor disturbance that reliably portends a seizure. She denies a history of childhood febrile seizures, meningitis, or TBI, but does recall experiencing significant head injury following a minivan rollover at age ___ in which she was a passenger. During that admission she had ___ hours of continuous electroencephalographic monitoring which was negative for abnormal discharges or organized seizures. Her primary care doctor was contacted who stated that she frequently no-shows for her appointments and they have not written her anti-epileptic medication prescriptions. Review of records from ___ and other hospitals shows recent hospitalizations in ___ for seizure, which was felt to be due to a combination of alcohol withdrawal as well as medication non-compliance. She was treated in the ICU for alcohol withdrawal. Keppra and Lacosamide were resumed at her home doses. Of note, during this admission a TTE showed a possible right ventricular mass, but TEE showed this to be thickening of the tricuspid valve. She was also admitted to ___ in ___ after a seizure at home, after which she initially presented to ___. Seizure was described as "left eye gaze/ tonic-clonic", lasting ___, for which she apparently received several doses of benzodiazepines and was intubated for airway protection. At ___, she was noted to have left sided weakness raising concern for ___ paralysis vs stroke. An MRI did not show any stroke. Again, seizure was felt to be due to a combination of medication non-compliance as well as alcohol withdrawal. She was treated with Phenobarbital as well as her home anti-seizure medications. Continuous EEG monitoring during that time is reported as follows: "1. Continuous diffuse mixed frequency activity over both hemispheres with excessive beta activity consistent with known propofol use 2. When the propofol is weaned the recording displays reactivity" She was supposed to follow up with Neurology at ___ in ___. Past Medical History: Alcohol use disorder c/b withdrawal seizures (___) Cirrhosis c/b acute hepatic failure (___) Benzodiazepine use disorder Cocaine use disorder Heroin use disorder Depression Heparin-induced thrombocytopenia (___) C. difficile colitis (___) Portal vein thrombosis s/p warfarin (___) Tobacco use disorder Hepatitis C (per patient, not noted on CHA records) Social History: ___ Family History: Denies family history of seizures. Brother passed away from apparent overdose, mother passed away from leukemia. Her sister passed away in ___ from PE. Physical Exam: Admission Physical Examination: Vitals: 97.0 60 119/88 18 95% RA General: Awake, intermittently agitated and uncooperative. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Awake and alert. She occasionally tracks and regards the examiner but at other times appears to purposefully look away from providers. She quickly and easily responds to all questions, though her answers consist only of "what do you want" or "no" or "that's enough", etc. She otherwise cannot provide any history or answer questions. She does at times cooperate during the exam, for instance when asked to lift her arms or legs. At other times she forcefully resists examination, such as closing her mouth when asked to open it. -Cranial Nerves: II, III, IV, VI: PERRL 5 to 3mm and brisk. EOMI without nystagmus. Normal saccades. Blinks to threat bilaterally V: Unable to test facial sensation VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to voice. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. -Motor: Normal bulk and tone throughout, though at times forcefully resists examination. No pronator drift. No adventitious movements, such as tremor or asterixis noted. She is able to lift all extremities easily against gravity, though at times does this more with the left than right. Unable to participate in focused strength testing. -Sensory: Grimaces and withdraws to noxious stimuli in all extremities. -Reflexes: Unable to test tendon stretch reflexes as she forcefully contracts the limb. Plantar response was flexor bilaterally. -Coordination: No obvious dysmetria when reaching for objects. -Gait: Not tested =============================================== Discharge Physical Examination: ====================== Vitals: 24 HR Data (last updated ___ @ 353) Temp: 98.1 (Tm 98.4), BP: 99/63 (99-130/63-84), HR: 87 (87-96), RR: 18, O2 sat: 95% (95-98), O2 delivery: RA General: awake, appears comfortable, appears older than stated age HEENT: NC/AT, no scleral icterus noted, MMM, edentulous, dentures in place Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused Abdomen: deferred Extremities: No ___ edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: awake, oriented to self, and hospital ___. Remembers examiner's name. Tracks and regards examiner. She is answering questions. Very pleasant. Follows most commands. Language is fluent. Confused by some commands. -Cranial Nerves: PERRL 4 to 2 mm and brisk. EOMI with no nystagmus. Normal saccades. No facial droop, facial musculature symmetric. Hearing intact to voice. Tongue protrudes in midline. -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis noted. She is able to lift all extremities easily against gravity. She has been full strength throughout bilaterally. -Sensory: intact to light touch throughout -Reflexes: deferred -Coordination: intact FNF b/l. -Gait: Normal initiation, narrow based. Pertinent Results: Admission labs: ___ 11:00PM BLOOD WBC-8.4 RBC-4.36 Hgb-13.2 Hct-39.1 MCV-90 MCH-30.3 MCHC-33.8 RDW-12.9 RDWSD-42.4 Plt ___ ___ 11:00PM BLOOD ___ PTT-29.0 ___ ___ 11:00PM BLOOD Glucose-95 UreaN-3* Creat-0.5 Na-139 K-4.8 Cl-99 HCO3-25 AnGap-15 ___ 11:00PM BLOOD ALT-11 AST-38 AlkPhos-87 TotBili-0.6 ___ 11:00PM BLOOD Albumin-4.4 Calcium-9.8 Phos-4.1 Mg-1.6 ___ 10:05AM BLOOD Ammonia-44 Discharge labs: ___ 04:40AM BLOOD WBC-5.5 RBC-4.00 Hgb-11.9 Hct-35.8 MCV-90 MCH-29.8 MCHC-33.2 RDW-12.7 RDWSD-41.3 Plt ___ ___ 04:37AM BLOOD ___ PTT-32.1 ___ ___ 04:11AM BLOOD Glucose-92 UreaN-10 Creat-0.5 Na-139 K-4.1 Cl-101 HCO3-29 AnGap-9* ___ 04:11AM BLOOD ALT-8 AST-16 LD(LDH)-126 AlkPhos-86 TotBili-0.2 ___ 04:11AM BLOOD Albumin-4.1 Calcium-9.6 Phos-5.2* Mg-1.6 ___ 03:55PM BLOOD Phenyto-17.4 ___ 06:33AM BLOOD Phenyto-18.5 ___ 05:27AM BLOOD Phenyto-19.2 ___ 04:37AM BLOOD Phenyto-24.4* ___ 06:10AM BLOOD Phenyto-29.9* ___ 03:50PM BLOOD Phenyto-34.8* ___ 04:11AM BLOOD Phenyto-29.7* ___ 05:00AM BLOOD Phenyto-23.2* ___ 05:45AM BLOOD Phenyto-16.3 ___ 06:25AM BLOOD Phenyto-13.8 MRI Brain ___: IMPRESSION: No acute intracranial abnormality on noncontrast MRI brain. There is no infarct. No suspicious parenchymal FLAIR signal abnormality. X-Ray Abd ___: FINDINGS: There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: There are no radiopaque foreign bodies. Brief Hospital Course: ___ year old woman with a history notable for seizure disorder reportedly complicated by medication non-adherence, alcohol use disorder (complicated by cirrhosis), and multiple additional substance use disorders (including benzodiazepines, heroin, and cocaine) transferred from ___ due to concern for stroke after an episode of confusion, during which she was also noted to have some right sided weakness as well as possible oral automatisms. Weakness and oral automatisms resolved, but she continued to be confused. EEG showed subclinical seizures from left temporal region with spread. Unclear cause for breakthrough seizures; unclear whether from alcohol withdrawal, polysubstance abuse, or medication nonadherence. However, Keppra level was therapeutic on admission. Infectious, toxic/metabolic work-up negative. LP done showing 0 cells, normal protein, and glucose. Unable to do MRI safety checklist and family was not able to be contacted for days. abd x-ray cleared patient for MRI. MRI without any acute process. Patient required oral phenytoin load due to difficulty in IV access. EEG improved with fewer discharges. After almost 1 week, patient became supra-therapeutic with PHT level up to 34.8. Phenytoin was held for 2 days. Patient appears to be close to her baseline mental status and became oriented to ___, ___. Daughter was difficult to reach initially. Patient lives with late-sister's boyfriend. Later, HCP form obtained from ___ showing daughter ___, ___ yo) was HCP. After OT and psych evaluations, she was deemed to not have capacity to leave AMA and cannot care for herself. Planned for patient to go to ___ after HCP agreed. #Encephalopathy #Seizure Disorder - Continued home Levetiracetam ___ mg BID, Lacosamide 200 mg BID - phenytoin 100 mg Q8H - keppra level therapeutic at 22.4 on admission - MRI brain unremarkable - LP unremarkable with 0 WBC, normal protein and glucose. #Cognitive Impairment - evaluated by OT, ___ on MOCA - psych consulted; patient has no capacity - started Seroquel 50mg QHS for sleep - Nicotine replacement per psych - patient close to baseline per ___ (brother-in-law) Chronic issues: #History of Hepatic Failure - hepatic function appears wnl currently - ammonia 44 on admission - Continue home lactulose - Continue home rifaximin. Can hold while at ___ as hepatic encephalopathy is unlikely cause of her symptoms currently. #Alcohol Abuse, multi-substance abuse - Urine tox negative. EtOH negative - Monitored CIWA score for withdrawal but did not need diazepam except for 6 days into hospitalization when she was agitated. - Treated with high dose thiamine for 3 days - continued on Thiamine 100 mg daily - Continued home folic acid 1 mg daily #Mood disorder - Continue home sertraline - psych consulted and patient DOES NOT have bipolar - seroquel for sleep Transitional Issues: - ***Does not have Bipolar disorder per psych - Consider mood stabilizing AED - f/u epilepsy clinic with Dr. ___ - check phenytoin level in 1 week - may need EEG and can consider weaning phenytoin and cross titrating to mood stabilizing AED - f/u with PCP ___ on ___: Home Medications: (per CHA records) Levetiracetam 2000mg BID Multivitamin daily thiamine 100mg daily Sertraline 100mg daily In addition, pharmacy profile shows recent fills of: Lacosamide 200mg BID Folic acid 1mg daily Ellipta 62.5mcg INH daily Discharge summary from ___ in ___ lists the following: Ellipta 62.5mcg INH daily Albuterol 90mcg INH 2 puffs as needed Folic acid 1mg daily Lacosamide 200mg BID Lactulose 15mL TID Levetiracetam 2000mg BID Multivitamin daily Naltrexone 50mg daily Omeprazole 40mg BID Rifaximin 550mg BID Sertraline 100mg daily Thiamine 100mg daily Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever 2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 3. Nicotine Lozenge 2 mg PO Q2H:PRN craving 4. Nicotine Patch 21 mg/day TD DAILY 5. Phenytoin Infatab 100 mg PO Q8H 6. QUEtiapine Fumarate 50 mg PO QHS 7. Senna 8.6 mg PO BID:PRN Constipation - Second Line 8. Thiamine 100 mg PO DAILY 9. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 10. FoLIC Acid 1 mg PO DAILY 11. LACOSamide 200 mg PO BID 12. Lactulose 15 mL PO TID 13. LevETIRAcetam ___ mg PO BID 14. Multivitamins 1 TAB PO DAILY 15. Omeprazole 40 mg PO DAILY 16. Sertraline 100 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Seizure disorder Secondary diagnoses: Cognitive impairment likely due to alcohol abuse History of Alcohol Abuse History of polysubstance abuse Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ due to confusion. You were found to have right-sided weakness and lip smacking at the outside hospital, which resolved. You had a breakthrough seizure. You were monitored on EEG which showed subclinical seizures which cannot be seen physically. You needed to be started on phenytoin as an additional anti-seizure medication. Continue to take phenytoin 100 mg TID. An appointment was made for you to follow-up in Epilepsy clinic with Dr. ___. Please see your PCP ___ ___ weeks of discharge. Thank you for letting us participate in your care. Sincerely, Your ___ Neurology Team Followup Instructions: ___
10309532-DS-6	10,309,532	26,333,520	DS	6	2180-03-21 00:00:00	2180-03-21 12:36:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: ___ Attending: ___ Chief Complaint: L ankle pain Major Surgical or Invasive Procedure: L ankle I&D, ex fix (___) L ankle ORIF (___) History of Present Illness: He was climbing a ladder when he fell out of a tree, approximately 6 foot fall. He initially presented to ___ ___, where it was partially reduced, then he was transferred for orthopedic management. He denies any paresthesias in the toes on his arrival. He received Ancef, gentamicin, and pain control at the outside hospital. Past Medical History: none Social History: Former smoker Physical Exam: Gen: well appearing in NAD LLE: short leg splint in place wiggles toes toes WWP Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have an open L ankle fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for L ankle ex-fix, I&D and subsequent surgery on ___ for ORIF L ankle fx, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is non weight bearing in the left extremity, and will be discharged on ASA for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H Duration: 14 Days 2. Aspirin 325 mg PO DAILY 3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate RX hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every four to six hours Disp #35 Tablet Refills:0 4. Senna 8.6 mg PO BID RX sennosides [___] 8.6 mg 1 tablet by mouth twice daily Disp #20 Tablet Refills:0 5.Outpatient Physical Therapy NWB LLE. Evaluate and treat. 6.Crutches Diagnosis: L ankle fracture Prognosis: Good Length of Need: 13 months Discharge Disposition: Home Discharge Diagnosis: Left open ankle fracture dislocation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Non weight bearing of the left lower extremity in a splint MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add Dilaudid ___ mg PO every four hours as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Aspirin 325 mg daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Splint must be left on until follow up appointment unless otherwise instructed. - Do NOT get splint wet. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Followup Instructions: ___
10310173-DS-18	10,310,173	23,982,429	DS	18	2172-02-12 00:00:00	2172-02-12 16:34:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M ___: MEDICINE Allergies: Penicillins / lisinopril Attending: ___. Chief Complaint: weakness, disorientation Major Surgical or Invasive Procedure: PPM battery replacement ___ History of Present Illness: ___ PMH CAD (s/p PCI ___ x1 to LAD ___, Afib on eliquis, SSS s/p PPM, HTN, HLD, BPH, patient of Dr. ___ presents after experiencing episodes of disorientation, blurry vision, and weakness at home with concern for PPM malfunction. Since ___, patient reports experiencing intermittent episodes of disorientation, blurry vision, and weakness, ___, without any actual syncopal events or falls. He states that his symptoms occur at random and are not associated with exertion. He denies any associated chest pain, palpitations, or shortness of breath. He states that his cardiologist had planned to replace his PPM later this month, but given his worsening symptoms, he presented for more urgent evaluation. He also reports worsening SOB / decreased exercise tolerance w/ exercise, treadmill time now ___ min from >30 min previously. No fevers, chills, illness; headache/dizziness; GI sx; GU sx; focal weakness or numbness. In the ED initial vitals were: HR 89, BP 103/66 RR 16 100% on RA. EKG: Paced at 65. Labs/studies notable for: - Hg 11.6, normal WBC and plt - chem10 with Cr of 1.2 and K of 4.8 - Trop <0.01 - UA Benign - CXR: The heart is is moderately enlarged. There is hilar congestion without frank edema. Patient was given nothing. EP consulted and recommended admission to ___ with formal EP consult in AM to interrogate PPM. Vitals stable on transfer. On the floor, the patient reports generally feeling well, without chest pain, palpitations, or SOB. REVIEW OF SYSTEMS: Positive per HPI, otherwise negative Past Medical History: 1. CARDIAC RISK FACTORS: - Hypertension - Dyslipidemia 2. CARDIAC HISTORY: -CAD s/p PCI x2 in ___, x1 in ___ -SSS s/p PPM ___ (at ___) -Afib 3. OTHER PAST MEDICAL HISTORY: Eczema BPH GERD Social History: ___ Family History: Mother and father both w/ MI, Mom w/ sudden cardiac death Physical Exam: ADMISSION PHYSICAL EXAMINATION: =============================== VS: 98.6 128/70 65 18 98/Ra GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP of 8 cm. CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. NEURO: CN ___ intact, strength ___ and sensation intact throughout DISCHARGE PHYSICAL EXAMINATION: =============================== VS: 24 HR Data (last updated ___ @ 659) Temp: 97.6 (Tm 98.6), BP: 130/66 (101-160/57-91), HR: 59 (52-65), RR: 16, O2 sat: 98% (96-98), O2 delivery: Cpap, Wt: 197.09 lb/89.4 kg GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. No JVD. CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. NEURO: A&Ox3, CN II-XII intact, moves all extremities Pertinent Results: ADMISSION LABS: =============== ___ 03:50PM BLOOD WBC-8.3 RBC-3.59* Hgb-11.6* Hct-35.5* MCV-99* MCH-32.3* MCHC-32.7 RDW-13.3 RDWSD-48.1* Plt ___ ___ 03:50PM BLOOD Neuts-58.5 ___ Monos-11.6 Eos-3.1 Baso-0.7 Im ___ AbsNeut-4.87 AbsLymp-2.14 AbsMono-0.97* AbsEos-0.26 AbsBaso-0.06 ___ 03:50PM BLOOD ___ PTT-29.4 ___ ___ 03:50PM BLOOD Glucose-99 UreaN-23* Creat-1.2 Na-141 K-4.8 Cl-107 HCO3-24 AnGap-10 ___ 03:50PM BLOOD cTropnT-<0.01 ___ 03:50PM BLOOD Calcium-9.1 Phos-3.4 Mg-2.3 ___ 03:20PM URINE Color-Straw Appear-Clear Sp ___ ___ 03:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG PERTINENT/DISCHARGE LABS: ========================= ___ 03:50PM BLOOD cTropnT-<0.01 ___ 11:05PM BLOOD cTropnT-<0.01 ___ 07:55AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 07:55AM BLOOD TSH-2.6 ___ 07:40AM BLOOD WBC-8.0 RBC-4.01* Hgb-13.1* Hct-39.7* MCV-99* MCH-32.7* MCHC-33.0 RDW-13.2 RDWSD-48.3* Plt ___ ___ 07:40AM BLOOD ___ PTT-30.6 ___ ___ 07:40AM BLOOD Glucose-92 UreaN-19 Creat-0.9 Na-140 K-4.7 Cl-102 HCO3-24 AnGap-14 ___ 07:40AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.3 MICROBIOLOGY: ============= ___ 3:20 pm URINE URINE CULTURE (Pending): IMAGING/STUDIES: ================ CXR ___: FINDINGS: PA and lateral views of the chest provided. Left chest wall pacemaker is noted with leads extending into the region of the right atrium and right ventricle. The heart is is moderately enlarged. There is hilar congestion without frank edema. No large effusion or pneumothorax. No signs of pneumonia. Imaged bony structures are intact. Brief Hospital Course: Mr. ___ is a ___ man with PMH of CAD s/p PCI to LAD x 1 in ___ and CHB s/p PPM ___ who presented after experiencing frequent episodes of lightheadedness, presyncope, and global weakness at home who was found to have a drained PPM battery now s/p battery change. ACUTE ISSUES: ============= # SSS s/p PPM: Patient w/ paced rhythm on EKG at 65. Symptomatic with ___ episodes of lightheadedness and presyncope that started on ___. Found to be v-pacing only on EKG. EP was consulted and found the pacemaker battery drained. The generator was changed on ___ with improvement in symptoms. # CAD: She is s/p PCI DESx1 to LAD ___ troponin negative x 3 during this admission. EKG paced, but no clear ischemic concerns. No chest pain. Home ASA and Rosuvastatin continued this admission. # Afib Diagnosed ___. Rhythm paced. Continued Eliquis during this admission. # OSA: Continued home CPAP. TRANSITIONAL ISSUES: - Continue cardiology follow-up - Medicine changes: - Discontinued Amlodipine due to orthostasis - Change Losartan from 100mg qd to 50mg bid due to orthostasis - Follow-up results of carotid ultrasound - Patient to follow-up in device clinic for scheduled setup of ___ # CODE STATUS: Full # CONTACT: Name of health care proxy: ___ Relationship: wife Phone number: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Tamsulosin 0.4 mg PO QHS 2. Ranitidine 300 mg PO QHS 3. Aspirin 81 mg PO DAILY 4. Rosuvastatin Calcium 10 mg PO QPM 5. amLODIPine 2.5 mg PO DAILY 6. Losartan Potassium 100 mg PO DAILY 7. Apixaban 5 mg PO BID 8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain Discharge Medications: 1. Clindamycin 300 mg PO Q6H Duration: 3 Days RX clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6) hours Disp #12 Capsule Refills:*0 2. amLODIPine 2.5 mg PO DAILY 3. Apixaban 5 mg PO BID 4. Aspirin 81 mg PO DAILY 5. Losartan Potassium 100 mg PO DAILY 6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 7. Ranitidine 300 mg PO QHS 8. Rosuvastatin Calcium 10 mg PO QPM 9. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: PRIMARY: ======== PPM Battery Failure Afib CAD SECONDARY: ========== HTN GERD OSA BPH 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 of frequent episodes of lightheadedness and weakness with exertion. You were found to have a drained pacemaker battery. This battery was replaced and your pacemaker was working appropriately. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Follow up with your Cardiologist, Dr. ___, as indicated below. - Complete the antibiotics as prescribed over next 3 days. - If you continue to have episodes of lightheadedness please inform you care providers. - Monitor for fever and spreading redness at procedure site. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team Followup Instructions: ___
10310261-DS-11	10,310,261	29,504,906	DS	11	2185-05-10 00:00:00	2185-05-10 11:55:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: agitation, anxiety, panic attacks Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ male with the past medical history of HTN and recent admission for facial nerve palsy related to otitis media and mastoiditis discharged on CTX and high dose steroids who presents with agitation, anxiety and panic attacks likely related to adverse effect from steroids. Patient was admitted ___ after presenting with facial droop, L ear pain, found to have otitis media with tympanic membrane rupture and mastoiditis after failing outpatient treatment. He was seen both by ENT and ID, recommended for 2 week course of CTX. For his L facial nerve palsy, he was started on high dose steroids. While in the hospital, he experienced insomnia related to steroids however was hopeful this would improve after discharge. However, since being home, he has experienced racing thoughts, poor sleep, panic attacks and overall felt like he's been "high on cocaine, really amped up." He states he has had a "short fuse" whereas normally he is very calm and patient. He notes he has been unkind to his wife and his parents. Wife corroborates this history and states he is not like himself. He denies AVH, no prior psychiatric history. Patient last took steroids on morning of ___. After having another panic attack late last night, patient decided to come in for evaluation. In the ED, patient's vitals were as follows: T 98.4, HR 81, BP 157/105, RR 16, 100% on RA. CBC without leukocytosis, BMP wnl. CXR without acute process, CT orbits with improving otitis media and mastoiditis. He was given 1 mg Ativan, admitted to medicine for further work up and management. Past Medical History: Childhood recurrent sinusitis Essential Hypertension Social History: ___ Family History: Mother: ___ Father: CAD, ___, Hypertension, OSA Physical Exam: Admission exam VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert, resting in bed, NAD EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate, mild TTP over L mastoid process, no pain with palpation of sinues CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted, RUE midline in place - dressing c/d/i NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout, very subtle L facial droop PSYCH: pressured speech, anxious Discharge exam VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert, resting in bed, NAD EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate, mild TTP over L mastoid process, no pain with palpation of sinuses CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted, RUE midline in place - dressing c/d/i NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout, very subtle L facial droop PSYCH: calm, linear thought process, appropriate affect Pertinent Results: Admission labs ___ 05:34AM BLOOD WBC-8.8 RBC-4.46* Hgb-13.2* Hct-38.2* MCV-86 MCH-29.6 MCHC-34.6 RDW-12.8 RDWSD-39.1 Plt ___ ___ 05:34AM BLOOD Glucose-83 UreaN-10 Creat-0.7 Na-139 K-3.8 Cl-100 HCO3-25 AnGap-14 ___ 05:34AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.0 CXR ___ IMPRESSION: 1. Right antecubital line ends in the right upper arm 2. No acute cardiopulmonary abnormality. CT orbits ___ IMPRESSION: 1. Interval improvement to resolution of previously seen left otitis externa and left otitis media. Mild interval improvement of left mastoiditis. No definite evidence of abscess or osseous erosive changes. 2. Stable, mild paranasal sinus disease. Brief Hospital Course: Mr. ___ is a ___ male with the past medical history of HTN and recent admission for facial nerve palsy related to otitis media and mastoiditis discharged on CTX and high dose steroids who presents with agitation, anxiety and panic attacks likely related to adverse effect from steroids. ACUTE/ACTIVE PROBLEMS: # Severe mood changes # Anxiety # Insomnia ___ steroid use - patient presented with severe anxiety and mood changes related to high dose steroids. Also with insomnia as well. Per informal discussion with ENT, ok to hold steroids as they were started for facial palsy rather than infection - his last dose was ___. Patient did not endorse prior psychiatric history and denied audio or visual hallucinations. His symptoms improved with Ativan 0.5 mg q8h prn and ramelteon for sleep. His affect was much calmer and patient much more appropriate on day of discharge. He will be given a short course of Ativan on discharge and will follow up with his PCP ___ ___. Patient was instructed to seek referral to psychiatry if mood lability/anxiety/agitation does not improve further off steroids. #Otitis media #Mastoiditis #L facial nerve palsy - continue CTX 2g q24h for two week course, holding steroids which was for nerve palsy. He received Toradol for pain while admitted. Patient has ENT follow up on ___. CHRONIC/STABLE PROBLEMS: #HTN - initially elevated to SBP 170s on admission however improved with anxiolytics. ___ further improve off steroids, patient also does not want pharmacologic therapy at this point in time. He will follow up with his PCP. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. CefTRIAXone 2 gm IV Q24H 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY 4. Ketoconazole 2% 1 Appl TP BID to feet 5. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID 6. Artificial Tears ___ DROP BOTH EYES Q1H:PRN Dry eyes 7. Artificial Tears ___ DROP BOTH EYES Q4H Dry eyes 8. Naproxen 500 mg PO Q12H:PRN Pain - Moderate 9. Zolpidem Tartrate 5 mg PO HS:PRN Insomnia Discharge Medications: 1. LORazepam 0.5 mg PO Q8H:PRN anxiety, panic attack RX lorazepam 0.5 mg 1 tab by mouth every 8 hours Disp #15 Tablet Refills:0 2. Ramelteon 8 mg PO QHS RX ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth nightly Disp #7 Tablet Refills:0 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 4. Artificial Tears ___ DROP BOTH EYES Q1H:PRN Dry eyes 5. Artificial Tears ___ DROP BOTH EYES Q4H Dry eyes 6. CefTRIAXone 2 gm IV Q24H 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY 8. Ketoconazole 2% 1 Appl TP BID to feet 9. Naproxen 500 mg PO Q12H:PRN Pain - Moderate 10. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Adverse effect from steroids Anxiety, agitation 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 severe mood swings, anxiety and agitation related to an adverse effect of steroids. Steroids were stopped with improvement in your symptoms. Your CT scan of the sinuses and ears showed improving infection and there were no abnormalities on your lab work. Please continue to take Ativan as needed over the next few days however please note this should not be taken long term. If your anxiety and agitation do not improve further after stopping steroids, please discuss with your PCP if you need to see a psychiatrist. Continue the same antibiotics at home. Thank you for allowing us to participate in your care, Your ___ team Followup Instructions: ___
10310361-DS-20	10,310,361	23,199,856	DS	20	2169-01-21 00:00:00	2169-01-21 16:19:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Latex / Cefazolin Attending: ___. Chief Complaint: vomiting Major Surgical or Invasive Procedure: ___: EGD History of Present Illness: ___ year old female s/p lap band placement by Dr ___, ___. She presents with complaint of vomiting since yesterday. She reports that the last meal she tolerated was salmon and salad. She reports that anything taken PO would just be regurgitated back up. She states that this feels like a past episode where she had immediate relief of symptoms after removal of fluid from her band. At time of examination she had no chest pain, SOB, abdominal pain, or fever. She reports bright yellow urine. In the ED, she was given glucose for hypoglycemia. Past Medical History: DM1 (on insulin pump), hyperlipidemia, hypothyroidism, obesity status post laparoscopic band, PCOS, depression, and rosacea Past Surgical History: lap band placement (___) Social History: ___ Family History: CAD in her father at age ___ who underwent CABG. Hypertension in both parents. Breast cancer in a paternal grandmother in her ___. ___ cancer in her father of unknown type. Depression in her mother and maternal grandmother. ___ cancer in her mother. ___ in a maternal grandfather. Physical Exam: 98.2 97.9 71 128/63 18 98% GEN: NAD, A&Ox3 CV: RRR PULM: CTAB ABD: s/nt/nd, lap-band port palpated in expected location EXT: WWP NEURO: grossly intact Pertinent Results: ___ 05:52AM BLOOD WBC-7.2 RBC-3.88* Hgb-11.3* Hct-35.6* MCV-92 MCH-29.2 MCHC-31.8 RDW-12.2 Plt ___ ___ 05:52AM BLOOD Glucose-223* UreaN-10 Creat-0.8 Na-136 K-4.3 Cl-104 HCO3-20* AnGap-16 ABD (SINGLE VIEW ONLY) Study Date of ___ 6:18 AM IMPRESSION: 1. Gastric band projecting over the left upper quadrant, incompletely evaluated on this study. Upper GI study would provide more detailed evaluation of gastric band orientation and positioning of the stomach relative to the band. 2. Nonspecific paucity of small bowel gas without evidence for ileus or obstruction. UGI SGL W/O KUB Study Date of ___ 9:28 AM IMPRESSION: 1. Findings concerning for prolapse of the gastric lap band. The lap band channel is tight with slow passage of contrast through the band despite it being deflated. 2. No leak. Upper GI endoscopy, ___ Moderate esophagitis with ulcerations was noted (biopsy) Lap band was noted at about 40 cm from the incisors. No resistance to passage of adult gastroscope into stomach. An angulation was noted distal to the GEJ consistent with Lap band placement. On retoflexion, deformity was noted in the cardia consistent with Lap band placement. Otherwise normal EGD to third part of the duodenum. Brief Hospital Course: Ms ___ was admitted following deflation of her lap band, for monitoring of her PO tolerance. She did well during her hospital course. She tolerated bariatric stage 1 and then stage 2 diets the day of admission. She was advanced to stage 3 the next day; however, she felt nauseated and was unable to tolerate stage3. She therefore had an EGD the following day, and this showed erosive esophagitis. High-dose PPI was begun, to be continued at discharge. She was then able to tolerate stage 3 and then later stage 4 diets. She was maintained on insulin via her home pump for her history of type 1 diabetes, and her blood sugars were checked at least every 6 hours. A ___ consult was obtained, and they followed the patient and made appropriate adjustments. She did have some episodes of hypoglycemia, treated well with dextrose; these episodes were discussed with the ___ consultant on a continuing basis and adjustments to the insulin pump were made. During her stay, the patient mentioned needing to arrange ___ for a previously-discovered breast mass, and her PCP was contacted; the patient and her PCP arranged appropriate ___ for this. On the day of discharge, she was sent home in stable condition and tolerating a stage 4 bariatric diet, on twice-daily PPI. She will be seen in Dr ___ clinic in 2 weeks, and will have ___ with her PCP and with ___. Medications on Admission: levothyroxine 150', desogestrel-ethinyl estradiol .15/.03', B12, simvastatin 10, omep 20, bupropion 200ER', lexapro 20', D3, ASA81, MVI, Finacea, metrogel, plexion cleansing cloths Discharge Medications: 1. subcutaneous insulin pump Misc Miscellaneous 2. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. bupropion HCl 200 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QAM (once a day (in the morning)). 5. escitalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multi-Vitamins W/Iron Oral 7. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day: Open capsule; sprinkle contents onto applesause and swallow whole. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: vomiting Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the surgical service for your intolerance of solids and liquids by mouth. After removing fluid from your lap band, your symptoms initially improved, however, you were later unable to tolerate a stage 3 diet. Therefore, you underwent an EGD, which showed esophagitis and gastritis. You were subsequently placed on twice daily omeprazole. You will need to ___ with Dr. ___ 2 weeks. Discharge Instructions: Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, redness or swelling around any wounds, or any other symptoms which are concerning to you. Diet: Stay on Stage 4 diet until your ___ appointment. Do not self advance diet, do not drink out of a straw or chew gum. Medication Instructions: Resume your home medications, CRUSH ALL PILLS. - Continue to use your insulin pump - You should take a stool softener, Colace, if you are constipated. - You should not use NSAIDS (non-steroidal anti-inflammatory drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and Naproxen. These agents could cause bleeding and ulcers in your digestive system. Followup Instructions: ___
10310588-DS-3	10,310,588	22,847,309	DS	3	2120-08-31 00:00:00	2120-09-05 18:43:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Compazine Attending: ___. Chief Complaint: Head bleed Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ right-handed woman, with history of hypothyroidism and bi-frontal glioblastoma (diagnosed on ___ at ___ by brain biopsy) s/p 30 radiation treatments to brain along with IV Temodar, C1D15 of Avastin, transferred for head bleed. On ___, she had a syncopal episode, while standing at the sink to make coffee she stiffened and then fell down. Her husband caught her before she hit the floor. Her teeth were clenched and she was starring straight at him. Her walking and speech improved with avastatin, but have now deteriorated over the past 2 days. On her ___ clinic visit, her language was noted to be sparse but she answered questions slowly and correctly. It was suspected that this could have been a seizure so she was started on levetiracetam 500 mgs BID. On ___, she had another syncopal episode, though this time with head strike. She went to ___, where she had a head CT that reportedly showed increased density of left temporal/parietal lobe suspicious for subarrachnoid hemorrhage. She got an extra dose of dexamethasone and was transferred to ___. In ___ ___, her vital signs were stable. She had CT of the cervical spine that did not show fracture and CXR was stable. Neurosurgery was consulted. Review of Systems: (+) Per HPI (-) She denies fever, chills, night sweats, recent weight loss or gain. She denies blurry vision, diplopia, loss of vision, photophobia. Denies headache, sinus tenderness, rhinorrhea or congestion. She denies chest pain or tightness, palpitations, lower extremity edema. She denies cough, shortness of breath, or wheezes. She denies nausea, vomiting, diarrhea, constipation, abdominal pain, melena, hematemesis, hematochezia. She denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. She denies rashes or skin breakdown. She has no numbness/tingling in extremities. All other systems negative. Past Medical History: PAST ONCOLOGIC HISTORY: ___ Neurological History: It began while vacationing in ___ with her family during the week of ___. Her husband noticed that she was less engaged in conversation and activities than before, more distracted and less focused. When she returned to ___, her family took her to the emergency department at ___ on ___. CT disclosed a mass in the frontal brain. She was transferred to ___ and biopsy showed a grade IV glioblastoma with negative mutation for IDH1. She had: (1) a stereotaxic brain biopsy at ___ on ___ that showed a grade IV glioblastoma with negative mutation for IDH1, (2) started on ___ external beam irradiation but without concurrent daily temozolomide, (3) started on ___ IV temozolomide at a dose of 100 mg, and (4) started on ___ bevacizumab 5 mg/kg every 2 weeks. PAST MEDICAL HISTORY: Hypothyroidism Heart murmur Three cesarean sections Removal of an ovarian cyst Hayfever Social History: ___ Family History: Her parents are deceased. Her mother died of smoking-related lung cancer and she also had mastoiditis, post-partum depression, major depression and emphysema. Her father died of a cerebral hemorrhage; he also had a history of tuberculosis requiring a lobectomy of a lung, multiple head traumas from parental abuse and motor cycle accidents. She has a brother who had ___ thyroiditis and underwent a partial thyroidectomy. She has 2 daugthers and a son; they are all healthy. Physical Exam: ADMISSION EXAMINATION: VITALS: Temperature 97.8 F, blood pressure 130/64, pulse 62, respiration 16 and oxygen saturation 95% in room air General: Laying in bed HEENT: EOMI/PERRL, mmm Neck: Supple, no LAD CARDIOVASCULAR: RR, no mrg Lungs: CTAB Abdomen: Soft, +BS, NT/ND EXTREMITIES: Wwp, no edema LINES: Right-sided Portacath NEUROLOGICAL EXAMINATION: Her ___ Performance Score is 50. She is awake, alert, but very abulic. She follows commands readily. There is no right-left confusion. Her language is fluent with fair comprehension. Cranial Nerve Examination: Her pupils are equal and reactive to light, 3 mm to 2 mm bilaterally. Extraocular movements are full; there is no nystagmus. Visual fields are full to threat bilaterally. Her face is symmetric. Facial sensation is intact bilaterally. Her hearing is intact bilaterally. Her tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: She does not have a drift. Her muscle strengths are ___ at all muscle groups. Her muscle tone is normal. Her reflexes are ___ throughout. Her ankle jerks are absent. Her toes are down going. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal appendicular dysmetria or truncal ataxia. Gait and stance are deferred. Pertinent Results: LABS: ___ 08:10PM BLOOD WBC-10.8 RBC-4.53 Hgb-14.3 Hct-41.5 MCV-92 MCH-31.5 MCHC-34.4 RDW-13.7 Plt ___ ___ 09:10AM BLOOD WBC-9.6 RBC-4.26 Hgb-13.2 Hct-38.4 MCV-90 MCH-31.1 MCHC-34.5 RDW-13.7 Plt ___ ___ 08:10PM BLOOD ___ PTT-24.0* ___ ___ 06:05AM BLOOD ___ PTT-25.1 ___ ___ 08:10PM BLOOD Glucose-119* UreaN-14 Creat-0.4 Na-143 K-4.3 Cl-104 HCO3-27 AnGap-16 ___ 05:55AM BLOOD Glucose-84 UreaN-8 Creat-0.4 Na-132* K-4.0 Cl-99 HCO3-28 AnGap-9 ___ 09:10AM BLOOD Glucose-91 UreaN-8 Creat-0.5 Na-134 K-4.1 Cl-100 HCO3-28 AnGap-10 ___ 08:10PM BLOOD ALT-19 AST-18 AlkPhos-50 TotBili-0.3 ___ 08:10PM BLOOD Calcium-9.0 Phos-2.5* Mg-2.3 ___ 09:10AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.0 ___ 03:51PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 03:51PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ 03:51PM URINE RBC-40* WBC->182* Bacteri-FEW Yeast-NONE Epi-0 RenalEp-1 ___ 03:51PM URINE CastHy-2* ___ 03:51PM URINE WBC Clm-MANY Mucous-OCC MICRO: ___ URINE URINE CULTURE-FINAL INPATIENT no growth ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT no growth CXR ___: No acute cardiopulmonary process. CT C-Spine ___: No acute fracture or malalignment. EEG ___: This is an abnormal routine EEG in the awake and asleep states due to the presence of intermittent left frontal focal slowing and a slow, disorganized background. These findings suggest focal subcortical dysfunction in the left frontal region, as well as an underlying diffuse encephalopathy which implies widespread cerebral dysfunction but is non-specific as to etiology. No epileptiform features were seen. ECG ___: Sinus rhythm. Short P-R interval without other signs of pre-excitation. QS complexes in leads V1-V2 with small R wave in lead V3. Possible anteroseptal myocardial infarction of indeterminate age, although could be due to lead placement. No previous tracing available for comparison. Rate PR QRS QT/QTc P QRS T 63 112 72 378/383 29 23 20 CT Head ___: 1. Acute subarachnoid hemorrhage. 2. Stable findings related to the bilateral frontal lobes masses with surrounding vasogenic edema. CT Head ___: 1. Interval evolution of left parietal subarachnoid hemorrhage, without increased hemorrhage. No new hemorrhage. 2. Bilateral frontal lobe vasocgenic edema due to known masses is stable. Brief Hospital Course: ___ is a ___ right-handed woman, with history of hypothyroidism and bi-frontal glioblastoma (diagnosed ___ at ___ by brain biopsy) s/p 30 radiation treatments to brain along with IV Temodar, C1D15 of Avastin, with 2 syncopal episodes admitted for SAH and sparse speech. (1) Subarachnoid Hemorrhage: Repeat CT Head at ___ shows mild-moderate SAH. She has been evaluated by neurosurgery and neuro examination currently stable. There is no overt coagulopathy on labs to be reversed. Mechanism is likely SAH in setting of fall with headstrike. Given blood pressure, would not be able to tolerate CCB for cerebral vasospasm in setting of bleed. The maximal swelling has passed and her mental status is improving. This could also be from the increase in the dexamethasone dose to 6 mg in a.m (from 4mg). (2) Falls: EEG showed no seizure activity. Telemetry showed no arrhythmia likely to be responsible for the falls. ___ saw the patient and thought she was safe to go home with 24 hour supervision. Keppra was continued. Encephalopathy was seen on the EEG and might be responsible for decreased talking (at times was almost completely non-verbal). There is no known specific cause of her encephalopathy. UA was suggestive of UTI, so antibiotics were started, but they were stopped when urine culture was negative. The fall risk and mental status will have to be followed in the outpatient setting. (3) Glioblastoma: She has a bi-frontal glioblastoma. She has completed radiation and temozolomide. She will wait ___ weeks for her restaging head MRI with ASL and MR spectroscopy. The bevacizumab will need to be on hold for at least 4 weeks from the subarachnoid hemorrhage. (4) Hypothyroid: Continued synthyroid. (5) Transitional Issues - Follow up phosphate level at next outpatient appointment - FULL CODE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dexamethasone 4 mg PO DAILY 2. LeVETiracetam Oral Solution 500 mg PO BID 3. Multivitamins 1 TAB PO DAILY 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Dexamethasone 6 mg PO DAILY RX dexamethasone 6 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:2 2. LeVETiracetam Oral Solution 500 mg PO BID RX levetiracetam 100 mg/mL 5 mL by mouth twice a day Disp #300 Milliliter Refills:0 3. Multivitamins 1 TAB PO DAILY 4. Vitamin D ___ UNIT PO DAILY 5. Neutra-Phos 2 PKT PO BID RX potassium & sodium phosphates [Phos-NaK] 280 mg-160 mg-250 mg 2 PKT Powder(s) by mouth twice a day Disp #28 Packet Refills:*0 6. Levothyroxine Sodium 50 mcg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: - subarachnoid hemorrhage Secondary: - falls - glioblastoma multiforme - encephalopathy - hypothyroidism Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to the hospital after falling down and hitting your head. You were found to have a bleed inside your head, likely due to hitting your head. You were seen by neurosurgery, and they did not think that surgery is necessary. A repeat CT scan suggested that you do not have active or new bleeding inside your head at this time. We do not know what caused your falls. We did an EEG to look for evidence of seizure and saw no seizure activity on the EEG. We did not detect any evidence of a cardiac cause for the fall either. You were seen by a physical therapist who recommended home physical therapy. Please attend the follow up appointments listed below. Please also see below for an updated list of medications, and please take all medications as prescribed. It was a pleasure caring for you here at ___ ___. Followup Instructions: ___
10310675-DS-15	10,310,675	23,802,458	DS	15	2167-10-06 00:00:00	2167-10-06 12:21:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Penicillins Attending: ___. Chief Complaint: trouble swallowing, difficulty speaking, arm/leg numbness/weakness, and low back pain Major Surgical or Invasive Procedure: ___ percutaneous endoscopic gastrostomy tube placement History of Present Illness: Mr. ___ is a ___ year old right-handed man with no PMH who neurology has been consulted because of concern for GBS. Mr. ___ about one month ago had a two week bout of a flu-like upper respiratory infection. He had nasal and sinus congestion. No sore throat and no difficulty with breathing. He had diffuse myalgias. He was able to work normally. He is a ___ at a ___ and works outside a lot. Mr. ___ and his mother were concerned that he might have Lyme disease so he went to his physician. Mr. ___ screening lyme serologies were positive, but confirmatory western blot was negative. Mr. ___ on ___ noticed that he started to have a pins and needles sensation in his fingers and toes. He over the next couple of days noticed that his whole feet felt numb. He went to visit his physician for these symptoms on ___ and he was told that his symptoms were because he was wearing his work boots improperly. Mr. ___ on ___ started to have a severe lower back and buttocks pain that was characterized as tearing with radiation down the back of the hamstrings. He could not sleep because of his symptoms. He went to his PCP ___ ___ and was told that he might have hepatitis C (this has sense been proven not true). Mr. ___ reports that on ___ overnight that he got no sleep because of his symptoms. He called his doctor's office ___ and was written for doxycycline, despite there being low concern for Lyme disease, which was not of benefit. He on ___ reports that his legs started to feel weak, in particular in the thighs. He fell for the first time. He ___ went to the emergency room at ___ and was seen by an ED physician, but not a neurologist. He had his reflexes tested at the patella and they were normal. His ankle reflexes were not tested. No LP or imaging studies were done. He was to follow up with neurology as an outpatient. Mr. ___ over the last few day reports that his symptoms are getting worse. He continues to have tingling in his feet with the most proximal involvement being the calves. He feels his bilateral lower back/buttocks/calf pain is getting worse. He feels most weak in his proximal legs and has had five falls in the last three days. He noticed this morning that he is having trouble with talking, but cannot pin down why. Mr. ___ parents think his voice sounds normal. He thinks his tongue might be numb, but the tongue is not weak when it moves. He does feel that when he swallows pills that they are getting stuck in the oropharynx. Mr. ___ has had poor appetite over the last few days. He denies change in vision and double vision. He does sometimes short of breath when he should not be. He endorses some subtle arm weakness. He tells me he has trouble pushing himself up when he falls. He has incoordination with walking, but it is because of the leg weakness. Past Medical History: He has had two ACL surgeries and one meniscus surgery to the left knee. Social History: ___ Family History: No family history neurologic or rheumatologic conditions. Physical Exam: Tmax: 37.9 °C (100.3 °F) T current: 37.1 °C (98.8 °F) HR: 108 (103 - 122) bpm BP: 128/78(92) {108/62(76) - 128/81(92)} mmHg RR: 20 (20 - 49) insp/min SPO2: 93% Heart rhythm: ST (Sinus Tachycardia) Gen: pleasant & cooperative, lying in bed MS: AO to name, place, & date. Conversational. Language fluent w/o errors. Mild improving dysarthria. CN - EOMI, 0.5mm aniscicoria (L>R), PERRL, left>right upper/lower facial palsy w/ inability to close eye (smile improved); voice is mildly hypophonic, facial sensation is intact, hearing is intact to conversation, palate elevates symmetrically, tongue midline Motor: Normal bulk. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ ___ L 4+ ___ 4+ ___ 4 4 4 5 4 R 4+ ___ 4+ 4 4+ 3 4 4 4 5 4 DTRs absent. Sensation: Decreased sensation to light touch and temperature in feet (90% compared to leg) and hands, subjectively improved from prior. Coordination: FNF somewhat limited by deltoid weakness but no apparent dysmetria. Pertinent Results: ___ 05:01PM BLOOD WBC-9.5 RBC-5.45 Hgb-16.4 Hct-46.4 MCV-85 MCH-30.1 MCHC-35.3 RDW-12.5 RDWSD-38.2 Plt ___ ___ 05:01PM BLOOD Neuts-58.8 ___ Monos-8.7 Eos-2.6 Baso-0.4 Im ___ AbsNeut-5.58 AbsLymp-2.76 AbsMono-0.83 AbsEos-0.25 AbsBaso-0.04 ___ 05:01PM BLOOD ___ PTT-28.9 ___ ___ 05:01PM BLOOD Glucose-93 UreaN-22* Creat-0.9 Na-140 K-4.3 Cl-107 HCO3-20* AnGap-13 ___ 05:01PM BLOOD CK(CPK)-179 ___ 08:40AM BLOOD ALT-75* AST-38 AlkPhos-80 TotBili-0.7 ___ 08:40AM BLOOD Calcium-9.8 Phos-3.2 Mg-1.9 ___ 07:59PM BLOOD TSH-1.3 ___ 07:59PM BLOOD ___ Titer-1:80* ___ 06:45PM BLOOD CRP-2.1 ___ 06:45PM BLOOD Lyme Ab-NEG Trep Ab-NEG ___ 06:45PM BLOOD HIV Ab-NEG ___ 04:33AM BLOOD HIV1 VL-PND ___ 05:14PM BLOOD Lactate-1.3 ___ 05:25PM BLOOD GQ1B IGG ANTIBODIES-Test ___ 06:45PM BLOOD SED RATE-Test ___ 06:30PM CEREBROSPINAL FLUID (CSF) TNC-0 RBC-1 Polys-9 ___ ___ 06:30PM CEREBROSPINAL FLUID (CSF) TotProt-86* Glucose-66 ___ 6:30 pm CSF;SPINAL FLUID FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count, if applicable. FLUID CULTURE (Final ___: NO GROWTH. ___ 09:56PM STOOL CDIFPCR-NEG ___ 11:50AM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 07:50PM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 3:26 pm BLOOD CULTURE Source: Line-pheresis. Blood Culture, Routine (Pending): No growth to date. ___ 3:26 pm BLOOD CULTURE Source: Line-pheresis. Blood Culture, Routine (Pending): No growth to date. ___ 3:26 pm SPUTUM Source: Expectorated. FINAL REPORT ___ GRAM STAIN (Final ___: <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. ___ 3:26 pm MRSA SCREEN Source: Nasal swab. *FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. Imaging: ___ MRI head w/ & w/o contrast IMPRESSION: -No acute intracranial hemorrhage, edema, mass effect or acute infarction -Subtle diffuse enhancement of the bilateral seventh and eighth cranial nerves. Primary differential diagnostic considerations include inflammatory conditions such as ___ syndrome or Lyme disease. ___ MRI C spine w/ & w/o contrast IMPRESSION: 1. The spinal cord demonstrates normal signal intensity and contour. No abnormal contrast enhancement is seen. 2. Trace degenerative changes of the cervical spine, described above. ___ Video Oropharyngeal Swallow IMPRESSION: 1. Aspiration with thin and nectar thick liquids. 2. Minimal pharyngeal clearance ___ CTA chest IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Right upper lobe focal consolidation. Labs at Discharge: ___ 03:58AM BLOOD WBC-8.3 RBC-3.70 Hgb-11.2* Hct-32.2* MCV-87 MCH-30.3 MCHC-34.8 RDW-13.1 RDWSD-40.8 Plt ___ ___ 04:33AM BLOOD Glucose-154* UreaN-12 Creat-0.6 Na-138 K-3.5 Cl-100 HCO3-29 AnGap-9* ___ 04:33AM BLOOD Calcium-8.8 Phos-2.4* Mg-1.9 Brief Hospital Course: This is a ___ year old previously healthy male admitted for acute-on-subacute sensory changes progressing to distal>proximal weakness with gait instability and subjective oropharyngeal sensory changes. Exam notable for bilateral facial weakness (tongue in cheek), hypophonic/nasal quality voice, and distal>proximal weakness with sensory deficits to joint position sense. LP with albuminocytologic dissociation. Presentation consistent with GBS (GQ1b Ab neg, no ophthalmoplegia or ataxia to suggest ___ variant), but also initially considered infectious (lyme, HIV, treponemal neg) or paraneoplastic processes or other auto-immune etiologies (unlikely with only ___. PLEX ___ (5 sessions). NIFs remained stable. PEG placed ___ for continued dysphagia. Course complicated by significant anxiety requiring PRN ativan/hydroxyzine and frequent, nonsustaining sinus tachycardia up to HR 160s (multiple EKGs unchanged and trop negative) and hypertension (SBP up to 170s), which was likely secondary to autonomic dysfunction with GBS and treated with spot doses of clonidine/labetalol. Noted to have sustained tachycardia, worsening chest pain, and mild hypoxia ___, CTA chest negative for PE but notable for RUL opacity concerning for HAP. Improved with vanc/cefepime, vanc stopped ___ with negative MRSA screen, plan for 7 day total antibiotic course. ___ eval recs for rehab. Discharged in improved condition to rehab with neurology resident clinic follow-up. #GBS - 5 sessions PLEX ___ - ___ - artificial tears/gel & eye patch QHS for facial weakness - scheduled gabapentin for parasthesias - Baclofen 5 mg BID for muscle spasms - scheduled tylenol and PRN oxycodone for neck/back pain - Trazadone 50 mg for sleep - hydroxyzine 50mg & low dose Ativan PRN for anxiety - PEG placed ___, titrate up TFs as tolerated to goal #HAP #Sepsis w/ mild hypoxia & worsened/sustained sinus tachycardia - vancomycin ___ - ___, stopped w/ MRSA screen negative) and cefepime ___ - ___ Transitional Issues: - follow-up has been requested in neurology resident clinic - anticipate will not need PRN ativan and oxycodone beyond rehab, will consider further pain/anxiety treatment at follow-up - will need general surgery follow-up for PEG removal when swallowing improved Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 975 mg PO Q6H:PRN Pain - Mild/Fever 2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN acid reflux 3. Artificial Tears GEL 1% ___ DROP LEFT EYE QHS 4. Baclofen 5 mg PO BID RX baclofen 5 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 5. Bisacodyl ___AILY 6. CefePIME 2 g IV Q8H Duration: 5 Days 7. CloNIDine 0.1 mg PO TID:PRN HR >110 or SBP>160 8. Gabapentin 400 mg PO TID RX gabapentin 400 mg 1 capsule by mouth three times each day Disp #90 Capsule Refills:0 9. HydrOXYzine 50 mg PO Q8H:PRN anxiety, first line 10. Loratadine 10 mg PO DAILY 11. LORazepam 0.5 mg PO BID:PRN anxiety RX lorazepam [Ativan] 0.5 mg 1 tablet by mouth twice each day as needed Disp #60 Tablet Refills:0 12. Multivitamins W/minerals 1 TAB PO DAILY 13. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Moderate RX oxycodone 10 mg 1 tablet(s) by mouth every four hours as needed Disp #30 Tablet Refills:0 14. Polyethylene Glycol 17 g PO DAILY 15. Ranitidine 150 mg PO BID 16. Senna 8.6 mg PO BID:PRN Constipation - First Line 17. TraZODone 50 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: Guillain ___ syndrome (improving) c/b autonomic dysfunction Secondary Diagnosis: Anxiety hospital acquired RUL pneumonia sinus tachycardia and labile hypertension dysphagia s/p PEG Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr. ___, You were admitted for tingling in your feet, lower back pain, arm/leg weakness, and difficulty talking/swallowing. You had a lumbar puncture, that did not show infection. Your brain/spine imaging did show abnormal signal on your cranial nerves. You received 5 treatments of plasmapheresis for Guillain ___ Syndrome and multiple pain medications for your neck/low back pain. Your strength gradually improved although your swallowing remained impaired per speech therapy evaluation, requiring a nasogastric tube that was converted to a percutaneous gastric tube for supplemental nutrition. You also had a significantly elevated blood pressure and heart rate during your course, with intermittent chest pain. Multiple chest pain evaluations were unremarkable, although you were noted to have a right upper lobe pneumonia on ___. Your heart rate improved somewhat with treatment of your pneumonia with antibiotics. You also had frequent anxiety associated with your medical condition and prolonged hospitalization, which improved with as needed medications. This also contributed to your elevated heart rate and blood pressure. Physical therapy, occupational therapy, and speech therapy evaluations found you most appropriate for rehab on discharge. You were discharged in improved condition to rehab on ___. You will follow-up in resident neurology clinic after discharge [you have an appointment with Dr ___ Dr ___ on ___ to continue to monitor your improvement after discharge. Thank you for allowing us to participate in your care. Sincerely, Your ___ neurology team Followup Instructions: ___
10310675-DS-16	10,310,675	22,927,899	DS	16	2167-10-24 00:00:00	2167-10-28 16:24:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Penicillins / peanuts Attending: ___. Chief Complaint: Weakness Major Surgical or Invasive Procedure: PLEX x5 sessions History of Present Illness: ___ is a ___ right-handed man with a history of GBS recently treated with plasmapheresis who presents today for progressive weakness. Patient was discharged from ___ to ___ on ___. There, his parents report that he was progressing well. In terms of his motor function, he was able to assist the nurses when they were trying to move him by rolling over slightly on his own. His speech had improved, and his swallowing also was heading in the right direction as they report that he was recently cleared for thin liquids and ground solids under supervision. On ___ noticed that he was having a harder time moving his ankles around. This progressed over the weekend, and he started noticing trouble with his speech on ___ evening worsening into ___. The day prior to presentation he began experiencing more back pain similar to when he was in the hospital previously. His parents deny any issues with abnormal blood pressure or heart rate at rehab, and they report that he has not had a fever recently. He did finish a course of antibiotics for pneumonia, but since then they have noticed no signs of infection. ___ did say that he was coughing a little bit the day prior to presentation, but this is not continued today and he has no fever. He does have loose stools, though this is thought to be related to his tube feeds. ___ says that currently he feels much worse than when he was discharged from ___ in mid ___. ___ endorses difficulty producing speech due to weakness of the face. He continues to endorse numbness and tingling in the hands and feet, which is overall unchanged since discharge. He endorses sweating all the time, which has been constant since the onset of GBS. On neurologic review of systems, the patient denies headache, lightheadedness, or confusion. Denies difficulty with comprehending speech. Denies loss of vision, blurred vision, diplopia, vertigo, tinnitus, hearing difficulty. Denies loss of sensation. On general review of systems, the patient 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. Patient initially presented with ascending paresthesias beginning ___, lower back pain, and falls. LP was notable for albuminocytologic dissociation with 0 WBC and 86 protein. During patient's hospitalization, GBS was thought to be the most likely diagnosis after infectious etiologies including Lyme, HIV, treponemal testing was negative. GQ 1B antibodies were negative. ___ was positive with a titer of 1:80. He was treated with plasma exchange from ___ to ___ with 5 sessions total. During this time, his NIFs remained stable. He had a PEG tube placed on ___ for dysphagia. He did experience significant amount of anxiety during his hospitalization requiring Ativan and hydroxyzine. Fortunately, he has no longer needed these medications since going to rehab. He also experienced non-sustaining sinus tachycardia up to a heart rate of 160s with a negative cardiac work-up as well as hypertension with systolic blood pressure up to the 170s, which was thought to be secondary to autonomic dysfunction from GBS. This has not been an issue at rehab. On ___, he had tachycardia, chest pain and hypoxia and was found to have a pneumonia treated with cefepime for 7 days total. He finished this antibiotic course and rehab and has had no further issues with infections. Past Medical History: He has had two ACL surgeries and one meniscus surgery to the left ___. Diagnosed with GBS in ___, completed PLEX x5 Social History: ___ Family History: No family history neurologic or rheumatologic conditions. Physical Exam: On Admission: General: Awake, cooperative. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. 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: warm, clammy skin. No rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive to conversation. Speech was dysarthric. Language is fluent. -Cranial Nerves: II, III, IV, VI: PERRL 4 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch V1-V3 bilaterally. VII: Face symmetric, no movement of facial musculature VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline with full excursions bilaterally. -Motor: Decreased bulk, tone. [Delt] [Bic] [Tri] [Fex] [Fflex] [IP] [Quad] [Ham] [TA] [Gas] L 3 4 4 4 4- 2 3 2 1 1 R 3 4+ 4 4+ 4- 2 3 2 1 1 ___ parents note that he could lift his IPs off the bed ___ Neck flexion ___ Can count to 21 in 1 breath NIF -50 VC 2.6 L in the ED -Sensory: He reports that the pinprick does not feel as sharp in the lower extremities bilaterally. Intact to pinprick in the upper extremities bilaterally which gets less intense distally. No abdominal spinal level. Intact to light touch. -DTRs: ___ throughout. Toes mute. -Coordination: Unable to assess. -Gait: Unable to assess. Discharge exam: Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive to conversation. Speech was hypophonic but significantly better compared to admission -Cranial Nerves: II, III, IV, VI: PERRL 4 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. bilateral mild ptosis, able to close eyes almost fully- 1 mm gap V: Facial sensation intact to light touch V1-V3 bilaterally. VII: Face symmetric, slight movement of facial musculature VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline with full excursions bilaterally. -Motor: Decreased bulk, tone. [Delt] [Bic] [Tri] [wrEx] [Fex] [Fflex] [IP] [Quad] [Ham] [TA] [Gas] L 5- 5 4 5 4 4 3 5 3 3 3 R 5 5 4 5 5- 4 3 5 3 3 3 Neck flexion ___ -Sensory: Intact to light touch bilaterally. -DTRs: Left ___ 1+, rest areflexic -Coordination: Unable to assess. -Gait: Unable to assess. Pertinent Results: ___ 04:36AM BLOOD WBC-7.2 RBC-4.66 Hgb-14.1 Hct-40.3 MCV-87 MCH-30.3 MCHC-35.0 RDW-13.7 RDWSD-42.3 Plt ___ ___ 01:00PM BLOOD Neuts-46.1 ___ Monos-8.6 Eos-2.4 Baso-0.4 Im ___ AbsNeut-3.93 AbsLymp-3.56 AbsMono-0.73 AbsEos-0.20 AbsBaso-0.03 ___ 04:36AM BLOOD Plt ___ ___ 04:36AM BLOOD ___ ___ 04:58AM BLOOD Glucose-117* UreaN-13 Creat-0.5 Na-141 K-3.9 Cl-103 HCO3-26 AnGap-12 ___ 04:20PM BLOOD ALT-41* AST-18 AlkPhos-57 TotBili-0.7 ___ 04:58AM BLOOD Calcium-9.7 Phos-3.8 Mg-1.7 ___ 04:20PM BLOOD PEP-HYPOGAMMAG IgG-496* IgA-106 IgM-31* IFE-NO MONOCLO ___ 01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 01:15PM BLOOD GreenHd-HOLD Brief Hospital Course: ___ is a ___ right-handed man with a history of GBS who was initially admitted on ___ for lower extremity weakness and paresthesias. During that hospital course he also developed bulbar features with facial weakness and dysphagia for which he had a PEG placed on ___. He was discharged on ___ to ___ s/p completion of five PLEX treatments over 10 days. Patient was readmitted on ___ for progressive weakness in his lower extremities and trouble with speech. The resurgence of these symptoms was felt to be consistent with treatment related fluctuation. His neurological exam on admission showed increased weakness in neck flexion, all extremities - more pronounced in lower extremities and his NIF were severely depressed. He was started on repeat PLEX treatments x 5 and was closely monitored. EMG with e/o subacute and ongoing sensorimotor polyneuropathy with primary demyelinating and secondary axonal features. GQ1b-IgG Ab was neg last admission, No metabolic or infectious etiology was identified and heavy metal screen was neg currently. His symptoms gradually improved along with improvement in NIF and VC. Features of dyautonomia were also noted to be better compared to previous admission. He also expressed subjective improvement in paresthesias. He was tolerating tube feeds and was participating well with ___ throughout and will be transferred to Rehab for continuation of therapy. Transitional issues: - Continue ___ - Continue tube feeds per instructions and can transition to oral feeds when tolerated. - Can discontinue the prophylactic dose lovenox for DVT PPx at discharge - Follow up with Neurology and PCP after discharge from Rehab Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN acid reflux 2. Bisacodyl ___AILY 3. CloNIDine 0.1 mg PO TID:PRN HR >110 or SBP>160 4. Gabapentin 400 mg PO TID 5. HydrOXYzine 50 mg PO Q8H:PRN anxiety, first line 6. Loratadine 10 mg PO DAILY 7. LORazepam 0.5 mg PO BID:PRN anxiety 8. Multivitamins W/minerals 1 TAB PO DAILY 9. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Moderate 10. Polyethylene Glycol 17 g PO DAILY 11. Ranitidine 150 mg PO BID 12. Senna 8.6 mg PO BID:PRN Constipation - First Line 13. TraZODone 50 mg PO QHS 14. Artificial Tears GEL 1% ___ DROP LEFT EYE QHS 15. Acetaminophen 975 mg PO Q6H:PRN Pain - Mild/Fever 16. Enoxaparin Sodium 40 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Artificial Tears GEL 1% ___ DROP BOTH EYES Q6H 3. OxyCODONE (Immediate Release) 5 mg PO/NG Q6H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth q6hprn Disp #5 Tablet Refills:*0 4. TraZODone 50 mg PO QHS:PRN insomnia 5. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO/NG QID:PRN acid reflux 6. Bisacodyl ___AILY 7. CloNIDine 0.1 mg PO TID:PRN SBP>160 8. Enoxaparin Sodium 40 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time 9. Gabapentin 400 mg PO/NG TID 10. HydrOXYzine 50 mg PO/NG Q8H:PRN anxiety, first line 11. Loratadine 10 mg PO DAILY 12. LORazepam 0.5 mg PO BID:PRN anxiety 13. Multivitamins W/minerals 1 TAB PO DAILY 14. Polyethylene Glycol 17 g PO/NG DAILY 15. Ranitidine 150 mg PO/NG BID 16. Senna 8.6 mg PO/NG BID:PRN Constipation - First Line Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: GBS- Treatment fluctuation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Mr. ___, you were admitted to the hospital for progressive weakness due to Guillian ___ Syndrome. You had difficulty protecting your airway after vomiting and went to the neurointensive care unit for monitoring. Given your respiratory status was stable, you were then transferred to the general neurology service. During this hospital admission you received another five treatments of plasmapheresis. Your facial and muscle weakness improved after these treatments along with physical therapy compared to when you were admitted. You were also seen by speech and swallow who recommended to continue receiving nutrition through your PEG tube with supervised sips of water. They recommended that you get a follow up video swallow test and ___ Rehab. Nutrition also saw you and recommended continuing your current feeding regimen. You were discharged to ___ Rehab in stable condition. Please continue your home medications as prescribed. Sincerely, Your ___ Neurology Team Followup Instructions: ___
10310675-DS-17	10,310,675	29,941,344	DS	17	2167-11-29 00:00:00	2167-12-02 22:15:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Penicillins / peanuts / house dust Attending: ___ Chief Complaint: worsening weakness and numbness from ___ Rehab. Major Surgical or Invasive Procedure: Central Line placement and removal. Midline placement on ___ History of Present Illness: The patient is a ___ year-old right-handed man/woman with a history of GBS recently treated with PLEX (x1 in ___, x1 in ___ p/w worsening weakness and numbness from ___ Rehab. Patient was most recently discharged from ___ on ___, after presenting similarly from rehab with worsening weakness and numbness. Patient reports that upon his last discharge, he has had numbness and tingling in his hands and feet, but had been otherwise making steady progress with daily ___. He had been able to stand with assistance and able to take several steps with a walker. He had also been cleared to have PO intake since about 2 weeks ago. About 10 days ago, the patient and his mother noticed that his voice was getting softer. The numbness/tingling in his feet gradually progress upward, now up to mid-calf bilaterally. The similar sensations in his hands have gotten worse without progressing proximally. He now has trouble lifting his feet from the ground to take a single step, feels that food is getting stuck in his throat, has noticed that he is chewing more with every bite of food, has increasing difficulty tranferring himself from bed to chair, can no longer bend his legs while in bed. He also complains that the strength in his shoulders are becoming weaker. Two weekends ago, he had a bout of abdominal pain for 3 days without any fevers, chills, nausea, vomiting, diarrhea. This spontaneously resolved. He was previously discharged on multiple medications, including clonidine PRN, hydroxyzine PRN, oxycodone PRN, lorazepam PRN, trazodone nightly, gabapentin TID. However, he has only taken gabapentin and PRN Tylenol since the most recent discharge. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. 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 nausea, vomiting, diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: He has had two ACL surgeries and one meniscus surgery to the left knee. history of GBS recently treated with PLEX (x1 in ___, x1 in ___ Peg tube in place Social History: ___ Family History: No family history neurologic or rheumatologic conditions. Physical Exam: on admission: Physical Exam: Vitals: Temp 98.5 P 97 BP 120/79 R 14 SpO2 99% RA FVC: 2.32 L MIP/ NIF: -48 cmH20 (@ discharge on ___: Vital Capacity: 2.62L, NIF over -60cmh2o General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no nuchal rigidity Pulmonary: breathing non labored on room air Cardiac: warm and well perfused Abdomen: soft, NT/ND, no masses or organomegaly noted. Extremities: No cyanosis, clubbing or edema bilaterally Skin: no rashes or lesions noted. Neurologic: -Mental Status: Awake, alert, oriented to self, place, time and situation. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Mildly hypophonic. Pt was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. The pt had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Fundoscopic exam performed, revealed crisp disc margins with no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric, weak buccinator bilaterally VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates higher on L side XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline; fasciculations noted, weak tongue-in-cheek bilaterally -Motor: Normal bulk, tone throughout. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc L 4+ 4+ 4+ 5- 4+ 4+ 4 3 5 4+ 2 1 R 4+ 4+ 4+ 5- 4+ 4+ 4 3 5 4+ 2 1 -Sensory: dullness from feet up to midshin bilaterally; feet - 25% to pinprick, 50% to LT, 90% to cold; calves 75% to pinprick, 0% to LT, 70% to cold; hands 70% to LT and pinprick, 90% to cold; decreased proprioception in great toes, intact @ thumbs -DTRs: mute throughout ___ response was mute bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF. Unable to HTS. -Gait: deferred ======================= Exam at time of discharge: Physical Exam: 24 HR Data (last updated ___ @ 742) Temp: 97.6 (Tm 98.3), BP: 106/65 (104-114/65-69), HR: 69 (69-90), RR: 18, O2 sat: 96% (96-100), O2 delivery: RA Vital Capacity: :3.59 L Negative Inspiratory Force:-60 Skin: diaphoretic, some ttp near pharesis line MS: alert, able to relate interval history, speech is fluent with only trace dysarthria CN: pupils 5->3, looks in all directions, bifacial weakness is trace Motor: Head flexion 4+, head extension 5. delt 5 bl, bicepts/triceps 5 bl, WrE/FE 5 bl, Fingerflex and Ext 5; IP 4 on R 3 on L, ham 4 R and 3+ on Left ; TA 3 bl, quads 5; ___ 4L 3R. Bastrox 4+ b/l. Reflexes: 2 biceps and 2 tri on right, 1L tric (iv placement made L bic untestable), pat 0, ach 0. Pertinent Results: ___ 06:55AM BLOOD 25VitD-12* ___ 07:10AM BLOOD WBC-7.3 RBC-3.75* Hgb-11.4* Hct-32.5* MCV-87 MCH-30.4 MCHC-35.1 RDW-12.7 RDWSD-40.3 Plt ___ ___ 07:10AM BLOOD ___ PTT-28.2 ___ ___ 06:55AM BLOOD ___ ___ 06:55AM BLOOD Glucose-86 UreaN-10 Creat-0.4* Na-144 K-4.1 Cl-104 HCO3-25 AnGap-15 ___ 06:55AM BLOOD ALT-32 AST-21 AlkPhos-54 TotBili-0.7 ___ 06:55AM BLOOD Calcium-9.3 Phos-2.4* Mg-1.7 ___ 05:30AM BLOOD %HbA1c-4.8 eAG-91 ___ 05:30AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG ___ 05:37AM BLOOD ___ dsDNA-NEGATIVE ___ 06:35AM BLOOD PEP-NO SPECIFI ___ 10:52AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 05:21AM BLOOD ___ pO2-108* pCO2-37 pH-7.45 calTCO2-27 Base XS-1 Comment-GREEN TOP ___ 05:21AM BLOOD Lactate-0.8 ___ 05:25AM BLOOD QUANTIFERON-TB GOLD-Test ___ 05:25AM BLOOD THIOPURINE METHYLTRANSFERASE (TPMT), ERYTHROCYTES-PND ___ 08:30PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 05:32PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 06:48PM URINE Porphob-NEGATIVE ___ 05:32PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG Micro: ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PRELIMINARY {STAPH AUREUS COAG +}; Aerobic Bottle Gram Stain-FINALINPATIENT ___ TIP-IVWOUND CULTURE-FINAL {STAPH AUREUS COAG +}INPATIENT ___ CULTUREBlood Culture, Routine-PRELIMINARY {STAPH AUREUS COAG +}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINALINPATIENT ___ CULTUREBlood Culture, Routine-FINAL {STAPH AUREUS COAG +}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINALINPATIENT ___ CULTUREBlood Culture, Routine-FINAL {STAPH AUREUS COAG +}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINALINPATIENT ___ CULTUREBlood Culture, Routine-FINAL {STAPH AUREUS COAG +}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINALINPATIENT ___ NOT PROCESSED INPATIENT ___ NOT PROCESSED INPATIENT ___ CULTURE-FINALEMERGENCY WARD -------- ECHO - CONCLUSION: The left atrial volume index is normal. The right atrial pressure could not be estimated. There is normal left ventricular wall thickness with a normal cavity size. There is suboptimal image quality to assess regional left ventricular function. Overall left ventricular systolic function is low normal. The visually estimated left ventricular ejection fraction is 50-55%. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Low normal LV systolic function. Mild tricuspid regurgitation. ----------- CTA Chest - EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: ___ year old man with CIDP, fever, hypoxia, tachycardia// Eval for PE TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Total DLP (Body) = 505 mGy-cm. COMPARISON: None FINDINGS: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus. Pulmonary artery start normal, measuring 30 mm. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. A right-sided central line catheter ends at the cavoatrial junction. AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal, is present. Bilateral 12-13 mm borderline hilar lymph nodes are noted. No mediastinal mass. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Lungs are clear without masses or areas focal consolidation. Mild posterior dependent atelectasis with a trace right pleural effusion are noted. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: Partially visualized spleen measuring 13 cm is top limit, otherwise the included portion of the upper abdomen is unremarkable. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: No evidence of pulmonary embolism or aortic abnormality. Borderline bilateral hilar lymph nodes are nonspecific. If there is clinical concern, follow-up chest CT could be performed in 6 months. Mild splenomegaly. Brief Hospital Course: Mr. ___ is a ___ right-handed male with history of GBS/AIDP (acute inflammatory demyelinating polyradiculoneuropathy) presenting with ___ worsening of his AIDP symptoms (increased weakness and increased difficulty with breathing) since initially presenting in ___. Presentation now concerning for CIDP (chronic inflammatory demyelinating polyradiculoneuropathy), patient was treated with 3 rounds of plasma exchange, and 4 doses of prednisone 60mg. These treatments were held in the setting of clinical improvement given development of a central line associated bacteremia from the pheresis line, STAPH AUREUS COAG +., treated with ceFAZolin 2 g IV Q8H (first negative blood culture ___ Midline placed ___ for chronic antibiotics administration for a four-week course. Patient clinically improving, and plan for rehab with follow up with the Neuromucular and Infectious Diseases services. The Neuromuscular service (Drs. ___, ___ should be contacted at the number above with any concerns for symptom deterioration, as re-treatment with IVIG may be considered. -------------- Transitional Issues: [] Continued follow-up with Infectious Diseases, to consider repeat TTE or surveillance blood cultures following discharge. [] Malnutrition, monitor nutrition status, follow up vitamin D level. Monitor electrolytes, magnesium, phosphate. [] Borderline bilateral hilar lymph nodes are nonspecific. If there is clinical concern, follow-up chest CT could be performed in 6 months. [] Vitamin D deficiency. Repeat Vit D Level in 6 weeks following supplementation with Vit D with 50,000 units weekly for 6 weeks. [] Please draw weekly labs (CBC with differential, BUN, Cr) and send to: ATTN: ___ CLINIC - FAX: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Artificial Tears GEL 1% ___ DROP BOTH EYES Q6H 3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH PAIN 4. TraZODone 50 mg PO QHS:PRN insomnia 5. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN acid reflux 6. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line 7. CloNIDine 0.1 mg PO PRN SBP>160 8. Enoxaparin Sodium 40 mg SC DAILY 9. Gabapentin 400 mg PO TID 10. HydrOXYzine 50 mg PO Q6H:PRN anxiety, first line 11. Loratadine 10 mg PO DAILY 12. LORazepam 0.5 mg PO Q8H:PRN anxiety 13. Multivitamins W/minerals Chewable 1 TAB PO DAILY 14. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 15. Ranitidine (Liquid) 150 mg PO BID 16. Senna 8.6 mg PO BID:PRN Constipation - First Line Discharge Medications: 1. CeFAZolin 2 g IV Q8H MSSA Bacteremia Duration: 14 Days 2. Heparin Flush (10 units/ml) 2 mL IV X1 PRN For Midline Insertion 3. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush 4. Vitamin D ___ UNIT PO 1X/WEEK (FR) Duration: 6 Weeks check levels in 6 weeks 5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 6. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN acid reflux 7. Artificial Tears GEL 1% ___ DROP BOTH EYES Q6H 8. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line 9. CloNIDine 0.1 mg PO PRN SBP>160 10. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time 11. Gabapentin 400 mg PO TID 12. HydrOXYzine 50 mg PO Q6H:PRN anxiety, first line 13. Loratadine 10 mg PO DAILY 14. LORazepam 0.5 mg PO Q8H:PRN anxiety 15. Multivitamins W/minerals Chewable 1 TAB PO DAILY 16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 17. Ranitidine (Liquid) 150 mg PO BID 18. Senna 8.6 mg PO BID:PRN Constipation - First Line 19. TraZODone 50 mg PO QHS:PRN insomnia Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. CIDP exacerbation. 2. MSSA Catheter associated Bacteremia. 3. Severe Malnutrition in the context of acute illness. 4. Vitamin D Deficiency. 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 for increased weakness and increased difficulty with breathing. You you were treated for an exacerbation of what is now likely to be CIDP (chronic inflammatory demyelinating polyradiculoneuropathy). You were treated with 3 rounds of plasma exchange, and 4 doses of prednisone 60mg daily. These treatments were held in the setting of clinical improvement given development of a central line associated bacteremia from the pheresis line, STAPH AUREUS COAG Positive MSSA Bacteremia (first negative blood culture ___. You are being treated with ceFAZolin 2 g IV every 8 hours for 4 weeks from ___. Your exam is improving and your are ready for rehab with neuromuscular follow up. If you notice lack of improvement while at rehab, increased work of breathing, decreased sensation, or decreased reflexes from your new baseline, you should contact your neuro-muscular doctor for likely need of additional treatment. Do not wait for a deterioration to call. The Infectious Diseases service will continue to follow up with you after leaving the hospital. They will discuss the need for a repeat Echocardiogram at a later date or serial blood cultures in a few months from now to further rule out the unlikely possibility of bacterial endocarditis. We are adding Vitamin D supplementation (50,000 units by mouth weekly) to your medications, as you were found to have low vitamin D. You should check these levels in one month. You also had an incidental/and non-specific finding on CT of chest, which you should discuss with your primary care provider to see if they feel you need to repeat imaging in 6 months. Thank you for the opportunity to partake in your care, The ___ neurology team. Followup Instructions: ___
10311237-DS-12	10,311,237	27,437,989	DS	12	2163-01-28 00:00:00	2163-01-28 23:24:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril / digoxin / minocycline / tramadol / Dilaudid Attending: ___. Chief Complaint: Foot pain Major Surgical or Invasive Procedure: Cardiac catheterization (___) Right femoral cutdown with stenting of popliteal artery (___) History of Present Illness: Mr. ___ is a ___ male with a history of paroxysmal afib (on Coumadin), COPD, CAD, systolic CHF, pulm HTN, recent NSTEMI, peripheral arterial disease, DM (not insulindependent), HTN, HLD, hx TIAs presents with shortness of breath, found to have AFwRVR, HF exacerbation, and pulseless LLE, transferred to ___ for vascular evaluation. Per patient and wife, he had worsening dyspnea on exertion starting on ___ and gradually worsening. The day prior to this, he woke up in sweats and had a HR in the 160s, which improved after taking his home beta blocker. He reports some ankle swelling and 10 lb weight gain in one week. His dry weight is 156lbs. He usually low salt, but had some ham on ___. His dyspnea was at rest, but worsened with exertion, and gradually became worse and he presented to ___. He reports several days non-productive cough, as well as cold L foot for 2 days. No fevers, chills, headache, neck pain, chest pain, sore throat, abdominal pain, n/v/d. At ___, they were unable to Doppler DP pulse on L foot and it was cool. Vascular was consulted and heparin gtt was started. He was found to be in AFwRVR and given IV and PO diltiazem. He was also given 20mg IV Lasix with unclear urine output. He was transferred for vascular surgery evaluation for his foot. In ___, tachycardic to 110s, normotensive, on 2L nasal cannula. Found to have undopplerable LLE pulses, so vascular was consulted. Vascular was able to find an in tact ___ signal in left foot and faint/monophasic one in the R foot. They recommended ABI/PVRs and duplex ultrasound in am to assess bypass grafts. He was also found to have bilateral crackles, elevated BNP to >6K, and supratherapeutic INR to 7.7. Decision made to admit to medicine for management of CHF exacerbation with vascular consult. Of note, patient was recently discharged for infected external iliac bypass graft pseudoaneurysm and MSSA bacteremia treated with IV antibiotics to end on ___ (cefazolin, cipro, and flagyl). On arrival to the floor, patient reports continued shortness of breath. No chest pain, palpitations, or lightheadedness. Past Medical History: # CARDIAC RISK FACTORS - HTN - HLD - DM2 # CARDIAC HISTORY - paroxysmal afib (on Coumadin) - CAD (5v CABG ___, NSTEMI in ___ - systolic CHF - pulm HTN # OTHER MEDICAL HISTORY - peripheral arterial disease s/p bilateral femoral cut down with patch angioplasty and R belwo the knee popliteal bypass and R toe amputations, left iliac stent/PTA ___ c/b graft aneurysm infection - hx TIAs - COPD - GERD - left CEA, right CEA x2 - right ICA angioplasty Social History: ___ Family History: noncontributory Physical Exam: ADMISSION EXAM ============== VS: 97.7 129/80 123(mostly 110s, occaisionally up to 120s-130s for short periods of time) 18 95 2L GENERAL: No apparent distress HEENT: anicteric sclera NECK: JVP elevated to mandible at 30 degrees HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: Bibasilar crackles, mild wheezes ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: LLE is cooler than RLE, 1+ pitting edema in ankles bilaterally PULSES: in tact ___ signal in left foot and faint/monophasic one in the R foot NEURO: No gross motor or coordination abnormalities SKIN: No rashes DISCHARGE EXAM ============== VS: T 98.3, 123/75, HR 74, RR 20, 100% RA GENERAL: NAD, resting in bed comfortably HEENT: PERRL, EOMI, mmm, oropharynx clear NECK: JVP at 8-9 cm at 30 degrees HEART: Irregular rhythm, tachycardic, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezing, crackles ABDOMEN: Soft, nondistended, nontender EXTREMITIES: RLE warm (LLE cooler). Right toes with mottling and cyanosis stable. Sensation intact in RLE and LLE. Dopplerable monophasic DP pulse present on right foot. NEURO: No gross motor or coordination abnormalities Pertinent Results: ADMISSION LABS ============== ___ 10:10PM BLOOD WBC-8.5 RBC-3.28* Hgb-8.6* Hct-29.4* MCV-90# MCH-26.2 MCHC-29.3* RDW-24.4* RDWSD-78.7* Plt ___ ___ 10:10PM BLOOD Neuts-74.5* Lymphs-13.8* Monos-8.6 Eos-1.8 Baso-0.9 NRBC-0.2* Im ___ AbsNeut-6.29* AbsLymp-1.17* AbsMono-0.73 AbsEos-0.15 AbsBaso-0.08 ___ 10:10PM BLOOD ___ PTT-62.1* ___ ___ 10:10PM BLOOD Plt ___ ___ 10:10PM BLOOD Glucose-134* UreaN-15 Creat-0.6 Na-139 K-4.5 Cl-103 HCO3-24 AnGap-12 ___ 10:10PM BLOOD proBNP-___* ___ 10:10PM BLOOD cTropnT-<0.01 ___ 10:10PM BLOOD Albumin-3.1* Mg-2.0 IMAGING ======= ___ CXR IMPRESSION: 1. Findings most suggestive of volume overload and/or heart failure, although concurrent infection is possible if the clinical history suggests such. 2. Tip of the right PIC line is indistinct, probably in the low right atrium at least 7.5 cm below the estimated location of the superior cavoatrial junction. ___ TTE A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is severe global left ventricular hypokinesis (LVEF = XX %). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. The right ventricular cavity is dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, biventricular systolic function has deteriorated. The severity of mitral and tricuspid regurgitation has increased substantially. Pulmonary hypertension is now severe. The heart rate is faster. ___ ART EXT (REST ONLY) FINDINGS: Right: Doppler waveform analysis reveals triphasic waveforms at the right common femoral artery phasic waveforms at the popliteal posterior tibial and DP. Resting ABI is 0.7. PVRs demonstrate normal waveforms in the thigh with significant dampening at the calf level and minimal additional dampening at the ankle and metatarsal level. Left: Triphasic waveforms are seen by Doppler at the common femoral and popliteal while monophasic waveforms are seen at the posterior tibial and dorsalis pedis. An ABI could not be obtained due to noncompressible vessels. Pulse volume recordings demonstrate the preserved waveforms in the thigh with an absence of calf augmentation and minimal additional dampening at the ankle and metatarsal level. IMPRESSION: Right SFA and bilateral tibial arterial disease. ___ VENOUS DUPLEX US IMPRESSION: Patent right thigh great saphenous vein right small saphenous vein left great and small saphenous veins with diameters as noted. See the scanned worksheet for detailed diameter locations. ___ ARTERIAL DUPLEX US Patent bilateral fem popliteal grafts. 4 cm pseudoaneurysm, partially thrombosed but still with multiple areas of significant flow at the distal anastomosis of the right graft. CTA ___ 1. Severe atherosclerotic disease as described above. 2. Status post right femoral popliteal bypass graft which appears patent with significant narrowing. New 4.4 cm pseudoaneurysm at the level of the distal graft in the posterior distal right thigh. 3. Patent left femoral popliteal bypass graft with delayed flow. 4. Bilateral pleural effusions. CXR ___ Compared to chest radiographs since ___, most recently ___. Mild to moderate pulmonary edema has improved since ___. Small pleural effusions are probably unchanged. Moderate cardiomegaly also stable. Bibasilar opacification probably combination of dependent edema and atelectasis. No pneumothorax. Right PIC line ends close to the superior cavoatrial junction. TTE ___ Overall left ventricular systolic function is severely depressed (LVEF= 20 %). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. There is depressed free wall contractility of the right ventricle. IMPRESSION: Severe global left ventricular systolic dysfunction. Depressed right ventricular systolic function. Compared with the prior study (images reviewed) of ___ this was a focused study for function only and global left ventricular systolic function is not significantly changed. Cardiac catheterization ___ Coronary Anatomy Dominance: Right * Left Main Coronary Artery The LMCA has a distal 90% stenosis. * Left Anterior Descending The LAD is fully occluded proximally. There is antegrade flow to a S1 and D1. * Circumflex The Circumflex is flush occluded at the origin. It fills vial collaterals from LIMA-LAD-D. * Right Coronary Artery was not imaged given prior known ostial CTO. LIMA-LAD patent. SVG-RCA patent. There is a distal 30% stenosis right after the landing. Impressions: Normal left-side filling pressure. Severe three vessel disease unchanged from prior angiogram. TEE ___ A left-to-right shunt across the interatrial septum is seen at rest. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed ___ The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There are complex (>4mm) atheroma in the aortic root. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. DISCHARGE LABS ============== ___ Na 140 K 4.6 Cl 96 HCO3 33 BUN 20 Cr 0.8 Glu 159 ___ WBC 7.4 Hb 9.8 Hct 33.5 Plt 438 ___ MB 1 Trop-T < 0.01 Brief Hospital Course: HOSPITAL COURSE =============== Mr. ___ is a ___ male with a history of paroxysmal afib (on Coumadin), COPD, CAD, systolic CHF, pulm HTN, recent NSTEMI, peripheral arterial disease, DM (not insulin dependent), HTN, HLD, hx TIAs who presented with shortness of breath, found to have AF with RVR, HF exacerbation, and pulseless LLE, transferred to ___ for vascular evaluation, found to have HFrEF exacerbation with newly depressed EF 40% to ___ over past month and new pseudoanuerysm. Prior to discharge on ___ patient noted to feel clammy for several minutes after PICC was removed. ACTIVE ISSUES ============= # ACUTE ON CHRONIC SYSTOLIC HEART FAILURE EXACERBATION Patient with hx of systolic HF EF 41% presented with 10 lb weight gain in one week, elevated JVP, and dyspnea on exertion with CXR consistent with volume overload. Patient had Lasix dosing switched from 40mg daily to 3x/week by rehab due to urinary retention and starting bethanechol, per wife. ___ triggers include Lasix dose change and dietary indiscretion. TTE on ___ showed newly reduced EF ___. After diuresis with IV lasix, repeat TTE on ___ still showed severe depressed LV systolic function (EF 20%). He underwent cardiac catheterization on ___, which showed both LIMA-LAD and SVG-RCA grafts patent. Etiology of reduced ejection fraction unclear, but hepatitis panel and HIV were negative. TSH elevated at 8.0, but free-T4 normal. Patient was diuresed with lasix 200 mg IV and drip at 20 mg/hr, then switched to PO regimen of torsemide 40 mg daily and patient remained negative to -500mL for several days. Metoprolol dose increased to succinate XL 175 mg daily. Started losartan 50 mg daily. Should continue to uptitrate Metoprolol as tolerated. # ATRIAL FIBRILLATION # SUPRATHERAPEUTIC INR Atrial fibrillation with RVR at OSH, likely ___ volume overload. Improved after IV diltiazem. HR 110s-120s on arrival. High stroke risk given his history of TIAs. Metoprolol dose increased as above. HRs improved to 70-80s. Heparin bridged and continued on warfarin after vascular procedure. Discharged on warfarin 3 mg daily. This was reduced from home dose of 5 mg daily because he was started on doxycycline. Dose may need to be readjusted as needed and when doxycycline is discontinued (per infectious disease). Patient should have INR checked with lab work on ___, and Dr. ___ agreed to follow patient's INR. ___ will send over results. Of note, patient supratherapuetic with INR 3.7 in setting of having received 7.5mg 2 days prior. The dose was reduced to 2mg and so INR 3.8 -> 3.7, is expected to continue to downtrend with goal INR ___. His home regimen of 5mg daily is likely too aggressive given current Doxycycline, which is why 3mg daily was thought to be a good dose. # PERIPHERAL VASCULAR DISEASE Patient with known tenuous runoff to bilateral lower extremities. Faint signals present in bilateral peroneal and ___ distribution. Arterial dopplers and CTA showing new pseudoaneurysm of right femoral popliteal bypass graft. Patient had significant pain in right lower extremity. He underwent right femoral cutdown with stenting of popliteal artery on ___ with vascular surgery. After the procedure, patient developed cyanosis of the right toes without changes in sensation. Continued to have monophasic dopplerable DP pulse on affected leg. Evaluated by vascular, who thought color change likely due to microemboli from clot in graft (not removed in procedure) and only treatment was anticoagulation. No urgent intervention was necessary. Color remained stable. Pain controlled with oxycodone 2.5 mg q4h PRN. Evaluated by ___ and OT, who felt he could be discharged to home with home ___. # HISTORY OF INFECTED PSEUDOANEURYSM Finished initial cefazolin, flagyl, and cipro course for infected pseudoaneurysm on ___. Then continued IV cefazolin until 48 hours after vascular procedure. Per ID recommendations, since entire graft was not replaced during procedure, he was continued on oral suppression with doxycycline 100 mg BID. Patient will follow-up with infectious disease. Duration of doxycycline to be determined by infectious disease. CHRONIC ISSUES ============== # ANEMIA - Hgb remained stable at baseline ___. # DIABETES - Held Januvia and glimepiride and metformin, SSI inpatient. These were restarted on discharge. # NEUROPATHY - Held pregabalin, patient prefered restarting gabapentin, so restarted at old home dose for 400mg TID # CAD s/p CABG and NSTEMIx2 - Continued plavix and statin (not on aspirin to reduce bleeding risk of triple therapy). # GERD - Continued pantoprazole # URINARY RETENTION - Continued bethanechol and tamsulosin TRANSITIONAL ISSUES =================== Diuretic regimen: Torsemide 40 mg daily Discharge weight: 68.4 kg Discharge warfarin dose: 3 mg daily Discharge INR: 3.7 [ ] Follow-up lab work: Chem 10, INR ___ to be faxed to Dr. ___ [ ] Please monitor weight and signs of volume overload. Would not adjust diuretic regimen unless discussed with patient's cardiologist. Call Cardiology clinic if gains > 3lbs. [ ] Consider work-up for ICD for EF < 30% [ ] Continue to monitor heart rates and atrial fibrillation [ ] Metoprolol was increased and losartan started during this admission. Please continue to monitor blood pressure. [ ] Patient can likely be uptitrated to Metop 200mg XL daily. [ ] Warfarin dose reduced to 3 mg daily (from 5mg daily) since he is on doxycycline. Continue to monitor INR. ___ need dose adjustment if doxycycline is discontinued, per ID. [ ] Continue oral doxycyline for pseudoaneurysm infection suppression. Will continue until infectious disease follow-up. [ ] Please ensure follow-up with vascular surgery for post-operative monitoring. Groin STAPLES WILL BE REMOVED AT THIS TIME. [ ] Patient is on plavix and warfarin. Not on aspirin to reduce bleeding risk. If plavix is stopped, aspirin should be restarted. [ ] Patient HBsAb negative. Consider HBV vaccination. [ ] Of note, patient will transfer his Cardiology care to ___ ___ per his request - appointments have been made. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. CeFAZolin 2 g IV Q8H 3. Ciprofloxacin HCl 500 mg PO Q12H 4. Clopidogrel 75 mg PO DAILY 5. Cyclobenzaprine 10 mg PO TID:PRN spasm 6. Furosemide 40 mg PO 3X/WEEK (___) 7. Januvia (SITagliptin) 50 mg oral DAILY 8. Metoprolol Succinate XL 50 mg PO DAILY 9. MetroNIDAZOLE 500 mg PO TID 10. Pantoprazole 40 mg PO Q24H 11. Pregabalin 75 mg PO BID 12. Tamsulosin 0.4 mg PO QHS 13. Warfarin 5 mg PO DAILY16 14. Bethanechol 50 mg PO QID 15. Ferrous Sulfate 325 mg PO DAILY 16. glimepiride 2 mg oral DAILY 17. Potassium Chloride 40 mEq PO 3X/WEEK (___) 18. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 19. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild Discharge Medications: 1. Doxycycline Hyclate 100 mg PO Q12H RX doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve (12) hours Disp #60 Tablet Refills:0 2. Gabapentin 400 mg PO TID RX gabapentin 400 mg 1 capsule(s) by mouth three times a day Disp #90 Capsule Refills:0 3. Losartan Potassium 50 mg PO DAILY RX losartan 50 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 4. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - Severe RX oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four (4) hours Disp #15 Tablet Refills:0 5. Senna 8.6 mg PO BID RX sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp #60 Tablet Refills:0 6. Torsemide 40 mg PO DAILY RX torsemide [Demadex] 20 mg 2 tablet(s) by mouth daily Disp #60 Tablet Refills:0 7. Metoprolol Succinate XL 175 mg PO DAILY RX metoprolol succinate 50 mg 3.5 tablet(s) by mouth daily Disp #120 Tablet Refills:0 8. Warfarin 3 mg PO ONCE Duration: 1 Dose RX warfarin [Coumadin] 1 mg 3 tablet(s) by mouth daily Disp #90 Tablet Refills:0 9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 10. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 11. Atorvastatin 80 mg PO QPM 12. Bethanechol 50 mg PO QID 13. Clopidogrel 75 mg PO DAILY 14. Cyclobenzaprine 10 mg PO TID:PRN spasm 15. Ferrous Sulfate 325 mg PO DAILY 16. glimepiride 2 mg oral DAILY 17. Januvia (SITagliptin) 50 mg oral DAILY 18. MetFORMIN (Glucophage) 1000 mg PO BID 19. Pantoprazole 40 mg PO Q24H 20. Potassium Chloride 40 mEq PO 3X/WEEK (___) Hold for K > 21. Tamsulosin 0.4 mg PO QHS 22.Outpatient Lab Work Labs: Na,K,Cl,HCO3,BUN,Cr,Glu,INR ICD: I50.2 (systolic heart failure), ___ Fax: ___. ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY ======== Acute on chronic heart failure with reduced ejection fraction Atrial fibrillation Peripheral vascular disease Pseudoaneurysm Anemia SECONDARY ========== Chronic obstructive pulmonary disease Diabetes Mellitus Neuropathy Coronary artery disease Gastroesophageal reflux disease Urinary retention 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. ___, WHAT BROUGHT YOU INTO THE HOSPITAL? - You were admitted for shortness of breath and pain in your feet. WHAT WAS DONE FOR YOU IN THE HOSPITAL? - You had an echocardiogram which showed that you were in heart failure and had excess fluid in your body. - You received medications to help you remove excess fluid from your body. - You had a cardiac catheterization which showed that your coronary arteries were not significantly changed. - You underwent a procedure to treat the pseudoaneurysm in your right leg with vascular surgery. - You were continued on antibiotics to prevent infection of your pseudoaneurysm. WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL? - It is important that you continue to take your medications as prescribed. - Weigh yourself every morning, call MD if weight goes up more than 3 lbs. - You need to follow up with your PCP, cardiologist and vascular surgeon according to the appointments below. We wish you the best in your recovery! Your ___ Care Team Followup Instructions: ___
10311237-DS-13	10,311,237	24,033,442	DS	13	2163-02-03 00:00:00	2163-02-03 16:58:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril / digoxin / minocycline / tramadol / Dilaudid Attending: ___. Chief Complaint: acute RLE pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ M with multiple medical admission due to heart failure and PVD. His PMH is notable for PVD (lower limbs, carotid), CAD (s/p CABG), HFrEF, pAfib on warfarin, COPD, PHTN, DM, HTN, HLD. He has significant PVD with a recent right Iliac artery stenting for a psudoanurysm c/b infection. 2 days after his most recent discharge, the patient presents with acute Rt leg pain requiring admission. The patient was recently discharge from the ___ after being admitted with CHF exacerbation and AFib with RVR. He was discharged home on ___. Since his discharge, he has been fine until the morning of ___ when the patient woke up with severe acute right sided leg pain starting from behind the knee going downwards towards the foot. The pain is worse with bending the knee and limits his mobility. It is associated with tenderness on the right shin and sensitivity to light touch. The pain is ___ with intact sensation. He presented initially to ___ where his vitals were stable. He had an US of the leg based on a recommendation from the oncall vascular surgeon here at the ___. The US of the and the recent fem-pop fistula demonstrated a thrombus in the R bypass graft proximal to a recently placed stent (stent placed in ___. Therefore, he was referred to the ___ for further evaluation. Of note, his wifes notes a significant increase in weight from discharge (~ 5lb since ___. However, the patient does not have shortness of breath, orthopnea, PND. Only his right leg is swollen. The left is normal and does not have edema. In the ED at the ___: ======================= Initial vitals: Temp: 97.0 HR: 66 BP: 109/49 Resp: 16 O2 Sat: 98 The limb is warm and red with trace edema. The pulses are deplorable. There was a significant swelling in the right leg with pitting edema. Symmetric capillary refill. Pain is significant to light touch, strength exam is limited of RLE given pain. Labs were significant for 8.8 MCV=88 7.7>-----<424 30.1 ___: 25.4 PTT: 35.7 INR: 2.4 proBNP: ___ AGap=16 ------------< 121 4.9 25 0.9 Ca: 9.3 Mg: 1.6 P: 4.0 Lactate:2.3 Out of concern of arterial ischemia or arterial thromboembolism a CTA of the Aorta/Bifem/ilian was ordered which showed the following: 1. Evaluation of the right popliteal stent is limited due to streak artifact, but likely appears patent. 2. Extensive atherosclerotic disease resulting in multifocal moderate to high-grade stenosis within the graft. No significant interval change since prior CTA runoff. 3. Acute on chronic hematoma adjacent to the distal bypass graft in the popliteal fossa appears to have minimally increased in size compared to prior. 4. At least moderate stenosis of the left distal bypass graft anastomotic site. 5. New 1.4 cm fluid collection anterior to the graft in the right upper thigh near the groin deep to skin ___ be postsurgical, cannot fully exclude possible infection. 6. Reflux of contrast into the IVC suggestive of possible right heart failure. The patient received: IV heparin ggt home medications including: - oxycodone - insulin - pantoprazole - Torsemide - losartan - gabapentin - Metoprolol - Bethanechol - ferrous sulfate. The patient was shifted to the floor. On the floor, the patient continued to have ___ pain which is improved with Tylenol and oxycodone. Per discussion with Vascular, the patient has similar episodes of pain in the past which are likely a result from his pseudoanurysm. given the lack of option in his treatment other than an amputation, the patient's vascular status should be treated conservatively and his INR should be bridge to therapeutic with heparin. Dr. ___ is the vascular surgeon who has taken care of him the most and he will be back on service on ___. Past Medical History: # CARDIAC RISK FACTORS - HTN - HLD - DM2 # CARDIAC HISTORY - paroxysmal afib (on Coumadin) - CAD (5v CABG ___, NSTEMI in ___ - systolic CHF - pulm HTN # OTHER MEDICAL HISTORY - peripheral arterial disease s/p bilateral femoral cut down with patch angioplasty and R belwo the knee popliteal bypass and R toe amputations, left iliac stent/PTA ___ c/b graft aneurysm infection - hx TIAs - COPD - GERD - left CEA, right CEA x2 - right ICA angioplasty Social History: ___ Family History: noncontributory Physical Exam: ADMISSION EXAM: VS: 97.1 PO 106 / 72 R Lying 76 16 98 RA GENERAL: The patient appears in pain. He is not in respiratory distress and not connected to oxygen. HEENT: anicteric sclera. Because of a prior carotid endarterectomy is noted on the right side. NECK: No JVP elevation. Hepatojugular reflux is negative. HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: Symmetrical chest expansion bilaterally. Equal air entry on auscultation with no added sounds. No crackles, no wheezes. Resonant on percussion throughout. ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: RLE is slightly warmer than LLE, 1+ pitting edema on the right ankle. There is redness noted along the anterior shin of the right leg. A scar from prior right bypass looks well-healed with mild surrounding ecchymosis outlined in ink. The groin is notable for scar of the previous bypass surgery. The scar is well-healed with staples still on. No lymphadenopathy noted. Pulses are dopplerable bilaterally with variability in Doppler signal due to atrial fibrillation. The skin on the right shin is tender to touch. Light touch causes significant pain. There is considerable tenderness only on the posterior aspect of the knee with both active and passive knee motion. NEURO: No gross motor or coordination abnormalities except for allodynia on the right shin. SKIN: No rashes. DISCHARGE EXAM: VS: 98.1 148/77 79 20 100 Ra General: Comfortable, NAD. HEENT: Anicteric sclerae; EOMs intact. Neck: Supple. CV: Irregularly irregular, no MRGs. Pulm: CTA b/l; no wheezes, rhonchi, or rales. Abd: Soft, non-tender, non-distended, NABS. Ext: R graft site nontender, without erythema or warmth, s/p amputation of toes on R foot. No pitting edema. Neuro: A&Ox3. Distal sensation intact to light touch. Pertinent Results: ADMISSION LABS: ___ 10:44PM BLOOD WBC-7.7 RBC-3.42* Hgb-8.8* Hct-30.1* MCV-88 MCH-25.7* MCHC-29.2* RDW-19.7* RDWSD-63.8* Plt ___ ___ 10:44PM BLOOD ___ PTT-35.7 ___ ___ 10:44PM BLOOD Glucose-121* UreaN-26* Creat-0.9 Na-137 K-4.9 Cl-96 HCO3-25 AnGap-16 ___ 10:44PM BLOOD Calcium-9.3 Phos-4.0 Mg-1.6 ___ 10:55PM BLOOD Lactate-2.3* DISCHARGE LABS: ___ 03:30AM BLOOD WBC-7.7 RBC-3.59* Hgb-9.4* Hct-31.8* MCV-89 MCH-26.2 MCHC-29.6* RDW-19.0* RDWSD-62.8* Plt ___ ___ 03:30AM BLOOD ___ PTT-52.4* ___ ___ 03:30AM BLOOD Glucose-145* UreaN-25* Creat-1.0 Na-139 K-5.2* Cl-96 HCO3-35* AnGap-8* ___ 03:30AM BLOOD Calcium-9.7 Phos-3.9 Mg-2.0 UricAcd-7.7* IMAGING: CTA AORTA 1. Evaluation of the right popliteal stent is limited due to streak artifact, but is likely patent though significantly narrowed. 2. Extensive atherosclerotic disease otherwise with multifocal stenoses are not significantly changed from prior CTA runoff and described in detail above. 3. Acute on chronic hematoma adjacent to the distal bypass graft in the popliteal fossa appears to have minimally increased in size compared to prior. 4. New 1.4 cm fluid collection anterior to the graft in the right upper thigh near the groin deep to skin staples is likely a seroma, but infection cannot be completely excluded. 5. Reflux of contrast into the peripheral hepatic veins suggestive of right heart failure. MICRO: BCx, UCx ___ NGTD Brief Hospital Course: ___ with history of PVD, CAD s/p CABG, chronic systolic CHF, pAfib on warfarin, and recent right Iliac artery stenting for a pseudoanurysm c/b infection presents with R leg pain. Imaging lacked evidence of clot; patient discharged home with services with Lovenox bridging for AFib. Investigations/Interventions: 1. R leg pain, history of peripheral vascular disease: localized to site of recent vascular intervention; some overlying erythema on initial exam. There was concern for infection vs clot in prior stent; CTA demonstrated NO evidence of clot. Patient given 1 dose of IV vancomycin then switched back to home suppressive doxycycline regimen. There was also concern for possible hematoma as cause of pain/erythema. Heparin gtt was given for sub-therapeutic INR (in setting of AFib and CHADS2 score of 6) without any evidence of expansion/new hematoma . He is discharged home with Lovenox bridge; ___ will draw follow up INR. Plavix continued throughout hospitalization. 2. Chronic systolic CHF: followed by cardiology, visits the ___ for diuresis. Patient was continued on torsemide 40 mg daily and discharged with cardiology follow up. Transitional Issues: []Discharged with Lovenox bridge; discharge INR 1.9, ___ to draw next INR on ___ and fax results to PCP (manages INR) []Discharge weight 69.3 kg #Contact: ___ (wife) ___ ======== Greater than 30 minutes was spent on discharge planning and coordination Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Atorvastatin 80 mg PO QPM 3. Bethanechol 50 mg PO QID 4. Clopidogrel 75 mg PO DAILY 5. Metoprolol Succinate XL 175 mg PO DAILY 6. Pantoprazole 40 mg PO Q24H 7. Tamsulosin 0.4 mg PO QHS 8. Warfarin 3 mg PO ONCE 9. Doxycycline Hyclate 100 mg PO Q12H 10. Gabapentin 400 mg PO TID 11. Losartan Potassium 50 mg PO DAILY 12. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - Severe 13. Senna 8.6 mg PO BID 14. Torsemide 40 mg PO DAILY 15. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 16. Cyclobenzaprine 10 mg PO TID:PRN spasm 17. Ferrous Sulfate 325 mg PO DAILY 18. glimepiride 2 mg oral DAILY 19. Januvia (SITagliptin) 50 mg oral DAILY 20. MetFORMIN (Glucophage) 1000 mg PO BID 21. Potassium Chloride 40 mEq PO 3X/WEEK (___) Discharge Medications: 1. Enoxaparin Sodium 80 mg SC Q12H Duration: 5 Days Start: Today - ___, First Dose: Next Routine Administration Time RX enoxaparin 80 mg/0.8 mL 80 mg sq twice a day Disp #10 Syringe Refills:0 2. Warfarin 5 mg PO DAILY16 RX warfarin 2.5 mg 2 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild RX acetaminophen 325 mg ___ capsule(s) by mouth every six (6) hours Disp #40 Capsule Refills:0 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 5. Atorvastatin 80 mg PO QPM 6. Bethanechol 50 mg PO QID 7. Clopidogrel 75 mg PO DAILY 8. Cyclobenzaprine 10 mg PO TID:PRN spasm 9. Doxycycline Hyclate 100 mg PO Q12H 10. Ferrous Sulfate 325 mg PO DAILY 11. Gabapentin 400 mg PO TID 12. glimepiride 2 mg oral DAILY 13. Januvia (SITagliptin) 50 mg oral DAILY 14. Losartan Potassium 50 mg PO DAILY 15. MetFORMIN (Glucophage) 1000 mg PO BID 16. Metoprolol Succinate XL 175 mg PO DAILY 17. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - Severe RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #40 Tablet Refills:0 18. Pantoprazole 40 mg PO Q24H 19. Potassium Chloride 40 mEq PO 3X/WEEK (___) Hold for K > 20. Senna 8.6 mg PO BID 21. Tamsulosin 0.4 mg PO QHS 22. Torsemide 40 mg PO DAILY 23.Outpatient Lab Work I48.0 Atrial fibrillation Please check INR on ___ and fax results to ___ (Dr. ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: R leg pain Atrial fibrillation Peripheral vascular disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. ___, You were hospitalized with leg pain, and we were worried there was a clot in your recent stent placed by vascular surgery. Thankfully imaging showed that there is NO clot. We continued your home antibiotics and discharged you with Lovenox bridging for anticoagulation. Please continue to take Coumadin, and the ___ will come draw you lab work. It was a pleasure taking care of you! Your ___ team Followup Instructions: ___
10311503-DS-13	10,311,503	25,226,887	DS	13	2131-04-20 00:00:00	2131-04-20 19:17:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfasalazine / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: three falls at home, leg weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old man with a history of kyphoscoliosis s/p two recent spine surgeries at ___ in ___ and ___ by Dr. ___ ependymoma s/p partial resection in ___, bilateral hip and R shoulder osteonecrosis secondary to steroid use s/p bilateral hip replacements and R shoulder replacement who is transferred from OSH for 3 falls over the past week in the setting of bilateral leg weakness and hemoglobin drop from 10.8 (1 week ago) to 7.6. The patient reports that over the past week, his "legs gave out" contributing to three falls to the floor. He does not recall hitting his head or losing consciousness. No pain noted after the falls. His last fall was yesterday morning, and he presented to ___. At the outside hospital, an MRI was completed. It was poor quality due to interference from recently placed hardware during surgery ___ weeks ago; however concern for large seroma posterior to thecal sac adjacent to hardware. Patient has no sensation below mid back at baseline, denies fecal incontinence. Notably, hemoglobin was 9.4 at the outside hospital. Of note, the patient was recently admitted for a small bowel obstruction, anemia, and dysphagia. His SBO was thought to be due to adhesions from prior abdominal surgeries. He was given a bowel regimen and counseled on narcotic use. He had dysphagia with a history of esophageal dilations. He was seen by speech and swallow and his symptoms were thought likely due to central cause given his cervical spine disease. He was shown to be an aspiration risk. However, the patient accepted this risk and continued a regular diet with thin liquids. He had anemia with concern for coffee ground emesis from NG tube. He was thought to have anemia of chronic disease, and no intervention was completed. Past Medical History: HTN Esophageal stricture Spinal cord tumor s/p resection bilateral hip and R shoulder osteonecrosis ___ steroid use s/p bilateral hip replacements and R shoulder replacement kyphoscoliosis for ___ years s/p surgical repair in ___ and ___ RA currently off medications R. inguinal hernia s/p repair with recurrence Bipolar d/c Social History: ___ Family History: DM, prostate CA, colon CA, carcinoid tumor Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: ___ 1625 Temp: 97.7 PO BP: 135/54 HR: 84 RR: 18 O2 sat: 96% O2 delivery: Ra GENERAL: Lying in bed, very pleasant man, soft spoken, in no acute distress. HEENT: Head atraumatic, normocephalic. PERRL. Moist mucous membranes. NECK: No lymphadenopathy. No thyromegaly. CARDIAC: Regular rate and rhythm. Normal S1 and S2. No murmurs or gallops. LUNGS: CTAB with no wheezing or crackles. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Warm and well perfused. Minimal ___ edema. NEUROLOGIC: ___ strength of the bilateral lower extremities. Minimal sensation to light touch and pinprick below the nipples. SKIN: No pallor visible. No rashes. DISCHARGE PHYSICAL EXAM: Temp: 98.0 (Tm 98.2), BP: 117/75 (110-1217/68-79), HR: 109 (83-109), RR: 18, O2 sat: 96% (95-96), O2 delivery: Ra GENERAL: Lying in bed, in no acute distress. CARDIAC: Regular rate and rhythm. Normal S1 and S2. No murmurs or gallops. LUNGS: CTAB with no wheezing or crackles. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Warm and well perfused. No ___ edema. NEUROLOGIC: Sensation to light touch and pinprick intact in bilateral ventral and dorsal hands/fingers. Limited range of motion with left arm weakness in deltoid. Gait unsteady with significant leaning toward right side. SKIN: No pallor visible. No rashes. Pertinent Results: ADMISSION LABS: ___ 08:45PM BLOOD WBC-6.1 RBC-2.60* Hgb-7.6* Hct-24.1* MCV-93 MCH-29.2 MCHC-31.5* RDW-14.1 RDWSD-47.8* Plt ___ ___ 08:45PM BLOOD Neuts-73.3* Lymphs-13.3* Monos-9.5 Eos-3.3 Baso-0.3 Im ___ AbsNeut-4.46 AbsLymp-0.81* AbsMono-0.58 AbsEos-0.20 AbsBaso-0.02 ___ 08:45PM BLOOD ___ PTT-26.4 ___ ___ 08:45PM BLOOD Glucose-103* UreaN-11 Creat-0.7 Na-135 K-3.7 Cl-94* HCO3-32 AnGap-9* ___ 08:45PM BLOOD Albumin-2.6* Iron-21* ___ 08:52PM BLOOD Lactate-0.9 IMAGING / REPORTS: MRA / MRI BRAIN ___: 1. No evidence of acute ischemic changes. Preservation of major intracranial flow voids without evidence of aneurysm. No abnormal post-contrast enhancement. 2. Ventricles and sulci are prominent, which may be consistent with age-related global parenchymal loss. However, given that the ventricles are dilated out of proportion to the sulci, in the correct clinical setting, it is difficult to exclude normal pressure hydrocephalus. 3. Nonspecific periventricular and subcortical FLAIR hyperintensities, which likely represent sequela of chronic microvascular ischemic disease. 4. On the MRA of the head, there is no evidence of flow stenotic lesions or aneurysms. MR ___ SPINE ___: 1. Stable cervical spine MRI examination demonstrating an approximately 6 cm long lobulated, and in areas peripherally enhancing, cervical spine syrinx. No interval change since ___. 2. Unchanged mild-to-moderate multilevel cervical spondylosis causing neural foraminal narrowing is worst (moderate to severe) on the left at C5-6. EEG ___: This is a mildly abnormal continuous ICU EEG monitoring study due to diffuse excessive beta activity, which could be consistent with medication effect (e.g. benzodiazepines). No areas of focal slowing, epileptiform discharges, or electrographic seizures are seen. DISCHARGE LAS: ___ 07:15AM BLOOD WBC-5.1 RBC-3.52* Hgb-10.3* Hct-33.5* MCV-95 MCH-29.3 MCHC-30.7* RDW-14.6 RDWSD-51.4* Plt ___ ___ 07:54AM BLOOD Glucose-87 UreaN-13 Creat-0.6 Na-139 K-4.5 Cl-95* HCO3-32 AnGap-12 ___ 07:54AM BLOOD Calcium-9.4 Phos-4.5 Mg-2.3 Brief Hospital Course: Mr. ___ is a ___ year old man with a history of kyphoscoliosis s/p two spine surgeries at ___ in ___ and ___ by Dr. ___ ependymoma s/p partial resection in ___, bilateral hip and R shoulder osteonecrosis secondary to steroid use s/p bilateral hip replacements and R shoulder replacement who was transferred from an outside hospital for three falls in the week prior to admission in the setting of bilateral leg weakness and hemoglobin drop to 7.8 (from 10.8 one week earlier). During the hospitalization, he developed new onset nausea, dizziness, and vertigo that varied based on position. Exhaustive workup (MRI/MRA head, MRI cervical spine, EEG) showed no acute findings. Most likely thought to be due to BPPV. ACUTE ISSUES: ============= #Multiple falls at home #Benign paroxysmal positional vertigo Patient presented with three new falls at home. No loss of consciousness during falls. LFTs, TSH, CK all unremarkable. On ___ (three days into his hospitalization), the patient reported new onset nausea/dizziness/vertigo from moving lying down to sitting position and while ambulating. No recent ear infection and no findings on ear exam. Central etiology is unlikely given negative MRI / MRA head. CT neck showed no enlargement in size of syrinx. Neurosurgery also felt that his falls was unlikely to be due to syrinx. EEG negative. The patient had positive nystagmus during liberatory maneuver with physical therapy. Most likely etiology is benign paroxysmal positional vertigo. He has been working with physical therapy during the last week and performing the epley maneuver. Continues to have symptoms and thus will most benefit from discharge to rehab with consistent vestibular and physical therapy assistance. #Concern for peripheral neuropathy On ___, patient reported change in sensation in bilateral hands in glove distribution concerning for peripheral neuropathy. On prior exam with neurology, he was noted to have decreased sensation in his left posterior hand localizing to C7-C8 distribution. Neurology recommended outpatient EMG to assess brachial plexus. #Anemia: Hgb 7.6 on admission, down from 10.8 on ___ (one week prior). Likely anemia of chronic disease (transferrin low, TIBC low, ferritin high normal). Patient denies any bright red blood per rectum. During his last hospitalization, there was some concern for coffee ground-like output from NGT with initial placement. No current signs of GI bleed or retroperitoneal bleed here. Reticulcyte count c/w underproduction. CBC with diff with no atypical cells. Last hemoglobin 10.3 on ___. He had a blood smear in lab that showed spherocytes and occasional immature lymphocytes. Continued omeprazole 40mg daily. #Ependymoma with associated syrinx #Kyphoscoliosis Ependymoma s/p resection at ___ in ___, s/p two recent surgeries for kyphoscoliosis in ___ and ___. Patient continues to have significant pain related to this, especially with moving. Neurosurgery felt that there was no acute need for intervention. Treated his pain with oxycodone 5mg q6hrs, fentanyl patch 50mcg q72hrs, and tylenol 1g q8hr. Neurosurgery recommended follow-up with Dr. ___ in 3 months with repeat cervical Spine MRI with and without contrast. CHRONIC ISSUES ============== #Anxiety -Continued home celexa 40mg daily -Continued home ativan 1mg TID prn #Hyperlipidemia -Continued home atorvastatin 40mg #Vitamin supplementation -Continued Vitamin D, B6, B12 supplementation TRANSITIONAL ISSUES: ==================== []Outpatient EMG to assess brachial plexus. []Follow-up with Dr. ___ in 3 months with repeat cervical Spine MRI with and without contrast [] Continue Epley maneuvers for BPPV CORE MEASURES ============= #CODE: full code, confirmed #CONTACT: daughter, ___ ___ sister, ___ (___) ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Citalopram 40 mg PO DAILY 3. Fentanyl Patch 50 mcg/h TD Q72H 4. LORazepam 1 mg PO Q8H:PRN anxiety, muscle spasm 5. Omeprazole 40 mg PO DAILY 6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH PAIN 7. Polyethylene Glycol 17 g PO BID 8. Multivitamins W/minerals 1 TAB PO DAILY 9. Acetaminophen 1000 mg PO Q8H 10. Docusate Sodium 100 mg PO BID 11. Vitamin D ___ UNIT PO 1X/WEEK (WE) 12. Senna 17.2 mg PO BID 13. Pyridoxine 100 mg PO DAILY 14. Cyanocobalamin 250 mcg PO DAILY Discharge Medications: 1. Ondansetron 4 mg PO Q8H:PRN nausea RX ondansetron 4 mg 1 tablet(s) by mouth three times a day as needed Disp #120 Tablet Refills:*0 2. Acetaminophen 1000 mg PO Q8H 3. Atorvastatin 40 mg PO QPM 4. Citalopram 40 mg PO DAILY 5. Cyanocobalamin 250 mcg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Fentanyl Patch 50 mcg/h TD Q72H 8. LORazepam 1 mg PO Q8H:PRN anxiety, muscle spasm 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Omeprazole 40 mg PO DAILY 11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH PAIN 12. Polyethylene Glycol 17 g PO BID 13. Pyridoxine 100 mg PO DAILY 14. Senna 17.2 mg PO BID 15. Vitamin D ___ UNIT PO 1X/WEEK (WE) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: Benign paroxysmal positional vertigo Secondary Diagnosis: Anemia Ependymoma with associated syrinx Kyphoscoliosis Anxiety Hyperlipidemia 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. ___, What brought you to the hospital? You had three falls at home in the week prior to admission in the setting of leg weakness and low hemoglobin. What did we do for you in the hospital? You had a thorough workup of your anemia. We think your low hemoglobin has been a chronic issue. We think that the falls that you had were likely due to a neurological cause. During this hospitalization, you developed nausea, dizziness, and vertigo. You had brain imaging (MRI head, MRA head, MRI neck, EEG) that did not show a significant finding. You worked with physical therapy to assist you with walking. We think you may have benign paroxysmal positional vertigo or BPPV. What should you do after leaving the hospital? -You should work with physical therapy and perform the epley maneuver. -You should follow-up with neurology as scheduled below. It was a pleasure taking care of you in the hospital. We wish you the very best. Sincerely, Your ___ Team Followup Instructions: ___
10311624-DS-8	10,311,624	23,571,103	DS	8	2125-11-23 00:00:00	2125-11-23 09:51:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hydrocephalus/ Fourth ventricular mass Major Surgical or Invasive Procedure: ___ Right Ventriculostomy ___ Left posterior fossa craniectomy resection of tumor History of Present Illness: ___ y/o M, ___ speaking only, presents with AMS. Patient examined with interpreter and unable to provide history. He was seen at ___ where a ___ CT was done and showed L cerebellar lesion with hydrocephalus. He was transferred to ___ for further evaluation and management. No family present at time of examination. Patient denies any headache, nausea, or vomiting. Past Medical History: -chronic hyponatremia -Hyperlipidemia -BPH s/p TURP Social History: ___ Family History: nc Physical Exam: On admission: PHYSICAL EXAM: O: T:99.0 BP:133/66 HR: 76 R: 18 O2Sats: 98%RA Gen: WD/WN, comfortable, NAD. HEENT: atraumatic, normocephalic Pupils: 3-2mm bilaterally EOMs: intact Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person and place. Face symmetrical tongue midline No pronator drift Full motor Discharge exam AVSS Pleasant and cooperative, sitting in bed in no apparent distress PERRL 4-2mm, EOM intact, AOX3, face symmetric Motor ___ b/l Sensory intact slight dysmetria on the left incision is c/d/i with monocryl sutures in place Pertinent Results: CT ___ ___: IMPRESSION: 1. New right frontal approach EVD terminates midline immediately superior to the third ventricle. No definite change in ventriculomegaly. 2. Cerebellar mass causing effacement of the fourth ventricle is unchanged. MRI Brain ___: IMPRESSION: 1. There is a cerebellar mass lesion with significant restricted diffusion, strongly suggesting an epidermoid tumor. There is no significant enhancement in this lesion, therefore other entities like abscess or parasitic cystic lesion are more remote considerations. 2. The patient is status post right frontal ventricular shunt with decrease in the size of the ventricles. Nonspecific areas of high signal intensity are identified in the subcortical white matter, likely reflecting a combination of transependymal migration of CSF and small vessel disease. CTA ___ ___: IMPRESSION: 1. Predominantly extraventricular mass, located at the level of the obex of the fourth ventricle, extending to the plane of the foramen magnum, is much better-characterized on the concurrent enhanced MR examination. Though this most likely represents an epidermoid (as suggested previously), subependymoma occupying the foramen of Magendie is an additional diagnostic consideration. 2. Status post placement of right transfrontal ventriculostomy with tip in the anterior recess of the third ventricle, and significant overall improvement in the appearance of obstructive ventriculomegaly, with persistent transependymal migration of CSF. 3. Unremarkable CTA, with no finding to suggest tumoral vascularity. However, note that a relatively large-caliber dominant left ___ vessel is significantly draped around the lesion, above. 4. No significant mural irregularity or flow-limiting stenosis involving the intracranial vessels. 5. Incidental "triplex" anterior cerebral artery, variant anatomy. MR ___ ___: IMPRESSION: Limited examination, re-demonstrating the well-defined, heterogeneous T2-intermediate-hyperintense mass with overall signal characteristics most suggestive of an epidermoid, as reported previously. However, an additional prime diagnostic consideration, given the site of origin, the intimate relationship to the subependymal region of the fourth ventricle, and the overall signal characteristics is subependymoma; however, while subependymomas, too, may demonstrate slow diffusion, this is more likely to be focal than uniform. Furthermore, subependymomas in the infratentorial compartment are more likely to demonstrate enhancement, which does not appear present in this lesion. ___ MRI ___ - Re- demonstration of a 3 x 2.4 x 2.2 cm nonenhancing posterior fossa lesion, which was previously seen to the hyperintense on T2 weighted images the hand demonstrate abnormally slow diffusion. Overall, this appearance is most suggestive of a posterior fossa epidermoid. ___ Echo - Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. No echocardiographic evidence of valvular endocarditis or pathologic flow. ___ MRI ___ - 1. Focus of slow diffusion at surgical site appears identical in signal characteristics to resected lesion in preoperative MR, raising concern for residual tumor, blood products, slow diffusion in brain adjacent to resection bed or a combination of these factors. 2. Expected post surgical changes include dural enhancement in the posterior fossa and minimal remnant blood products in the resection bed. Stable position of ventricular shunt. ___ LENIs - No evidence of right or left lower extremity DVT. ___ CT ___ - 1. Status post removal of ventriculostomy catheter with small amount of blood in b/l vents and no evidence of hydrocephalus. Brief Hospital Course: ___ who was admitted with a fourth ventricular mass and hydrocephalus. An EVD was placed and admitted to the ICU. He was monitored in the ICU and noted to be febrile on ___, cultures were sent and he was started on Vanc and Cefepime empirically. Blood cultures were positive and he was started on Ampicillin after an ID consult. He received PPX treatment for strongyloides w/ Ivermectin x2. His exam remained unchanged. On ___, he remained stable and surgical planning was made for ___. MRI was obtained preoperatively for surgical planning. Pt underewent the above stated procedure on ___. Please review dictated operative report for details. He tolerated the procedure and was extubated without incident. Pt was transferred to ICU in stable condition. On ___, pt required Haldol 0.5mg PRN for agitation and was requirign intermittent nipride gtt for labile HTN. Labetalol PRN was added for BP control and then amlodipine was added. The following day his agitation improved. Neuro exam remain stable and EVD showed good ICP and minimal drainage. A TTE was obtained which was normal. On ___ his EVD was clamped. He had some confusion in AM w/ elevated WBC. UA negative, CXR negative, ___ US negative for DVT. Pt mental status continued to wax and wane, generally improved throughout day and was normal w/ family. Tolerated clamp trial throughout day, ICPs ___. On ___ EVD was removed in routine fashion. CT ___ on ___ showed minimal blood in b/l vents, no hydrocephalus. on ___, he continued to improve. ___ recommended acute rehab. The patient was discharged to rehab in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Rosuvastatin Calcium 10 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Multivitamins 1 TAB PO DAILY 2. Rosuvastatin Calcium 10 mg PO DAILY 3. Acetaminophen 650 mg PO Q6H:PRN pain 4. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN pain 5. Amlodipine 10 mg PO DAILY 6. Ampicillin 2 g IV Q4H Duration: 6 Days 7. Bisacodyl 10 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Heparin 5000 UNIT SC TID 10. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 11. LeVETiracetam 750 mg PO BID 12. Ondansetron 4 mg IV Q8H:PRN nausea 13. Pantoprazole 40 mg PO Q24H 14. Polyethylene Glycol 17 g PO DAILY:PRN constipation 15. Senna 1 TAB PO BID 16. Sodium Chloride 1 gm PO TID 17. Dexamethasone 4 mg PO TID Continue dose until ___ then taper to 3 mg TID x 6 doses, 2mg TID x6 doses, 1mg TID x6 doses then d/c Tapered dose - DOWN Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Fourth ventricular mass Hydrocephalus cerebral edema delirium confusion labile hypertension bacteremia aseptic meningitis Chronic hyponatremia Discharge Condition: Mental Status: Confused at times Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You underwent a craniectomy and resection of an epidermoid cyst. You will follow-up with Brain Tumor Clinic in 2 weeks. Have a friend/family member check your incision daily for signs of infection. Take your pain medicine as prescribed. Exercise should be limited to walking; no lifting, straining, or excessive bending. You have dissolvable sutures on back of neck. Sutures on your ___ should be removed on ___. Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) & Senna while taking narcotic pain medication. Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. Clearance to drive and return to work will be addressed at your post-operative office visit. Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING New onset of tremors or seizures. Any confusion or change in mental status. Any numbness, tingling, weakness in your extremities. Pain or headache that is continually increasing, or not relieved by pain medication. Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. Fever greater than or equal to 101.5° F. Followup Instructions: ___
10311837-DS-8	10,311,837	23,554,770	DS	8	2150-09-04 00:00:00	2150-09-04 13:55:00	Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: ___ Attending: ___. Chief Complaint: Medication management Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ year-old right-handed man with a history of ___ disease and hypothyroidism who is referred to the ___ by his Neurologist, Dr. ___ recent decline in function, motor fluctuations, and hallucinations. At the age of ___, he developed right hand tremor and was subsequently diagnosed with idiopathic ___ diease at the age of ___. His symptoms were primarily characterized as rigidity, bradykinesia, mild-moderate tremor. He has subsequently been on a number of medications and ultimately had bilateral STN DBS placed in ___ for motor fluctuations. Right IPG replaced in ___. Over the past couple of months, he again developed motor fluctuations and wearing off of his medication. Dr. ___ has adjusted his DBS settings on an outpatient basis, but this has helped only minimally. He then decided to uptitrate his own medications to minimize his symptoms. He increased primarily his am and pm doses of Stalevo to 3 tabs for these doses. This past week, he developed hallucinations of drug dealers after him or flood lights in his bedroom or people in the driveway. His wife noted he was very paranoid. There were multiple phone conversations to Dr. ___ and he was urged to taper his Baclofen to off and to decrease to Stalevo and Sinemet 1 tab 6x daily, which he has done. Unfortunately, this has worsened his stiffness considerably. His motor complaints are primarily of severe stiffness, bradykinesia and shuffling gait with freezing. He relies on a cane or walker and no longer is able to walk unsupervised. His wife is now helping with all ADLs as he is so rigid. He does not have significant tremor burden. Speech is soft, slowed, and very dysarthric. He has had drooling for a while and received botox treatment in the past. Some intermittent dysphagia as well, but this is minimal recently. With regards to other non-motor symptoms, he reports minimal depression, orthostasis, urinary urgency/frequency. No recent history consistent with REM behavior disorder. With regards to medication compliance, Mr. ___ rates himself a "c-" when asked how reliable he is in taking his levodopa on time. He has not been ill recently and there have been no other med changes. ROS: positive as above. No headache, lightheadedness, or confusion. Denies difficulty comprehending speech. Denies loss of vision, blurred vision, diplopia, vertigo, tinnitus, hearing difficulty. Denies focal muscle weakness, numbness, parasthesia. Denies loss of sensation. The patient denies fevers, rigors, night sweats, or noticeable weight loss. Denies chest pain, palpitations, dyspnea, or cough. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. Denies myalgias, arthralgias, or rash. Past Medical History: - ___ disease - Bilateral STN DBS placed ___ in staged procedure - Removal and placement of new right-sided pulse generator ___ - sialorrhea s/p Botox injections (last on ___ by Dr. ___ - Depression - Kidney stones - Double hip replacement - Bilateral carpal tunnel syndrome Social History: ___ Family History: No family history of ___ disease, tremor, dystonia, seizure, stroke. Physical Exam: ADMISSION PHYSICAL EXAMINATION Vitals: 97.5 90 109/68 16 97% RA General: pleasant man, overall bradykinetic and rigid, NAD HEENT: NCAT, no oropharyngeal lesions Neck: cervical dystonia with right laterocollis of 20 degrees and minimal retrocollis. Limited AROM of neck to the left (60degrees, otherwise full). Prominent, hypertrophied left SCM. ___: RRR, no M/R/G Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, trace edema in lower extremities to mid shins. Neurologic Examination: - MS - Awake, alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Speech is fluent with full sentences, but with marked dysarthria. Repetition intact with marked dysarthria. Intact verbal comprehension. Naming intact. No paraphasias. Able to register 3 objects and recall ___ at 5 minutes, and additional 2 with cuing. No apraxia. No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. - Cranial Nerves - PERRL 4->2 brisk. VF full to finger wiggle. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline and strong bilaterally. - Motor - Normal bulk (apart from SCMs listed above). No drift. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 - MOVEMENT EXAM - 90 minutes after sinemet ___ 1 tab and stalevo 50/200/200 1 tab. Severe hyomimia and moderate hypophonia. Slowed speech, but no clear bradyphrenia. Reduced blink rate bilaterally. Tone: Bilateral arms with mild-mod rigidity that augments to severe with distraction technique. Mild cogwheeling at both wrists with distraction technique only. Bilateral legs with mod-severe rigidity that augments to severe. Moderate axial rigidity. Cervical dystonia as described above under "neck". Tremor: Coarse resting tremor of chin. Intermittent resting tremor of the bilateral ___ fingers bilaterally with distraction techniques. No postural tremor. Minimal intention tremor bilaterally. Fingertapping: bilateral severe bradykinesia Fist opening: bilateral severe bradykinesia Pronation/Supination: B/l moderate bradykinesia Heel tapping: clumsy with mild bradykinesia Apart from dystonia, there was no dyskinesias seen. - Sensory - No deficits to light touch bilaterally. No exinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 1 2 1 1 R 2 1 2 1 1 Plantar response flexor bilaterally. - Coordination - No dysmetria with finger to nose testing bilaterally. See above for rest of movement exam. - Gait - Requires use of hands to arise from sitting. Stands with stooped posture at 45 degrees. Walks with a cane in right hand. Absent left arm swing. Hesitant initiation. Very short steps with reduced stride length and height. narrow base. En block turn with at least 7 steps. He seems to turn on left foot, which upon walking becomes dystonic with curled toes and foot turned inwards. Pull test not performed. Bilateral IPGs were functioning normal as per interrogation by Dr. ___ in the ___ = = = = = = = = = = ================================================================ Discharge Exam: Notable for: Mental Status: improved voice with decreased stutter and hypophonic speech CN: Asymmetric smile, jaw tremor, masked facies Motor: ___ Throughout. Dystonia in Left great toe. Increased toe in R>L, worse in ___ compared to UE. Mild cogwheel rigidity. Finger tap worse on right compared to left, small amplitude Sensation: LT and pinprick intact throughout. Gait: Able to get out of chair, walked with walker. moves quickly with improved stride length. improved turn ___ step en-bloc turn) Pertinent Results: ___ 04:10PM BLOOD WBC-6.5 RBC-4.09* Hgb-13.9 Hct-40.0 MCV-98 MCH-34.0* MCHC-34.8 RDW-12.9 RDWSD-45.7 Plt ___ ___ 04:10PM BLOOD Neuts-59.8 ___ Monos-9.2 Eos-4.9 Baso-0.6 Im ___ AbsNeut-3.91 AbsLymp-1.63 AbsMono-0.60 AbsEos-0.32 AbsBaso-0.04 ___ 04:10PM BLOOD Plt ___ ___ 04:10PM BLOOD Glucose-111* UreaN-25* Creat-1.1 Na-143 K-4.3 Cl-107 HCO3-27 AnGap-13 ___ 04:10PM BLOOD ALT-6 AST-18 AlkPhos-63 TotBili-0.3 ___ 04:10PM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.3 Mg-2.3 ___ 04:10PM BLOOD TSH-3.2 ___ 04:10PM BLOOD ASA-16.3 Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ============================================== CXR: no acute intrathoraic process (___) Brief Hospital Course: ___ year-old right-handed man with a history of ___ disease and hypothyroidism who presents with recent marked decline in function, severe motor fluctuations, and hallucinations and was admitted for close titration of medication as guided by his outpatient Movement Disorders specialist. During his admission, he completed hourly self assessments graded ___. On day 1 he had mostly 1's, and on exam displayed rigidity on lower extremities with small shuffling steps and en bloc turning of 10 steps. Based on his assessments, Sinemet was increased to 2 tabs 5 times daily. On day 2, his "off" symptoms improved dramatically and his scores then ranged from ___, and his rigidity improved and he took longer strides, with en bloc turning using ___ steps. He consequently also developed dyskinesias particularly of the right foot/toes. Per consultation with his outpatient provider, the following changes were made to his stimulator settings: L ___- 3v/60/185 and R C+2- 3.5v/60/185. His exam improved with stimulator and medication changes. ___ and OT recommended rehab. He improved to discharge to ___ Disease Program at ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Stalevo 200 (carbidopa-levodopa-entacapone) 50-200-200 mg oral Q3.5H 2. Carbidopa-Levodopa (___) 1 TAB PO Q3.5H 3. Thyroid 90 mg PO DAILY 4. Pregabalin 75 mg PO DAILY Discharge Medications: 1. Carbidopa-Levodopa (___) 2 TAB PO 6X/DAY At 6 am, 9:30 am, 1 pm, 4:30 pm, 8pm, 11:30pm. Can hold 11:30 pm dose if patient is sleeping. 2. Pregabalin 75 mg PO DAILY 3. Stalevo 200 (carbidopa-levodopa-entacapone) 50-200-200 mg oral 6x per day At 6 am, 9:30 am, 1 pm, 4:30 pm, 8pm, 11:30pm. Can hold 11:30 pm dose if patient is sleeping. 4. Thyroid 90 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: ___ disease Bilatearl STN DBS placed in ___ Sialorrhea s/p botox Depression 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 facilitate titration of your ___ disease medications and stimulator settings. We overall increased the dose of your Sinemet from 1 to 2 tabs every 3.5 hours and continued your stalevo 1 tab every 3.5 hours. We also adjusted your Deep Brain Stimulator Settings during your hospital stay. You have improved and were accepted to ___ ___ for ___ Disease Program. Sincerely, Your ___ Neurology Team. Followup Instructions: ___
10312052-DS-18	10,312,052	22,873,205	DS	18	2155-03-15 00:00:00	2155-03-19 16:32:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fevers Major Surgical or Invasive Procedure: ___ Aspiration of right chest wall hematoma History of Present Illness: Recent 2 month hospital stay (discharged ___ to rehab) after right lower lobectomy for lung ca (combined large cell neuroendocrine - squamous cell carcinoma T2N1), ultimately requiring tracheostomy after reintubation postop and long ICU treatment course for ARDS. Was treated for afib, HAP, DVTs and PE, chest wall hematoma, and malnutrition. He had recurrent temp spikes (culture negative). He also had right pneumothorax treated with chest tube, then right pleural effusion treated with pigtail drainage. He represents from rehab today with fever, tachycardia, and increased WOB. Past Medical History: PAST MEDICAL HISTORY: Hypercholesterolemia Anemia, iron deficiency Cancer of ascending colon Colonic adenoma History of herpes zoster Degenerative disc disease, lumbar Post-traumatic stress disorder, chronic Depressive disorder History of alcohol abuse Peripheral neuropathy due to chemotherapy Diverticulosis of large intestine without hemorrhage COPD mixed type PAST SURGICAL HISTORY: ___ VATS right lower lobe wedge resection followed by VATS right lower lobectomy, mediastinal lymph node dissection and bronchoscopy with lavage ___ Bronchoscopy ___ Bronchoscopy ___ Bronchoscopy ___ Bronchoscopy ___ Right pleural pigtail catheter placement ___ Portex Per-Fit tracheostomy tube placed percutaneously and a PEG tube placement. ___ Right PICC placement ___ Right common femoral Vein approach IVC filter placement. Right common femoral artery approach right subclavian arteriogram with gel foam embolization of lateral thoracic, pectoral, and humeral branch Social History: ___ Family History: Mother Father: throat cancer Siblings: brother : ___ Other Physical Exam: VS T 101.7 HR 111 BP 107/64 RR ___ SaO2 100% RA , placed on vent by RT on arrival GENERAL [ ] WN/WD [x] NAD [x] AAO [x] abnormal findings: cachexia HEENT [x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric [x] OP/NP mucosa normal [x] Tongue midline [x] Palate symmetric [x] Neck supple/NT/without mass [x] Trachea midline [x] Thyroid nl size/contour [x] Abnormal findings: tracheostomy in good position with mild leakage of green-tinged mucous around the tube RESPIRATORY [x] CTA/P [ ] Excursion normal [ ] No fremitus [ ] No egophony [ ] No spine/CVAT [ ] Abnormal findings: CARDIOVASCULAR [x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [ ] No edema [x] Peripheral pulses nl [x] No abd/carotid bruit [ ] Abnormal findings: GI [x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia [ ] Abnormal findings: GU [x] Deferred [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] Strength intact/symmetric [x] Sensation intact/ symmetric [x] Reflexes nl [x] No facial asymmetry [x] Cognition intact [x] Cranial nerves intact [ ] Abnormal findings: MS [x] No clubbing [x] No cyanosis [x] No edema [ ] Gait nl [x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl [x] Nails nl [ ] Abnormal findings: LYMPH NODES [ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl [ ] Inguinal nl [ ] Abnormal findings: SKIN [ ] No rashes/lesions/ulcers [x] No induration/nodules/tightening [x] Abnormal findings: anterior chest wall with purple, yellow and green discoloration from ecchymosis PSYCHIATRIC [x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect [ ] Abnormal findings: Pertinent Results: WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct ___ 00:08 16.3* 3.26* 9.4* 31.2* 96 28.8 30.1* 16.8* 58.2* 428* ___ 01:37 13.3* 3.08* 8.9* 29.7* 96 28.9 30.0* 16.9* 59.9* 409* ___ 01:33 12.6* 2.69* 7.7* 26.0* 97 28.6 29.6* 17.0* 59.7* 358 ___ 13:05 13.6* 3.25* 9.2* 31.1* 96 28.3 29.6* 17.0* 59.9* 415* ___ 03:45 15.6* 3.24* 9.3* 31.0* 96 28.7 30.0* 17.1* 60.5* 428* Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 00:08 ___ 133* 4.5 91* 35* 7* ___ 14:59 ___ 137 3.7 90* 35* 12 ___ 01:37 ___ 138 4.1 95* 33* 10 ___ 01:33 ___ 140 3.8 100 31 9* ___ 13:05 ___ 135 4.2 97 31 7* ___ 5:21 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ @ 0426 ON ___ - ___. GRAM POSITIVE COCCI IN CLUSTERS. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS ___ 5:40 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date ___ 10:54 pm SWAB Source: right chest wall hematoma. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ___ 3:57 pm Mini-BAL FINAL REPORT ___ GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: ~7000 CFU/mL Commensal Respiratory Flora. PSEUDOMONAS AERUGINOSA. 10,000-100,000 CFU/mL. SUSCEPTIBILITIES test result performed by ___. YEAST. 10,000-100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- S CEFTAZIDIME----------- S CIPROFLOXACIN--------- S GENTAMICIN------------ S MEROPENEM------------- S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ S ___ CXR : Difficult to exclude small right apical pneumothorax. Re-demonstrated right pleural effusion with possible partial loculation. Right mid to lower lung opacity may represent combination of pleural effusion and chronic lung changes common appears similar to ___ chest radiograph, but underlying pneumonia not excluded. Brief Hospital Course: Mr. ___ was evaluated by the Thoracic Surgery service in the Emergency Room and admitted to the TSICU for further management of his fevers and leukocytosis. Other than his initial blood cultures he had an aspiration of his right chest hematoma to see if it was possibly infected and the source of his troubles. He was placed on Vancomycin and Cefapime after cultures were obtained and his WBC and exam was followed closely. His WBC continued to stay elevated at 14K-19K and he had one of two blood cultures from ___ which was positive for coag negative staph aureus. His PICC line was removed following report of the initial positive blood culture and the tip was no growth. His chest hematoma culture was no growth and the Infectious Disease service was consulted for further insight and advise. He eventually grew pseudomonas from a mini BAL on ___ which was sensitive to Cefapime and based on his serial chest xrays and exam, pseudomonas pneumonia was thought to be the culprit. A 2 week course of Cefapime was recommended which will go through ___. The Infectious Disease service reevaluated him on ___ to address the question of the need for double coverage for pseudomonas. They felt that if he was febrile he should undergo the usual steps of pan culturing, possibly repeating a chest CT and any of those steps pointed to a pulmonary source then Cipro should be added. If he became hemodynamically unstable then IV Tobramycin should be added. Currently his chest wall hematoma is receding and he's had no temperature spikes but his leukocytosis remains. As far as weaning from the ventilator, it continues to be a slow process. He has been maintained on CPAP with varying levels of pressure support and occasional brief trials on a T piece or a trach collar. Currently at night he rests on CPAP 40% O2 5 PEEP/12 PS and is comfortable and able to sleep. He requires suctioning 2=3 times per shift and his secretions are generally light tan. His calories are maintained with Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ipratropium-Albuterol Neb 1 NEB NEB Q4H 2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 3. Diltiazem 60 mg PO Q6H 4. Docusate Sodium 100 mg PO BID 5. melatonin 5 mg oral QHS 6. Metoprolol Tartrate 50 mg PO Q6H 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Pravastatin 40 mg PO QPM 10. QUEtiapine Fumarate 25 mg PO Q8H 11. LORazepam 0.5 mg PO TID 12. Gabapentin 400 mg PO TID 13. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 14. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 15. Artificial Tears ___ DROP BOTH EYES Q4H:PRN Dry eyes 16. Bisacodyl ___AILY:PRN Constipation - Second Line 17. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate Discharge Medications: 1. Acetylcysteine 20% ___ mL NEB Q6H:PRN dyspnea 2. Artificial Tears GEL 1% ___ DROP BOTH EYES Q4H 3. Atorvastatin 10 mg PO QPM Crush, mix in water and give via PEG tube, flush with 20 mls water 4. CefePIME 2 g IV Q8H 5. Ciprofloxacin 400 mg IV Q12H 6. Heparin 5000 UNIT SC BID 7. Lidocaine 5% Patch 1 PTCH TD QPM 8. Miconazole Powder 2% 1 Appl TP TID:PRN cutaneous candidiasis groin 9. Multivitamins W/minerals 1 TAB PO DAILY use liquid and give via PEG tube, flush with 20 mls water 10. OxyCODONE Liquid ___ mg PO Q6H:PRN Pain - Moderate RX oxycodone 5 mg/5 mL 5 ml by mouth three times a day Refills:0 11. Pantoprazole (Granules for ___ ___ 40 mg G TUBE DAILY give via PEG and flush with 20 mls water 12. Ramelteon 8 mg PO QPM crush, mix in water and give via PEG tube, flush with 20 mls water 13. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line flush 14. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever use elixir and give via PEG tube, flush with 20 mls water 15. Gabapentin 600 mg PO TID crush, mix in water and give via PEG tube, flush with 20 mls water 16. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze and w/ acetylcsyeine treatments 17. LORazepam 0.5 mg PO BID Crush, mix in water and give via PEG tube, flush with 20 mls water 18. Metoprolol Tartrate 25 mg PO Q6H Hold for SBP < 100, HR < 60 Crush, mix in water and give via PEG tube, flush with 20 mls water 19. QUEtiapine Fumarate 25 mg PO QHS crush, mix in water and give via PEG tube, flush with 20 mls water 20. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 21. Artificial Tears ___ DROP BOTH EYES Q4H:PRN Dry eyes 22. Bisacodyl ___AILY:PRN Constipation - Second Line 23. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 24. Diltiazem 60 mg PO Q6H Crush, mix in water and give via PEG tube, flush with 20 mls water 25. Docusate Sodium 100 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Pseudomonas pneumonia Rapid atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: * You were readmitted to the hospital due to questions of ongoing infection due to fevers and an elevated white blood cell count that you had at rehab. You were cultured on multiple occasions and the Infectious Disease service also evaluated you for pneumonia. * Your trach tube and PEG tube will eventually be removed once you are breathing well on your own and able to swallow safely and take I enough calories to meet your nutritional needs. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * Take Tylenol on a standing basis to avoid more opiod use. * Continue your tube feedings which give you 100% of your caloric needs. You will be able to eat normally again once your breathing better on your own and eventually the feeding tube will be removed. * Shower daily. Wash incision with mild soap & water, rinse, pat dry * No tub bathing, swimming or hot tubs until incision healed * No lotions or creams to incision site * Work with Physical Therapy as much as possible to try to increase your mobility and endurance. Followup Instructions: ___
10312052-DS-19	10,312,052	21,567,940	DS	19	2155-04-16 00:00:00	2155-04-16 09:17:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right pneumothorax Major Surgical or Invasive Procedure: ___ Right pleural pigtail catheter placement History of Present Illness: Mr. ___ is a ___ man who is nearly 3 months status post VATS right lower lobe lobectomy for lung cancer, with a complicated postoperative course including ARDS requiring prolonged intubation ultimately tracheostomy and a right pneumothorax requiring a chest tube, presents from rehab with concern for worsening pneumothorax. When the patient left the hospital from his last admission, he had a moderate right-sided pneumothorax with a pleural effusion at the lung base. This is been followed at rehab with serial chest x-rays. On today's chest x-ray, the pleural effusion had resolved however the pneumothorax remained and was questionably enlarged. Therefore the patient was sent to the ___ emergency department for further evaluation. Patient is on full vent support, and thus detailed history is hard to obtain. However, he does report that his breathing has not changed recently. He has an intermittent cough, and intermittent dyspnea. His son does report that he thinks there has been a small increase in the amount of secretions recently. He denies fevers and chills. Past Medical History: PAST MEDICAL HISTORY: Hypercholesterolemia Anemia, iron deficiency Cancer of ascending colon Colonic adenoma History of herpes zoster Degenerative disc disease, lumbar Post-traumatic stress disorder, chronic Depressive disorder History of alcohol abuse Peripheral neuropathy due to chemotherapy Diverticulosis of large intestine without hemorrhage COPD mixed type PAST SURGICAL HISTORY: ___ VATS right lower lobe wedge resection followed by VATS right lower lobectomy, mediastinal lymph node dissection and bronchoscopy with lavage ___ Bronchoscopy ___ Bronchoscopy ___ Bronchoscopy ___ Bronchoscopy ___ Right pleural pigtail catheter placement ___ Portex Per-Fit tracheostomy tube placed percutaneously and a PEG tube placement. ___ Right PICC placement ___ Right common femoral Vein approach IVC filter placement. Right common femoral artery approach right subclavian arteriogram with gel foam embolization of lateral thoracic, pectoral, and humeral branch Social History: ___ Family History: Mother Father: throat cancer Siblings: brother : ___ Other Physical Exam: Temp 97.8 HR 86 BP 160/90 RR 22 O2 sat 96% General: frail appearing, alert and oriented in no distress however difficult to communicate secondary to tract HEENT: NC/AT, EOMI, trach in place Resp: on vent support via trach, lungs clear bilaterally, however decreased breathsounds on the right CV: mildly tachycardic, regular Abd: soft, mildly distended, mildly tender to palpation throughout Ext: well-perfused, no edema Pertinent Results: WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct ___ 01:25 22.0* 4.11* 11.5* 37.5* 91 28.0 30.7* 16.0* 53.5* 356 ___ 01:05 16.7* 4.15* 11.5* 38.2* 92 27.7 30.1* 16.2* 54.2* 371 ___ 01:45 18.6* 4.17* 11.7* 38.1* 91 28.1 30.7* 15.9* 53.6* 394 ___ 01:35 22.7* 4.15* 11.5* 37.8* 91 27.7 30.4* 16.1* 53.9* 448* ___ 14:55 22.7* 4.58* 12.8* 41.4 90 27.9 30.9* 16.3* 53.3* 486* ___ 22:10 19.9* 4.12* 11.5* 37.6* 91 27.9 30.6* 16.0* 52.8* 451* Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 01:25 ___ 135 4.9 93* 32 10 ___ 01:05 ___ 134* 5.0 96 30 8* ___ 01:45 ___ 136 4.8 94* 31 11 ___ 01:35 ___ 135 4.9 94* 30 11 ___ 14:55 ___ 135 5.3 96 26 13 ___ 22:10 ___ 134* 5.1 96 27 11 ___ CXR : Moderate right pneumothorax, with intervally resolved right pleural effusion. No signs of tension. Chronic lung disease re-demonstrated. PICC line appears well positioned. Tracheostomy in place. ___ Chest CT : 1. Small to moderate hydropneumothorax with some possibly loculated components. There is no obvious bronchopleural fistula. 2. Post right lower lobectomy. Consolidations in the left lower lobe and lingula are concerning for pneumonia, significantly progressed since ___. 3. The previously seen large right chest wall hematoma appears significantly decreased in size, now measuring 6.5 x 1.9 cm. 4. Post tracheostomy. Secretions are seen in the right main bronchus extending into the subsegmental bronchi of the right lower lobe 5. There is diffuse lower lobe predominance of interstitial reticulation and honeycombing, compatible with biopsy proven UIP. ___ CXR : In comparison with the study of ___, the monitoring and support devices are stable, as is the cardiomediastinal silhouette. The patient has taken a better inspiration with continued extensive reticular changes and right pleural effusion. Specifically, there is hazy opacification in the right apical region consistent with pleural fluid replacing the prior pneumothorax. Brief Hospital Course: Mr. ___ was evaluated by the Thoracic Surgery service in the Emergency Room and a right pleural pigtail catheter was placed to evacuate his right pneumothorax. He was then admitted to the ___ for vent management as well as management of his pigtail catheter. Most recently at rehab he had been able to tolerate a trach collar during the day and PSV overnight. He felt that his dyspnea improved following placement of the pigtail catheter but on xray, the pneumothorax was the same. There was no air leak from his pigtail catheter. The Pulmonary service was consulted to comment on his fibrotic lung disease which was confirmed on pathology (UIP). After the patient's initial roughly 1-month Prednisone taper, he was not on prolonged steroids. They felt that he didn't have clinical evidence of an ILD flare, and CT imaging did not demonstrate progressive fibrosis or ground glass in a pattern consistent with flaring. However, he did have significant LLL consolidation and mucus plugging; pulmonary hygiene and mucus clearance is key to help with vent weaning. They also felt that his remaining R lung has less parenchymal abnormality than his L lung and his oxygenation would significantly be affected by any pleural process that impairs R lung ventilation. They recommended starting albuterol nebs q6hr with dedicated coughing and airway clearance after, starting start Mucinex ___ mg BID. They will also arrange outpatient pulmonary follow-up for consideration of pirfenidone. Mr. ___ was able to be weaned off the ventilator and has been on a 60% trach collar for the last 72 hours. His pigtail catheter was removed on ___ and he denies any change on his baseline dyspnea. He was evaluated by the Speech and Swallow therapist and cleared for use of a passey muir valve for ___ minute spurts with supervision. His tube feedings were changed to Osmolite 1.5 from Jevity 1.2 due to loose bowel movements. All stool studies have been negative including C diff, banana flakes have been added and the beneprotein has been stopped. Cardiology was also consulted to comment on his PAF with RVR and they recommended titrating up his Metoprolol to 37.5 q 6 hrs, continuing his diltiazem at 60 mg q 6 hrs and if needed for rate control, possibly adding digoxin. Currently with his Metoprolol at 37.5 mg q 6 hrs his rate is better controlled. Anticoagulation was also discussed and deferred given his ___ sore is 1 and prior chest wall hematoma. Mr. ___ is gradually getting stronger and now off the ventilator but still needs more physical therapy as well as SLP before returning home. He was discharged back to rehab on ___ and will follow up with Dr. ___ in 4 weeks. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever 2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 3. Diltiazem 60 mg PO Q6H 4. Gabapentin 600 mg PO TID 5. LORazepam 0.5 mg PO BID 6. Metoprolol Tartrate 25 mg PO Q6H 7. QUEtiapine Fumarate 25 mg PO QHS 8. Acetylcysteine 20% ___ mL NEB Q6H:PRN dyspnea 9. Atorvastatin 10 mg PO QPM 10. Heparin 5000 UNIT SC BID 11. Multivitamins W/minerals 1 TAB PO DAILY 12. Pantoprazole (Granules for ___ ___ 40 mg G TUBE DAILY 13. Ramelteon 8 mg PO QPM 14. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line flush 15. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 16. Bisacodyl ___AILY:PRN Constipation - Second Line 17. Docusate Sodium 100 mg PO BID 18. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze and w/ acetylcsyeine treatments 19. Ciprofloxacin 400 mg IV Q12H 20. OxyCODONE Liquid 5 mg NG Q4H:PRN Pain - Moderate Discharge Medications: 1. Famotidine 20 mg PO DAILY 2. GuaiFENesin ___ mL PO TID 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 4. Heparin 5000 UNIT SC TID 5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 6. LORazepam 0.5 mg NG Q8H:PRN anxiety Cruch and give via PEG tube, flush w/ 10 mls water 7. Metoprolol Tartrate 37.5 mg NG Q6H Use suspension and give via PEG tube, flush w/ 10 mls water 8. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 9. Acetylcysteine 20% ___ mL NEB Q6H:PRN dyspnea 10. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 11. Atorvastatin 10 mg PO QPM crush and give via PEG tube, flush w/ 10 mls water 12. Bisacodyl ___AILY:PRN Constipation - Second Line 13. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 14. Diltiazem 60 mg NG Q6H Cruch and give via PEG tube, flush w/ 10 mls water 15. Gabapentin 600 mg NG TID crush and give via PEg tube. flush w/ 10 mls water 16. Multivitamins W/minerals 1 TAB PO DAILY use elixir and give via PEG tube, flush with 10 mls water 17. OxyCODONE Liquid 5 mg NG Q4H:PRN Pain - Moderate Give via PEG tube and flush with 10 mls water 18. QUEtiapine Fumarate 25 mg NG QHS Crush and give via PEG tube, flush w/ 10 mls water 19. Ramelteon 8 mg NG QPM Cruch and give via PEG tube, flush w/ 10 mls water Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Respiratory failure Trapped right lung Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: * You were admitted to the hospital for evaluation of your right pneumothorax and failure to wean from the respirator following your surgery. * You have done well in weaning from the ventilator and breathing on your own and are now ready to return to rehab for more therapy. * You will continue to require tube feedings via your PEG tube and the Speech and Swallow therapist will evaluate you when you are ready to safely swallow food. * Continue to work hard with Physical Therapy to get strong and improve your endurance. * You will need to follow up with Dr. ___ in ___ weeks and the rehab will arrange transportation for you to return to the Thoracic Clinic. * Call ___ with any questions about this hospitalization. Followup Instructions: ___
10312054-DS-4	10,312,054	23,582,980	DS	4	2150-10-23 00:00:00	2150-10-23 15:22:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left open ankle fracture dislocation Major Surgical or Invasive Procedure: Left ankle I&D, ORIF ___, ___ History of Present Illness: ___ female presents with the above fracture s/p mechanical fall. She was walking along her deck when her foot got caught in a hole and she sustained the above injury. She uses a cane for walking. She last took her warfarin ___ days ago (forgot to take last couple of days). ___ hx of diabetes. Past Medical History: afib on Coumadin and diltiazem Social History: ___ Family History: Non-contributory Physical Exam: AVSS NAD, A&Ox3 LLE: In short leg splint Fires FHL, ___ SILT over exposed toes Toes WWP Pertinent Results: ___ 04:48AM BLOOD WBC-6.9 RBC-3.55* Hgb-11.0* Hct-34.9 MCV-98 MCH-31.0 MCHC-31.5* RDW-13.4 RDWSD-48.2* Plt ___ ___ 04:48AM BLOOD ___ ___ 05:32AM BLOOD Glucose-132* UreaN-11 Creat-0.6 Na-140 K-3.8 Cl-103 HCO3-26 AnGap-11 Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left open ankle fracture dislocation and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for left ankle ORIF and I&D. which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. She was delirious preoperatively, but this resolved by POD1 with minimizing narcotics and sleep wake cycle regulation. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given 2 weeks of oral antibiotics given the open fracture and anticoagulation with a lovenox / Coumadin bridge. Her goal INR is 1.5-2.5, so her LVX was discontinued when her INR reached 1.8 on ___. Her coumadin was then changed to her home dose of 1.5 daily and should be adjusted per INR accordingly. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. She had one episode of bilious emesis on POD3, she was briefly made NPO and given a more aggressive bowel regimen. Narcotics were limited. After suppository administration, the patient passed a large amount of stool, continued passing gas, and her nausea resolved so she was progressed to a regular diet without further issue. The patient also failed void trial x3, so she will be sent to rehab with a foley and a follow up appointment should be made at the ___ clinic next week for a formal void trial. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is non weight bearing in the left lower extremity, and will be discharged on Coumadin for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: diltiazem Coumadin klonopin gabapentin Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Cephalexin 500 mg PO Q6H RX cephalexin 500 mg 1 capsule(s) by mouth every 6 hours Disp #40 Capsule Refills:0 4. Docusate Sodium 100 mg PO BID 5. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 0.5 (One half) capsule(s) by mouth every 4 hours Disp #40 Capsule Refills:0 6. Polyethylene Glycol 17 g PO DAILY 7. Senna 8.6 mg PO BID 8. Sulfameth/Trimethoprim DS 2 TAB PO BID RX sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2 tablet(s) by mouth twice daily Disp #40 Tablet Refills:0 9. Warfarin 2 mg PO QAM Adjust dosing according to INR RX warfarin [Coumadin] 3 mg 0.5 (One half) tablet(s) by mouth daily Disp #30 Tablet Refills:0 10. ClonazePAM 1 mg PO TID:PRN anxiety 11. Diltiazem Extended-Release 120 mg PO DAILY 12. Gabapentin 300 mg PO QAM 13. Gabapentin 600 mg PO NOON 14. Gabapentin 1200 mg PO QPM 15. Gabapentin 1200 mg PO QHS 16. Milk of Magnesia 30 ml PO BID:PRN Constipation 17. rOPINIRole 2.5 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Open left ankle fracture dislocation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Non weight bearing left lower extremity in splint 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. - Take Bactrim and Keflex for 2 weeks to prevent infection ANTICOAGULATION: - Please take coumadin as prescribed - Please check INR to ensure within target 1.5-2.5; may require more frequent INR checks given concurrent Bactrim therapy - Home regimen is 1.5 mg daily WOUND CARE: - You may shower if you can manage not getting your splint wet. 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. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. ___. You will have follow up with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Please follow up with ___ clinic ___ next week (___) for a void trial by calling this number: ___ Physical Therapy: ___ LLE in splint Treatments Frequency: Splint and sutures to be removed at post op visit Followup Instructions: ___
10312300-DS-19	10,312,300	28,844,999	DS	19	2186-11-20 00:00:00	2186-11-20 09:05:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___ Cardiac cath ___ Urgent coronary artery bypass graft x2: Left internal mammary artery to left anterior descending artery, and saphenous vein graft to posterior left ventricular branch. Endoscopic harvesting of the long saphenous vein. History of Present Illness: ___ year old male with a history of Hodgkins Lymphoma (s/p treatment ___, no residual disease) who presented with chest pain and found to have NSTEMI. He denied anginal chest pain but said that he awoke with palpitations prior to presenting to the ED, which went away after 3 min. On the day of admission he felt a sudden onset of chest pain over the left breast, extending down left arm, assiocated with diaphoresis and palpitations. Pt's brother checked his BP and it was 220 so he brought him to ED. Pt noted that chest pain continued, at less intensity, until he recieved nitroglycerin while at ___. At ___, his BP on triage was 180 systolic, and EKG reportedly with ST depressions. Troponins were elevated and he was given nitro paste, and transferred to ___ for further evaluation. While at ___ he was referred for a cardiac catheterization and was found to have coronary artery disease and is now being referred to cardiac surgery for revascularization. Past Medical History: Hodgkin's Lymphoma (treated at the age of ___ in ___ when he was in ___, (no records available so presumptive diagnosis) s/p 7 months CHEMO, XRT, seen by ONC here who felt there was no remaining disease, rec'd yearly LDH, CBC w/ diff, and LAD exam) Social History: ___ Family History: Premature coronary artery disease- Uncle had MI at ___ yrs of age, Father had CV/PVD, Mother hypertension Physical ___: Admission Exam: B/P Right:173/94 Left:167/86 ___ Weight:81.6 kg General:no distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [x] Edema [] none_____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ ___ Right:1+ Left:1+ Radial Right:2+ Left:2+ Carotid Bruit Right:none Left:none Discharge Exam: Temp: 99.6F Tmax, current 98.6F B/P:126/78 HR: 97, SR RR 18, sat: 98% on 2L ___ Weight:80 kg General:no distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Sternum: healing well, C/D/I Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: 1+ LLE [x] LLE EVH site: c/d/i Varicosities: None [x] Neuro: Grossly intact [x] Pulses: DP Right:1+ Left:1+ ___ Right:1+ Left:1+ Radial Right:2+ Left:2+ Pertinent Results: Admission Labs: ___ 01:18AM PLT COUNT-163 ___ 01:18AM WBC-9.0 RBC-4.63 HGB-13.5* HCT-37.2* MCV-80* MCH-29.1 MCHC-36.3* RDW-14.1 ___ 01:18AM ALBUMIN-4.0 ___ 01:18AM CK-MB-19* MB INDX-7.5* ___ 01:18AM cTropnT-0.29* ___ 01:18AM LIPASE-18 ___ 01:18AM ALT(SGPT)-27 AST(SGOT)-36 CK(CPK)-252 ALK PHOS-103 TOT BILI-0.3 ___ 01:27AM LACTATE-1.9 ___ 04:24AM %HbA1c-5.8 eAG-120 ___ 06:40AM ___ PTT-59.3* ___ ___ 01:18AM GLUCOSE-160* UREA N-15 CREAT-1.1 SODIUM-138 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-27 ANION GAP-12 Discharge Labs: ___ 06:35AM BLOOD WBC-14.9* RBC-3.27* Hgb-9.0* Hct-27.2* MCV-83 MCH-27.6 MCHC-33.2 RDW-13.6 Plt ___ ___ 04:36AM BLOOD WBC-20.1* RBC-3.34* Hgb-9.3* Hct-27.5* MCV-82 MCH-27.8 MCHC-33.8 RDW-13.6 Plt ___ ___ 01:18AM BLOOD WBC-9.0 RBC-4.63 Hgb-13.5* Hct-37.2* MCV-80* MCH-29.1 MCHC-36.3* RDW-14.1 Plt ___ ___ 11:27AM BLOOD ___ PTT-25.8 ___ ___ 04:36AM BLOOD Glucose-105* UreaN-21* Creat-0.8 Na-135 K-3.9 Cl-98 HCO3-30 AnGap-11 ___ 01:18AM BLOOD Glucose-160* UreaN-15 Creat-1.1 Na-138 K-4.0 Cl-103 HCO3-27 AnGap-12 ___ 01:20PM BLOOD ALT-31 AST-73* AlkPhos-99 Amylase-47 TotBili-0.4 ___ 01:18AM BLOOD cTropnT-0.29* ___ 06:40AM BLOOD CK-MB-47* MB Indx-9.6* cTropnT-2.19* ___ 11:15AM BLOOD CK-MB-46* MB Indx-9.1* cTropnT-2.46* ___ 06:10PM BLOOD CK-MB-26* MB Indx-7.2* cTropnT-1.64* ___ 10:35PM BLOOD CK-MB-18* MB Indx-6.3* cTropnT-1.46* ___ 04:36AM BLOOD Calcium-8.2* Phos-4.1 Mg-2.0 ___ 01:20PM BLOOD %HbA1c-5.9 eAG-123 STUDIES: ___ Cardiac cath: LMCA: 40% distal stenosis LAD: 90% proximal stenosis LCX: 50% mid stenosis. OM1 has a 40% stenosis. RCA: 80% stenosis in the ostium of the posterolateral branch. . ___ Chest CT: No ascending aortic calcifications identified. Minimal calcifications are seen along the arch of the aorta. No pulmonary abnormalities identified. . ___ Carotid U/S: 1. Normal carotid bifurcations bilaterally without evidence of plaque. 2. No hemodynamically significant stenoses on either side. 3. Antegrade flow in both vertebral arteries. . ___ Echo: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: 55% >= 55% Left Ventricle - Stroke Volume: 86 ml/beat Left Ventricle - Cardiac Output: 4.81 L/min Left Ventricle - Cardiac Index: 2.41 >= 2.0 L/min/M2 Aorta - Sinus Level: 3.4 cm <= 3.6 cm Aorta - Ascending: 2.8 cm <= 3.4 cm Aorta - Arch: 1.9 cm <= 3.0 cm Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 5 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 3 mm Hg Aortic Valve - LVOT VTI: 19 Aortic Valve - LVOT diam: 2.4 cm Aortic Valve - Valve Area: 2.5 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Good (>20 cm/s) ___ ejection velocity. No thrombus in the ___. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Simple atheroma in abdominal aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. ___ VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Written informed consent was obtained from the patient. A TEE was performed in the location listed above. I certify I was present in compliance with ___ regulations. No TEE related complications. Conclusions Prebypass: No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). No regional wall motion abnormality seen. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. There are simple atheroma in the abdominal aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Postbypass: Left Ventricular function preserved. EF>55%. Right ventricular function normal similar to pre bypass. Mitral valve, aortic valve, and tricuspid valve function unchanged. Rest of the exam is unchanged. Aorta intact. No aortic dissection seen. Electronically signed by ___, MD, Interpreting physician ___ ___ 09:34 . PA/LAT CXR ___: In comparison with the study of ___, there again is no definite evidence of pneumothorax. Bibasilar atelectatic changes are again seen, with bilateral pleural effusions. No definite vascular congestion. Dilated bowel is seen in the upper abdomen. ___ 06:35AM BLOOD Glucose-88 UreaN-18 Creat-0.7 Na-135 K-3.9 Cl-96 HCO3-28 AnGap-15 Brief Hospital Course: Mr. ___ was transferred from outside hospital to ___ on ___ for cardiac cath. Cath revealed severe coronary artery disease and Cardiac surgery was consulted. He underwent work-up for surgical revascularization while receiving medical management. He was initially scheduled for bypass surgery on ___ but surgery had to be delayed due to an emergency case. On ___ he was brought to the operating room where he underwent a coronary artery bypass graft x2. Please see operative note for surgical details. In summmary he had: Urgent coronary artery bypass graft x2: Left internal mammary artery to left anterior descending artery, and saphenous vein graft to posterior left ventricular branch. Endoscopic harvesting of the long saphenous vein. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued with small left apical pneumothorax that has since resolved. He was pancultured for leukocytosis (without fever) on ___, but has had no growth to date and spontaneous improvement in his WBC, so typical postoperative inflammatory response is suspected. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to his brother's home in good condition with appropriate follow up instructions. He does not have ___ benefits, but is being supplied with free care medications. Medications on Admission: Multivitamin 1 tablet Daily (occasionally) Discharge Medications: 1. Aspirin EC 81 mg PO DAILY RX aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Atorvastatin 80 mg PO DAILY RX atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 4. Metoprolol Tartrate 50 mg PO TID RX metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 5. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth every three (3) hours Disp #50 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Coronary artery disease s/p Coronary artery bypass graft x2 Secondary: Hodgkin's Lymphoma Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Oxycodone and Tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema - 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for one month or while taking narcotics. Driving will be discussed at follow up appointment with surgeon-when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours* Followup Instructions: ___
10312423-DS-24	10,312,423	26,943,121	DS	24	2142-04-16 00:00:00	2142-04-17 16:22:00	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: - History of Present Illness: Mrs. ___ is a ___ with h/o multiple abdominal surgeries, presented with 6-hour history of crampy lower abdominal pain. She points to a band across her lower abdomen when asked to localize the pain. She ate dinner prior to onset of pain, and has not had any nausea or vomiting. She cannot recall when she last passed gas, but did have a bowel movement immediately prior to presenting to the ED. She last had abdominal surgery in ___ for an incarcerated ventral hernia and ovarian cancer, and has not had any bowel obstructions since that time. Past Medical History: PMH: ovarian CA, breast CA, morbid obesity, HTN, hiatal hernia, GERD, arthritis, gout, glaucoma, multiple small bowel obstructions, pre-diabetes, history of PE (completed coumadin course) PSH: ___ lap, LOA, TAH-BSO, component separation; ___ for SBO, incisional hernia repair; ___ lumpectomy with SLN; ___ knee replacement; R rotator cuff repair; R carpal tunnel release; tonsillectomy; diagnostic laparoscopy 98 Social History: ___ Family History: Family history is negative for breast, colon, uterine, or ovarian cancer. Otherwise non-contributory. Physical Exam: Discharge PE: VS: Tm 99.2, Tc 98.0, HR 72, BP 142/64, RR 18, SO2 95%RA Gen: NAD Cards: RRR, no RMG Pulm: CTAB Abd: Obese, soft, nt, nd, normal bs Extrem: No CCE Pertinent Results: Admission Labs: ___ 11:40PM ALT(SGPT)-19 AST(SGOT)-16 LD(LDH)-181 ALK PHOS-90 AMYLASE-56 TOT BILI-0.2 ___ 11:40PM LIPASE-46 ___ 11:40PM ALBUMIN-4.4 ___ 11:40PM WBC-10.7# RBC-4.00* HGB-12.9 HCT-37.5 MCV-94 MCH-32.2* MCHC-34.3 RDW-12.6 F/u Labs: ___ 02:02AM ___ PTT-29.7 ___ ___ 02:18AM LACTATE-3.2* ___ 02:55AM URINE RBC-1 WBC-22* BACTERIA-FEW YEAST-NONE EPI-<1 TRANS EPI-<1 ___ 02:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM ___: Abdominal upright/supine XR: Few air-fluid levels are seen in non-dilated loops of bowel. There is no evidence for large free intraperitoneal air. Surgical clips project over the right upper quadrant and pelvis. Left axillary clips are incompletely imaged. Degenerative changes are seen in the spine. ___: CT Abd-pelvis with contrast: Mildly dilated loops of small bowel in the left abdomen with wall thickening, a small amount of adjacent ascites and fat stranding, and no transition point. These findings are suggestive of an inflammatory process in this region with secondary small bowel ileus. ___: KUB Dilated bowel loops with air-fluid levels appear unchanged in extent, distribution and severity consistent with inflammatory process and small bowel ileus as was described on the recent CT abdomen. No interval progression is noted within the limitations of that study technique assessment. The maximum dilated small bowel loops are approaching 4.2 cm in the left upper quadrant. The NG tube tip is in the proximal stomach ___: CXR The heart size is top normal. The lungs are clear. No pleural abnormality or evidence of central adenopathy. No labs done on day of discharge. Brief Hospital Course: Assessment: ___ y/o female with a history of small bowel obstructions presented with likely small bowel obstruction vs ileus. This was treated non operatively with an NGT and decompression and medications. The patient improved nicely. Diagnoses: # Small bowel obstruction vs ileus: The patient has a history of multiple intraabdominal surgeries and multiple small bowel obstructions of which have been managed both surgicically and non-operatively. Imaging suggested ileus with possible SBO but no obvious transition point. Because the patient was stable and did not have an acute abdomen the decision was made to try and treat this non-operatively. The patient was afebrile, without white count and without LFT elevations. Initially an NGT was placed and the patient was made NPO. Nausea was treated with zofran prn. Her pain was treated with IV dilaudid and IV tylenol. After several days the patient started passing flatus and having bowel movements again. Her diet was advanced appropriately. The first day she was put on clears she took in 1300 PO and had several episodes of emesis. She was again made NPO but an NGT was not placed as her nausea resolved with medications. After 24 hours her diet was again advanced more slowly and she tolerated this very well. At the time of discharge she was ambulating, tolerating good PO intake, afebrile, voiding, having bowel movements and passing lots of flatus. She was given instructions to follow up closely in clinic. # Hypertension: The patient was a bit hypertensive during her admission as she was not able to take her home BP meds. She was given IV metoprolol with good effect and transitioned back to PO antihypertensives when taking adequate PO intake. # Urinary Tract Infection: Patient was noted to have >20 WBC's in her urine. She was diagnosed with a UTI. She was treated with a short course of ciprofloxacin with good effect. Medications on Admission: omega-3 fatty acids, vitamin B12 1000mcg', vitamin D 2000u', ASA 81', albuterol inhaler prn, lisinopril 20', timolol maleate 0.5% 1 drop each eye BID, simvastatin 20', dorzolamide 2% 1 drop each eye BID, antivert 25''' prn dizziness, cipro 250" (Rx today for UTI), metoprolol 25", multivitamin, biotin 2500mcg', miralax' Discharge Medications: 1. Omega-3 Oral 2. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 3. Vitamin D 2,000 unit Capsule Sig: One (1) Capsule PO once a day. 4. aspirin 81 mg Tablet, Effervescent Sig: One (1) Tablet, Effervescent PO once a day. 5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q4H (every 4 hours) as needed for wheeze. 6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic BID (2 times a day). 8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic BID (2 times a day). 10. Antivert 25 mg Tablet Sig: One (1) Tablet PO three times a day as needed for dizziness/vertigo. 11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. multivitamin Oral 13. biotin 2,500 mcg Capsule Sig: One (1) Capsule PO once a day. 14. Miralax 17 gram/dose Powder Sig: One (1) dose PO once a day. 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation: Please take this medication as needed for constipation. Disp:60 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Partial small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the ___ Surgery Service for a likely small bowel obstruction given your symptoms and imaging. You were given IV fluids and closely observed until return of bowel function. Your pain is now well-controlled with oral medications and you are ready to continue the rest of your recovery at home. Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. You can stop taking the ciprofloxacin (antibiotic) at this time. You may 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 until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Thank you for letting us participate in your care. We wish you a speedy recovery. Followup Instructions: ___
10312423-DS-28	10,312,423	26,533,871	DS	28	2146-05-24 00:00:00	2146-05-25 13:04:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ciprofloxacin Attending: ___. Chief Complaint: Small bowel obstruction Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of multiple abdominal surgeries and recurrent SBO, presenting with acute onset abdominal pain. Pain began at 7pm yesterday, described as "like labor pains". Located primarily in RUQ, and consistent with previous bowel obstructions. Associated with nausea and one episode of NBNB emesis while in the ED. Has continued to pass gas, and last BM yesterday morning was normal. Last colonoscopy ___. Past Medical History: - Systolic congestive heart failure (LVEF 40%, global hypokinesis with beat-to-beat variability in Afib). - Hypertension. - Dyslipidemia. - Atrial fibrillation. - Atrial tachycardia/palpitations. - Morbid obesity. - Multiple pulmonary emboli, post operatively - Small bowel obstruction - Breast cancer (stage I clear-cell ovarian CA s/p chemo, breast CA s/p XRT/chemo) - Ovarian cancer - Osteoarthritis - Glaucoma - GERD - Hiatal Hernia - Arthritis - OSA - Glucose Intolerance - Restrictive Lung Disease PSH: ___ lap, LOA, TAH-BSO, component separation; ___ for SBO, incisional hernia repair; ___ lumpectomy with SLN; ___ knee replacement; R rotator cuff repair; R carpal tunnel release; tonsillectomy; diagnostic laparoscopy ___ Social History: ___ Family History: Her father died at age ___ of a myocardial infarction. He sustained his first myocardial infarction in his ___. Her mother died at age ___ in a house fire. She has four brothers, three sisters, one son and one daughter. One of her brothers had a myocardial infarction with bypass surgery in his early ___. Two of her sisters have diabetes, and all of her siblings suffer from hypertension. There is no family history notable for stroke, hyperlipidemia, cancer, or sudden cardiac death. Physical Exam: Admission Physical EXAM: Vitals: 98.5 84 146/80 18 95% RA Gen: a&o x3, nad CV: rrr, no murmur Resp: cta bilat Abd: soft, NT, ND, +BS Extr: warm, 2+ pulses Discharge Physical Exam: VS: T: 98.1, BP: 124/69, HR: 64, RR: 18, O2: 100% RA General: A+Ox3, NAD CV: regular rate, irregular rhythm Resp: rhonchi in b/l lower lobes w/ expiration. Otherwise CTA b/l Abd: soft, non-distended, mildly tender in LLQ to deep palpation. Pertinent Results: ___ 08:00AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 08:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 08:00AM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 03:18AM ___ PTT-37.5* ___ ___ 01:47AM GLUCOSE-160* UREA N-21* CREAT-0.8 SODIUM-140 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-28 ANION GAP-17 ___ 01:47AM ALT(SGPT)-17 AST(SGOT)-16 ALK PHOS-83 TOT BILI-0.3 ___ 01:47AM LIPASE-28 ___ 01:47AM ALBUMIN-4.4 ___ 01:47AM WBC-9.8# RBC-4.22 HGB-13.3 HCT-40.1 MCV-95 MCH-31.5 MCHC-33.2 RDW-13.7 RDWSD-47.8* ___ 01:47AM NEUTS-86.1* LYMPHS-8.1* MONOS-4.9* EOS-0.3* BASOS-0.2 IM ___ AbsNeut-8.46# AbsLymp-0.80 AbsMono-0.48 AbsEos-0.03* AbsBaso-0.02 ___ 01:47AM PLT COUNT-237 Imaging: ___: CT Abd/Pel: Small bowel obstruction, without discrete transition point. Gradual narrowing of bowel in the left upper quadrant. There is a likely internal hernia proximal to the most dilated loops of bowel, but this appears to be separate from the area of transition and cause of small bowel obstruction. This is similar in appearance to prior CT from ___. ___: CT abd/pel: 1. Small bowel obstruction with a transition point identified in the mid left hemiabdomen. 2. Increased edematous loops of bowel in the pelvis, which is separate from the transition point in the abdomen. Cause and clinical significance is uncertain, as there is no associated caliber transition along this segment of bowel. It is noted that the morphology of the small bowel has been very similar over multiple CT examinations, raising question of adhesions vs internal hernia as suggested on the prior CT (though the latter is not particularly evident on this study). 3. Slight interval increase in the amount of surrounding free fluid and increased engorgement of the surrounding mesenteric vessels. ___: CT abd/pel: 1. Interval resolution of small bowel obstruction with mild residual edema. 2. Left upper quadrant and pelvic small bowel loops have the appearance of underlying adhesions as previously suggested. Brief Hospital Course: Ms. ___ is a ___ year-old female with a history of multiple abdominal surgeries and recurrent SBO who presented to ___ on ___ with abdominal pain. CT abd/pel revealed a small bowel obstruction (SBO) and she was admitted to the Acute Care Surgery team for further medical care. The patient's SBO was managed conservatively and she was made NPO with IVF. On HD3, the patient had emesis and a NGT was placed. She had a repeat CT which showed SBO with a transition point identified in the mid left hemiabdomen. Later on HD3, the patient had 2 bowel movements. On HD4, the patient passed flatus and her NGT was removed. On HD5, the patient was started on a regular diet which was well-tolerated. The remainder of the ___ hospital course is summarized by systems below: Neuro: The patient was alert and oriented throughout hospitalization; pain was managed with oral pain medication once tolerating a diet. No prescriptions for pain medication were required upon discharge. CV: The patient has a history of atrial fibrillation. On HD3, the patient had an episode of atrial fibrillation with RVR which returned to a controlled rate without intervention. The patient was asymptomatic. Coumadin was restarted on ___ prior to discharge. 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. ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. The patient was informed INR should be checked within 2 days after discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. Anastrozole 1 mg PO DAILY 3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 4. Losartan Potassium 25 mg PO DAILY 5. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 6. Simvastatin 20 mg PO QPM 7. Warfarin 5 mg PO 5X/WEEK (___) 8. Warfarin 7.5 mg PO 3X/WEEK (___) 9. Aspirin 81 mg PO DAILY 10. Vitamin D ___ UNIT PO DAILY 11. Cyanocobalamin ___ mcg PO DAILY 12. Docusate Sodium 100 mg PO BID 13. Multivitamins 1 TAB PO DAILY 14. Fish Oil (Omega 3) 1000 mg PO BID 15. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Losartan Potassium 25 mg PO DAILY 5. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 6. Warfarin 5 mg PO 5X/WEEK (___) 7. Warfarin 7.5 mg PO 3X/WEEK (___) 8. Acetaminophen 650 mg PO Q6H:PRN pain 9. Senna 8.6 mg PO BID:PRN constipation 10. Anastrozole 1 mg PO DAILY 11. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 12. Fish Oil (Omega 3) 1000 mg PO BID 13. Multivitamins 1 TAB PO DAILY 14. Polyethylene Glycol 17 g PO DAILY:PRN constipation 15. Simvastatin 20 mg PO QPM 16. Vitamin D ___ UNIT PO DAILY 17. Cyanocobalamin ___ mcg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You presented to the ___ and were found to have a small bowel obstruction. You were admitted to the Acute Care Surgery team for further medical care. Your bowel obstruction self-resolved, you are now tolerating a regular diet and your pain is better controlled. You are now medically cleared to be discharged home to continue your recovery. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: ___
10312423-DS-29	10,312,423	20,812,033	DS	29	2148-04-26 00:00:00	2148-04-30 16:46:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ciprofloxacin Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: ___: 1. Exploratory laparotomy. 2. A 30-cm resection of jejunum. 3. Primary anastomosis with side-to-side jejunojejunostomy. History of Present Illness: ___ female with history of atrial fibrillation, morbidy obesity, HFrEF, breast cancer s/p mastectomy, XRT/chemo, ovarian cancer s/p chemotherapy and TAH/BSO, incisional hernia s/p repair and recurrent small bowel obstructions who presents with abdominal pain. She developed acute onset diffuse abdominal pain starting ___, worse with movement and deep inspiration. She reports associated nausea and emesis. Last BM and flatus were this morning. She recognized the symptoms as similar to previous obstructions, and presented to the ED for evaluation. Pt denies chest pain, shortness of breath, diarrhea, melena or BRBPR. Last colonoscopy in ___, with adenomatous polyps removed. Work-up was notable for leukocytosis, lactate of 3.0 and imaging concerning for recurrent small bowel obstruction. Surgery has been consulted for recommendations. Past Medical History: - Systolic congestive heart failure (LVEF 40%, global hypokinesis with beat-to-beat variability in Afib). - Hypertension. - Dyslipidemia. - Atrial fibrillation. - Atrial tachycardia/palpitations. - Morbid obesity. - Multiple pulmonary emboli, post operatively - Small bowel obstruction - Breast cancer (stage I clear-cell ovarian CA s/p chemo, breast CA s/p XRT/chemo) - Ovarian cancer - Osteoarthritis - Glaucoma - GERD - Hiatal Hernia - Arthritis - OSA - Glucose Intolerance - Restrictive Lung Disease PSH: ___ lap, LOA, TAH-BSO, component separation; ___ for SBO, incisional hernia repair; ___ lumpectomy with SLN; ___ knee replacement; R rotator cuff repair; R carpal tunnel release; tonsillectomy; diagnostic laparoscopy ___ Social History: ___ Family History: Her father died at age ___ of a myocardial infarction. He sustained his first myocardial infarction in his ___. Her mother died at age ___ in a house fire. She has four brothers, three sisters, one son and one daughter. One of her brothers had a myocardial infarction with bypass surgery in his early ___. Two of her sisters have diabetes, and all of her siblings suffer from hypertension. There is no family history notable for stroke, hyperlipidemia, cancer, or sudden cardiac death. Physical Exam: Admission Physical Exam: GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes dry, NGT in place CV: regular rate, irregular rhythm PULM: Clear to auscultation b/l, No W/R/R ABD: Tympanitic, very distended, tender to palpation in all quadrants but worse in LLQ, +rebound normoactive bowel sounds, no palpable masses Ext: No ___ edema, ___ warm and well perfused Discharge Physical Exam: VS: T: 98.6 PO BP: 141/81 L Sitting HR: 78 RR: 18 O2: 98% 2l Nc GEN: A+Ox3, NAD HEENT: MMM CV: irregular rhythm, regular rate PULM: CTA b/l ABD: soft, non-distended, non-tender to palpation. Midline surgical incision with staples, some staples removed and open areas packed loosely with gauze and covered with dsd. No s/s infection EXT: wwp, +1 b/l ___ edema, no induration or erythema Pertinent Results: ___ 10:00AM BLOOD WBC-10.6* RBC-2.39* Hgb-7.3* Hct-23.1* MCV-97 MCH-30.5 MCHC-31.6* RDW-14.6 RDWSD-50.8* Plt ___ ___ 06:53AM BLOOD WBC-12.8* RBC-2.46* Hgb-7.6* Hct-23.6* MCV-96 MCH-30.9 MCHC-32.2 RDW-15.9* RDWSD-54.9* Plt ___ ___ 03:30PM BLOOD WBC-15.7* RBC-2.42* Hgb-7.5* Hct-22.8* MCV-94 MCH-31.0 MCHC-32.9 RDW-16.6* RDWSD-56.1* Plt ___ ___ 09:15PM BLOOD WBC-15.2* RBC-2.23* Hgb-6.9* Hct-20.8* MCV-93 MCH-30.9 MCHC-33.2 RDW-16.2* RDWSD-54.6* Plt ___ ___ 07:27AM BLOOD WBC-11.5* RBC-2.64* Hgb-8.2* Hct-25.6* MCV-97 MCH-31.1 MCHC-32.0 RDW-14.1 RDWSD-49.7* Plt ___ ___ 05:55AM BLOOD WBC-9.1 RBC-3.07* Hgb-9.6* Hct-29.9* MCV-97 MCH-31.3 MCHC-32.1 RDW-14.3 RDWSD-50.7* Plt ___ ___ 01:10AM BLOOD WBC-10.5* RBC-2.83* Hgb-9.0* Hct-27.4* MCV-97 MCH-31.8 MCHC-32.8 RDW-14.2 RDWSD-50.0* Plt ___ ___ 02:00AM BLOOD WBC-9.4 RBC-2.63* Hgb-8.2* Hct-26.3* MCV-100* MCH-31.2 MCHC-31.2* RDW-14.3 RDWSD-51.9* Plt ___ ___ 02:04AM BLOOD WBC-12.1* RBC-2.79* Hgb-8.7* Hct-27.4* MCV-98 MCH-31.2 MCHC-31.8* RDW-13.8 RDWSD-49.8* Plt ___ ___ 05:35PM BLOOD WBC-13.8* RBC-3.08* Hgb-9.7* Hct-30.9* MCV-100* MCH-31.5 MCHC-31.4* RDW-14.0 RDWSD-50.4* Plt ___ ___ 05:38AM BLOOD WBC-11.2# RBC-3.38 Hgb-10.6* Hct-32.9* MCV-97 MCH-31.4 MCHC-32.2 RDW-13.7 RDWSD-49.3* Plt ___ ___ 04:31PM BLOOD WBC-5.4# RBC-3.82* Hgb-11.8 Hct-36.0 MCV-94 MCH-30.9 MCHC-32.8 RDW-13.6 RDWSD-46.8* Plt ___ ___ 06:53AM BLOOD ___ PTT-25.9 ___ ___ 06:15AM BLOOD ___ PTT-25.5 ___ ___ 01:45AM BLOOD ___ PTT-27.7 ___ ___ 06:30AM BLOOD ___ PTT-96.4* ___ ___ 07:27AM BLOOD ___ PTT-56.8* ___ ___ 05:55AM BLOOD ___ PTT-73.6* ___ ___ 05:36PM BLOOD ___ PTT-72.2* ___ ___ 11:22AM BLOOD ___ ___ 10:00AM BLOOD Glucose-150* UreaN-16 Creat-0.7 Na-137 K-4.4 Cl-94* HCO3-35* AnGap-8* ___ 06:53AM BLOOD Glucose-138* UreaN-17 Creat-0.7 Na-141 K-4.7 Cl-97 HCO3-29 AnGap-15 ___ 01:45AM BLOOD Glucose-131* UreaN-33* Creat-0.7 Na-139 K-5.3* Cl-100 HCO3-33* AnGap-6* ___ 06:30AM BLOOD Glucose-162* UreaN-43* Creat-0.7 Na-135 K-4.4 Cl-95* HCO3-25 AnGap-15 ___ 07:27AM BLOOD Glucose-147* UreaN-26* Creat-0.6 Na-138 K-4.4 Cl-97 HCO3-30 AnGap-11 ___ 05:55AM BLOOD Glucose-148* UreaN-20 Creat-0.6 Na-142 K-3.9 Cl-98 HCO3-31 AnGap-13 ___ 01:10AM BLOOD Glucose-125* UreaN-22* Creat-0.6 Na-146 K-4.3 Cl-105 HCO3-30 AnGap-11 ___ 02:04AM BLOOD Glucose-111* UreaN-33* Creat-0.8 Na-149* K-3.5 Cl-100 HCO3-40* AnGap-9* ___ 05:35PM BLOOD Glucose-130* UreaN-31* Creat-0.7 Na-150* K-4.2 Cl-100 HCO3-39* AnGap-11 ___ 03:19AM BLOOD Glucose-128* UreaN-33* Creat-0.8 Na-146 K-4.4 Cl-101 HCO3-38* AnGap-7* ___ 05:38AM BLOOD Glucose-149* UreaN-30* Creat-1.0 Na-142 K-5.1 Cl-100 HCO3-30 AnGap-12 ___ 01:20AM BLOOD Glucose-193* UreaN-29* Creat-0.9 Na-134* K-5.6* Cl-90* HCO3-26 AnGap-18 ___ 01:45AM BLOOD ALT-30 AST-24 AlkPhos-65 TotBili-0.4 DirBili-<0.2 IndBili-0.4 ___ 05:35PM BLOOD ALT-19 AST-22 AlkPhos-80 TotBili-0.2 ___ 01:20AM BLOOD ALT-25 AST-40 AlkPhos-83 TotBili-0.3 ___ 10:00AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.8 ___ 06:53AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.0 ___ 01:45AM BLOOD Albumin-2.7* Calcium-8.3* Phos-3.9 Mg-2.0 ___ 06:30AM BLOOD Calcium-7.7* Phos-4.0 Mg-1.9 ___ 07:27AM BLOOD Calcium-7.9* Phos-3.2 Mg-2.1 ___ 05:55AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.7 ___ 01:10AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9 ___ 05:36PM BLOOD Calcium-8.6 Phos-3.0 Mg-2.1 ___ 02:11AM BLOOD Calcium-7.8* Phos-2.6* Mg-2.0 ___ 02:13PM BLOOD Calcium-7.6* Phos-2.7 Mg-2.0 ___ 02:00AM BLOOD Calcium-7.7* Phos-3.1 Mg-2.2 ___ 08:30PM BLOOD Calcium-7.8* Phos-3.2 Mg-2.2 ___ 02:04AM BLOOD Calcium-8.1* Phos-1.5* Mg-2.2 ___ 05:35PM BLOOD Calcium-8.5 Phos-2.5* Mg-2.3 UricAcd-6.3* ___ 01:45AM BLOOD Hapto-318* ___ CT Ab/Pelvis: 1. No CT evidence of intra-abdominal hemorrhage. Small volume postoperative free fluid. 2. Postsurgical changes from laparotomy, small-bowel resection, and lysis of adhesions. No evidence of mechanical bowel obstruction. ___ CXR: Compared to the prior examination, the right IJ central venous catheter, endotracheal tube, and upper enteric tube have been removed. Lung volumes remain low with hazy left-greater-than-right basal opacities which are likely atelectatic. There remains mild to moderate cardiomegaly with unfolding of the thoracic aorta and the slight central pulmonary vascular engorgement though without frank interstitial edema. A left-sided pleural effusion is tiny, if any. There is no pneumothorax. There is no right-sided effusion. ___ Ct Ab/Pelvis: 1. Small-bowel obstruction with transitional point in the left lower anterior abdomen with fecalization of the small bowel and adjacent free fluid. No evidence of pneumatosis or extraluminal air. 2. Trace perihepatic ascites. Pathology: Peritoneal Fluid Ascites fluid: NEGATIVE FOR MALIGNANT CELLS. - Mesothelial cells, lymphocytes, histiocytes, and red blood cells. Brief Hospital Course: Ms. ___ is a ___ female with history of atrial fibrillation, morbid obesity and breast cancer, status post mastectomy, and ovarian cancer, status post chemotherapy and total abdominal hysterectomy with bilateral salpingo-oophorectomy who presented with worsening abdominal pain on ___. In our emergency department, she was peritonitic, tachycardic and appeared toxic. Despite NG tube placement, she did not improve and based on exam the decision was made to offer her an operative intervention. A thorough discussion of the risks and benefits of surgery was had with the patient. She consented to proceed. Please see operative report for details. She tolerated the procedure well and was extubated upon completion. She was subsequently taken to the PACU for recovery. She arrived on the floor NPO with nasogastic tube in place and on morphine PCA for pain control. On POD2 she had increased work of breathing and acute respiratory distress and was therefore transferred to the intensive care unit. ------ On ___, she was transferred to the ICU for respiratory distress. An ABG revealed that she was in hypercarbic respiratory failure, and she was eventually intubated in the evening that same day for this. The following morning she was weaned on the ventilator from a rate and allowed to breathe spontaneously. renal lytes obtained. She was weaned from CMV to spontaneous after the was weaned of propofol and transitioned to precedex. ___ mEq Hydrochloric Acid/500 mL D5W was given for her alkalosis. She was started on a heparin drip given her Afib and since there were no concerns for bleeding. On ___, she was noted to have alkalosis, and given 1L normal saline, with improvement in her bicarbonate levels and PCO2 on her gas. She was started on trickle tube feeds at 10cc/hour. She completed her 4-day course of antibitiotics for contaminated case coverage, however, was maintained on ceftriaxone until ___ given her pan-sensitive E. coli UTI. On ___, she was extubated without issue to face tent, then weaned to nasal cannula overnight. She was diuresed with 20mg IV Lasix. Her A-line was removed. On ___, she appeared to be doing well. She reports continuation of passage of flatus. She was tolerating some ice chips for comfort after her NGT was removed overnight given low residuals. She was started on a clear liquid diet, and resumed on her home medications by mouth. At this time, she was deemed stable for transfer out of the ICU. On the floor, the patient had afib with RVR to the 150s which stabilized with IV metoprolol and PO metoprolol. She was started on a regular diet and she was started on Coumadin while maintaining the heparin drip. The patient reported feeling dizzy and was bloused 500 ml NS. Her HCT downtrended to 19.2, thought to be caused by bleeding from her staple line. She was transfused with 2 units of PRBC and 1 unit of FFP. INR was 2.0. Her heparin drip was held. HCT went up after the transfusion to 23.6, but then decreased to 20.8 and she received 1 more unit PRBC and hct stabilized at 25.3. Chest x-ray was stable and she was started on nebs. The patient's HCT remained stable and she tolerated a regular diet. Heparin drip was discontinued and she was started on a lovenox bridge while transitioning to Coumadin. The patient had a large bowel movement on ___ which was negative for blood in the stool. The patient worked with Physical Therapy and it was recommended that she be discharged to rehab to continue her recovery. She was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Anastrozole 1 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY 4. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 5. Metoprolol Tartrate 100 mg PO BID 6. Warfarin 7.5 mg PO 6X/WEEK (___) 7. Aspirin 81 mg PO DAILY 8. Warfarin 10 mg PO 1X/WEEK (TH) 9. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild Do not exceed 4000 mg/24 hours. 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 120 mg SC BID Discontinue once INR therapeutic x2 days. 4. Glucose Gel 15 g PO PRN hypoglycemia protocol 5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze/sob 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Senna 8.6 mg PO BID:PRN constipation 8. Anastrozole 1 mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Atorvastatin 20 mg PO QPM 11. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 12. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY 13. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 14. Metoprolol Tartrate 100 mg PO BID 15. Multivitamins 1 TAB PO DAILY 16. Warfarin 7.5 mg PO 6X/WEEK (___) 17. Warfarin 10 mg PO 1X/WEEK (TH) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Bowel obstruction due to internal hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to the Acute Care Surgery Service on ___ with abdominal pain and found to have a bowel obstruction. You underwent surgery to remove the affected piece of intestine and then your bowel was surgically reconnected. You are now doing better, tolerating a regular diet, having bowel function, and your pain is controlled with oral pain medication. You are now ready to be discharged to rehab with the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. 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: ___
10312423-DS-30	10,312,423	21,950,807	DS	30	2148-05-29 00:00:00	2148-05-30 05:58:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ciprofloxacin Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. ___ is a ___ old woman with history of Afib on Coumadin, systolic heart failure, and breast and ovarian cancer s/p multiple abdominal operations and small bowel obstructions, previously known to our service for treatment of a small bowel obstruction s/p ex-lap, LOA, small bowel resection ___, presents now with 1day of abdominal pain and CT scan findings concerning for partial SBO. She reports that this morning she ate breakfast and then had a bowel movement, which was relieving as she had previously been constipated for the past two days. After she had that normal bowel movement, she started to have cramping diffuse abdominal pain, associated with nausea and dry heaves. She had three more loose bowel movements today, and came to the ED with increasing pain. She has had no fevers or chills at home. Otherwise she was doing well and her incision is now healed over. Past Medical History: - Systolic congestive heart failure (LVEF 40%, global hypokinesis with beat-to-beat variability in Afib). - Hypertension. - Dyslipidemia. - Atrial fibrillation. - Atrial tachycardia/palpitations. - Morbid obesity. - Multiple pulmonary emboli, post operatively - Small bowel obstruction - Breast cancer (stage I clear-cell ovarian CA s/p chemo, breast CA s/p XRT/chemo) - Ovarian cancer - Osteoarthritis - Glaucoma - GERD - Hiatal Hernia - Arthritis - OSA - Glucose Intolerance - Restrictive Lung Disease PSH: ___ lap, LOA, TAH-BSO, component separation; ___ for SBO, incisional hernia repair; ___ lumpectomy with SLN; ___ knee replacement; R rotator cuff repair; R carpal tunnel release; tonsillectomy; diagnostic laparoscopy ___ Social History: ___ Family History: Her father died at age ___ of a myocardial infarction. He sustained his first myocardial infarction in his ___. Her mother died at age ___ in a house fire. She has four brothers, three sisters, one son and one daughter. One of her brothers had a myocardial infarction with bypass surgery in his early ___. Two of her sisters have diabetes, and all of her siblings suffer from hypertension. There is no family history notable for stroke, hyperlipidemia, cancer, or sudden cardiac death. Physical Exam: Admission Physical Exam: V/S: T98.2, HR109, BP123/70, RR18, Sat98%RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, obese, mildly distended, mild tenderness to palpation in RLQ, no rebound or guarding, Healing midline laparotomy incision Ext: No ___ edema, ___ warm and well perfused Discharge Physical Exam: VS: GEN: awake, alert, pleasant and interactive. HEENT: No deformity. Mucus membranes pink/moist. CV: RRR PULM: Clear to auscultation bilaterally. ABD: Soft, non-tender, non-distended. EXT: Warm and dry. No edema. NEURO: A&Ox3. Follows commands and moves all extremities equal and strong. Pertinent Results: ___ 06:35AM BLOOD WBC-5.0 RBC-2.93* Hgb-9.0* Hct-28.7* MCV-98 MCH-30.7 MCHC-31.4* RDW-15.4 RDWSD-55.0* Plt ___ ___ 06:49AM BLOOD WBC-6.9 RBC-3.02* Hgb-9.3* Hct-30.0* MCV-99* MCH-30.8 MCHC-31.0* RDW-15.5 RDWSD-56.2* Plt ___ ___ 04:30PM BLOOD WBC-11.6* RBC-3.47* Hgb-10.8* Hct-32.9* MCV-95 MCH-31.1 MCHC-32.8 RDW-15.1 RDWSD-52.0* Plt ___ ___ 04:30PM BLOOD Neuts-85.4* Lymphs-8.5* Monos-5.2 Eos-0.3* Baso-0.3 Im ___ AbsNeut-9.92* AbsLymp-0.99* AbsMono-0.61 AbsEos-0.04 AbsBaso-0.03 ___ 06:49AM BLOOD ___ PTT-27.3 ___ ___ 04:30PM BLOOD ___ PTT-32.8 ___ ___ 06:35AM BLOOD Glucose-107* UreaN-15 Creat-0.6 Na-143 K-3.7 Cl-99 HCO3-32 AnGap-12 ___ 06:49AM BLOOD Glucose-127* UreaN-19 Creat-0.6 Na-142 K-4.1 Cl-97 HCO3-32 AnGap-13 ___ 04:30PM BLOOD Glucose-174* UreaN-19 Creat-0.7 Na-140 K-4.7 Cl-93* HCO3-30 AnGap-17 ___ 04:30PM BLOOD ALT-17 AST-25 AlkPhos-89 TotBili-0.3 ___ 06:35AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.0 ___ 06:49AM BLOOD Calcium-9.1 Phos-4.2 Mg-1.6 ___ 04:30PM BLOOD Albumin-3.9 Calcium-10.2 Phos-3.7 Mg-1.7 ___ CT abdomen/pelvis: Probable resolving small bowel obstruction given findings of small-bowel dilation, mesenteric edema without abrupt transition point. ___ Abdominal Xray: Administered oral contrast has reached at least the sigmoid colon, excluding a high-grade small bowel obstruction. Slightly prominent small bowel loops are similar or improved compared to 1 day prior, although featureless appearance of the small bowel wall is new and suggestive of nonspecific wall edema or enteritis. Brief Hospital Course: Ms. ___ is a ___ yo F with history of atrial fibrillation on Coumadin admitted to the Acute Care Surgery service on ___ with abdominal pain and history of recent exploratory laparotomy for lysis of adhesions and small bowel resection on ___. CT scan and physical exam findings concerning for partial small bowel obstruction. She was given IV fluids, made NPO, and nasogastric tube placed. After 6 hours of decompression gastrografin was given. The patient had follow up abdominal xray that showed contrast in the colon and spontaneous return of bowel function. On HD2 nasogastric tube was removed which she tolerated with no increase in abdominal pain or nausea. On HD3 diet was progressively advanced with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Anastrozole 1 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 5. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY 6. MetFORMIN (Glucophage) 1000 mg PO DAILY 7. Warfarin 7.5 mg PO DAILY16 8. Aspirin 81 mg PO DAILY 9. Calcium Carbonate 1500 mg PO DAILY 10. Vitamin D ___ UNIT PO DAILY 11. Cyanocobalamin ___ mcg PO DAILY 12. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.rhamn A - ___ - ___ 40-Bifido 3-S.thermop;<br>Lactobacillus acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 10 billion cell oral DAILY 13. Multivitamins 1 TAB PO DAILY 14. Fish Oil (Omega 3) 1000 mg PO BID 15. Polyethylene Glycol 17 g PO DAILY 16. Docusate Sodium 200 mg PO DAILY 17. Metoprolol Tartrate 100 mg PO BID Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Anastrozole 1 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Calcium Carbonate 1500 mg PO DAILY 6. Cyanocobalamin ___ mcg PO DAILY 7. Docusate Sodium 200 mg PO DAILY 8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 9. Fish Oil (Omega 3) 1000 mg PO BID 10. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY 11. MetFORMIN (Glucophage) 1000 mg PO DAILY 12. Metoprolol Tartrate 100 mg PO BID 13. Multivitamins 1 TAB PO DAILY 14. Polyethylene Glycol 17 g PO DAILY 15. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.rhamn A - ___ - ___ 40-Bifido 3-S.thermop;<br>Lactobacillus acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 10 billion cell oral DAILY 16. Vitamin D ___ UNIT PO DAILY 17. Warfarin 5 mg PO DAILY16 follow up with ___ clinic for further dosing. Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the Acute Care Surgery Service on ___ with abdominal pain. You had a CAT scan that was concerning for a small bowel obstruction. You were given bowel rest, IV fluids, and had a nasogastric tube placed. Your bowel function returned and therefore the nasogastric tube was removed and your diet was advanced to regular which you tolerated well. Be sure to continue to chew your food well and eat foods that are easy to digest for the next few weeks. You should avoid hard or raw vegetables. You are now doing better, tolerating a regular diet, and ready to be discharged to home to continue your recovery. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. 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: ___
10312645-DS-14	10,312,645	21,504,314	DS	14	2162-06-24 00:00:00	2162-06-26 13:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lithium / milnacipran / vancomycin Attending: ___. Chief Complaint: Found down unresponsive Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: ___ with h/o IVDA, bipolar disorder, migraines, and hep C, who was transferred from OSH after being brought in for being found on floor, nonverbal and not following commands. Pt. reported severe migraine headaches this past week. Fiance reported she used Aderall this past week as well. The day before admission, ___ at 3:30 pt's fiance last spoke to her while she was in bathroom and sounded to be in usual state. At 6:15AM he passed by her door and overheard her snoring heavily in bed. At 7:15AM he came to wake her up and was unable. He left the room briefly and returned to find her kneeling on the floor with vomit in front of her. Vomit reportedly had blood in it, was pink, some mucous material (blood likely from tongue laceration). Patient began shaking, developed goosebumps, and bit her tongue at some point. Unclear if this was a seizure. Pt. was brought in by fiance and mom to ___. At OSH, CTA of head and neck, CT c-spine did not reveal acute bleed or dissection. Tox screen was positive for cocaine and opiates. Labs notable for CK 1263, CPK 1263, AST 78, ALT 99, WBC 16. She was reportedly given at least 2mg lorazepam agitation and ?possible status epilepticus, Zofran 4mg, and Zosyn 3.375g IV for suspected aspiration pneumonia. She was transferred to ___ for further management. It was unclear to OSH whether the prolonged altered mental status was a post-ichtal state or a subclinical status epilepticus. At the ___ ED, intial vitals were: 98 88 115/59 16 100%. She was evaluated by neurology. LP attempt was failed due to patient agitation, swinging at staff. She was given vancomycin, lorazepam 1mg x2, haldol, acyclovir, and acetaminophen. STAT EEG in the ED revealed no seizure activity. Vitals prior to transfer were: Asleep 98.8 86 136/84 16 97%NC On the floor, patient is nonverbal and unable to participate in interview. She is able to nod and shake her head to some questions, but is very somnolent and inconsistent in responses. ROS: Unable to assess. Family denies recent fever. Notes that she had diarrhea last week as well and many in the family had GI illness as well. Past Medical History: Bipolar affective disorder - sees psych - ___ NP Hepatitis C Genotype IA , no IFN- sees Dr. ___ - GI in ___ Sjogren's synrome with visual Changes Migraine headache h/o drug abuse - cocaine, heroine, amphetamine, ?methamphetamine Insomnia Sinusitis - Dr. ___ with epigastric abd pain after meals- was planning for surgery soon Fibromyalgia with neck pain, lumbago - sees Rheumatology Dr. ___, microscopic Arthralgia Pelvic Pain Disturbance of Skin Sensation Wrist pain Sleep apnea GERD Carpal tunnel syndrome Contact/exposure to venereal disases Acne PSH: L carpal tunnel ___, C-section ___, Oral surgery, Sinus surgery ___, ORIF L ___ digit, Tendon repair R hand, Facial surgery to lip ___, LEEP-cervical CA follows at ___ Liver bx Social History: ___ Family History: Father - brain/lung cancer Mat GM - alzheimers Mat GF - stroke, prostate cancer pat GM - heart attack Physical Exam: Admission PHYSICAL EXAM: VS: 98.8 129/71 106 20 100 on ___ GENERAL: Asleep, occasionally arouses spontaneously and attempts to rise out of bed, yawning frequently. Non-verbal. Not obeying commands. Withdraws purposefully to pain. HEENT: supple neck, no LAD, pupils 3mm, reactive CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, anteriorly, slow respirations ABDOMEN: obese, no rebound/guarding EXTREMITIES: moving all extremities spontaneously PULSES: 2+ DP pulses bilaterally NEURO: Unable to cooperate with exam. Non-verbal. Moving all 4 extremities. Normal bulk and tone. Upgoing toes bilaterally but appears to be withdrawal reflex. SKIN: left antecubital fossa with 2x4cm induration with overlying erythema, and central point, no fluctuance Discharge Physical Exam: VS: 98.4 115/70 60 18 99 RA GENERAL: A&OX3. Much more lucid and conversant. Talked openly about drug history. Improved attention and memory HEENT: 2x2cm bruise on tongue from ___ tongue biting, supple neck, no LAD, pupils 3mm, reactive CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, anteriorly, slow respirations ABDOMEN: obese, no rebound/guarding EXTREMITIES: moving all extremities spontaneously PULSES: 2+ DP pulses bilaterally NEURO: Can tap fingers to thumb bilaterally, but slower and weaker on R hand. CNII-XII grossly intact. Moving all 4 extremities. 4+/5 strength b/l upper and lower extremities. Normal bulk and tone. gait deferred. SKIN: left antecubital fossa with 2x4cm induration with overlying erythema, and central point, no fluctuance Pertinent Results: Initial labs: ___ 01:00AM BLOOD WBC-5.5 RBC-3.65* Hgb-10.5* Hct-32.1* MCV-88 MCH-28.7 MCHC-32.7 RDW-13.9 Plt ___ ___ 01:00AM BLOOD Neuts-67.9 ___ Monos-6.4 Eos-0.4 Baso-0.3 ___ 01:00AM BLOOD ___ PTT-26.0 ___ ___ 01:00AM BLOOD Plt ___ ___ 01:00AM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-140 K-3.6 Cl-103 HCO3-23 AnGap-18 ___ 01:00AM BLOOD ALT-88* AST-82* CK(CPK)-1312* AlkPhos-59 TotBili-0.4 ___ 01:00AM BLOOD Lipase-12 ___ 01:00AM BLOOD Albumin-3.7 Calcium-8.7 Phos-2.3* Mg-1.8 ___ 01:00AM BLOOD TSH-1.3 ___ 05:40AM BLOOD HIV Ab-NEGATIVE ___ 08:46AM BLOOD Carbamz-<0.5* ___ 01:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 01:15AM BLOOD Lactate-1.2 ___ 04:00PM URINE Color-Straw Appear-Clear Sp ___ ___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 04:00PM URINE UCG-NEGATIVE Discharge Labs: ___ 06:58AM BLOOD WBC-5.6 RBC-4.86 Hgb-14.2 Hct-44.0 MCV-91 MCH-29.1 MCHC-32.2 RDW-14.5 Plt ___ ___ 06:58AM BLOOD Plt ___ ___ 06:58AM BLOOD Glucose-85 UreaN-20 Creat-0.9 Na-142 K-4.0 Cl-106 HCO3-22 AnGap-18 ___ 06:30AM BLOOD ALT-59* AST-37 CK(CPK)-100 AlkPhos-65 TotBili-0.3 ___ 06:58AM BLOOD Calcium-9.6 Phos-4.7* Mg-2.3 ___ 06:30AM BLOOD Albumin-4.1 Calcium-9.4 Phos-6.2* Mg-2.0 ___ 12:56PM BLOOD %HbA1c-5.4 eAG-108 ___ 12:56PM BLOOD Triglyc-133 HDL-45 CHOL/HD-3.8 LDLcalc-100 ___ 06:58AM BLOOD PTH-18 ___ 06:58AM BLOOD 25VitD-PND ___ 12:26AM URINE Color-Yellow Appear-Cloudy Sp ___ ___ 12:26AM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 12:26AM URINE RBC-11* WBC-3 Bacteri-NONE Yeast-NONE Epi-69 ___ 12:26AM URINE Mucous-MANY ___ 05:40PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-2* Polys-1 ___ ___ 05:40PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-2* Polys-0 ___ ___ 05:40PM CEREBROSPINAL FLUID (CSF) TotProt-27 Glucose-58 ___ 05:40PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-PND Micro: ___ 10:35 pm BLOOD CULTURE #1 SOURCE: VENIPUNCTURE. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 10:40 pm BLOOD CULTURE #2 SOURCE: VENIUPNCTURE. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 12:11 pm SWAB Source: Rectal swab. FINAL REPORT ___ R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final ___: No VRE isolated. ___ 1:00 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 4:00 pm URINE Source: Catheter. FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 3:45 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 12:26 am URINE Source: ___. URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. ___ 5:40 pm CSF;SPINAL FLUID Source: LP TUBE 3. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. Outside hospital: CTA head / neck (OSH): Unremarkable, no evidence of carotid or vertebral stenosis or dissection; substernal goiter; upper lobe infiltrates, right worse than left CT head (OSH): No acute eintracranial abnormality, chronic sinusitis CT c-spine: no fracture EEG ___ IMPRESSION: This is an abnormal EEG because of diffuse theta and delta slowing indicative of a moderate encephalopathy which is etiologically non- specific. There are no epileptiform discharges or electrographic seizures. CXR ___: FINDINGS: As compared to the previous radiograph, the previous opacity in the right upper lung has cleared. However, mild fluid overload remains present throughout the entire lungs. The lung volumes remain low. No pleural effusions. MRI Brain ___: FINDINGS: There is slow diffusion with associated increased T2/FLAIR signal within the left greater than right caudate head and putamen consistent with subacute infarct. No intracranial hemorrhage is identified. Ventricles are within normal limits. The major intracranial vessels exhibit the expected signal void related to vascular flow. Coronal imaging of the temporal lobes demonstrates mild asymmetric prominence of the left lateral ventricular temporal horn. No definite abnormal parahippocampal signal is appreciated. The paranasal sinuses demonstrate scattered areas of mucosal thickening, improved compared to the prior head CT. The mastoid air cells demonstrate normal signal. The sella turcica, craniocervical junction, orbits are unremarkable. IMPRESSION: Subacute left greater than right striatal infarcts which may be related to hypoxic-ischemic injury. Echo ___: Conclusions The left atrium is normal in size. A patent foramen ovale is present. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Patent foramen ovale. Normal global and regional biventricular systolic function. 24-hr EEG report pending Brief Hospital Course: ___ with h/o IVDA, bipolar disorder, migraines, and hep C, who was transfered from OSH after being brought in for being found on floor, nonverbal and not following commands. Over the course of the hospitalization consults were made to neurology, toxicology, social work, ___, and OT. #Subacute basal ganglia ischemic stroke L>R. Likely due to vasospam in the setting of cocaine use. Minimal residual symptoms significant for only decreased right hand find motor function and strength. Work up includes normal A1C, normal Lipid panel. ECHO did show a PFO but this does not appear to be an embolic stroke. Patient will follow up with general neurology and outpatient physical and occupational therapist for lingering fine motor hand impairment. #Encephalopathy. Patient initially presented very somnolent and difficult to awake. She was responsive to pain likely due toxic metabolic encephalopathy in the setting of drug overdose, polypharmacy (patient on multiple atypical psych meds that could not be collerated despite med recing with PCP, ___, family and pharmacy, as they all had different med lists) and seizure. Initially concerning for possible encephalitis and or meningitis vs inflammatory causes, but patient improved quickly. Was initially started on Vancomycin, Ceftriaxone and Acyclovir for meningitis coverage, but quickly discontinued (patient never got a dose of Ceftriaxone) in the setting of rapid improvement. #Seizure-like episodes. During hospitalization, patient experienced several episodes of "out of body" experiences, trembling of hands and/or body, unresponsiveness, or sleepiness. We performed 24hr EEG which found no evidence of epileptic seizures. It is possible these episodes were pseudoseizures and less likely sequelae of basal ganglia stroke. Will need to follow up final read of 24hr EEG results and final LP culture results. Patient will follow up with neurology. y #UTI. UCx positive for E. Coli. Will treat as complex given she pulled out her foley. Planned for 5 day coruse of Cipro to be completed on ___. Follow up culture results. #h/o Bipolar disorder. Did not exhibit depressive or manic symptoms throughout hospitalization. Denied suicidal or homicidal ideation. Home meds were slowly restarted once we were able to confirmed with pharmacy. Though of note the pharmacy, PCP, ___, and psych nurse all had different medication lists. We restarted the patient with the lowest confirmed doses of known medications and med list still needs further reconciliation. Patient was discharge with Citalopram 20mg daily, Oxcarbazepine 300mg daily, Quetiapine 100mg QHS, Lamotrigine 200mg daily. #h/o migraines. Complained of on-and-off headaches over course of hospitalization, which responded well to tylenol and ibuprofen. Patient was on Topiramate 100mg per med rec, but patient stated she was not taking it. Again recommend further med rec. Topiramate was discontinued. Per patient once of her triggers for drug use is her migraine headches. Will have patient follow up with neurology for the migraines. #h/o Drug Abuse. +Cocaine and Opioid on Tox. Patient reported recent injection of cocaine and adderall. H/o of crystal meth use. Denied recent heroin use. Patient will need to follow up with drug addiction counselor to prevent relapse. Recommend no further prescription of oxycodone. Patient was not given any during this admission nand did well without opioids. #Chronic Hep C. Trasaminitis stable. Follow up with PCP for continued management. #Substernal goiter. Incidentally found on CTA of neck. Follow up with PCP for further workup. #Patent foramen ovale. Found on echocardiogram. Given this is not an embolic stroke, likely no further intervention is required. Though there is some patients that benifit from closure of PFO in the setting of severe migriane headaches. Follow up with PCP and neurology. Transitional Issues: -follow up with neurology regarding stroke and migraine headaches. -follow up with PCP to reconcile meds and develop plan for rehabilitation and relapse prevention -follow up with physical and occupational therapist for lingering fine motor hand impairment -follow up with drug addiction counselor to prevent relapse -follow up 24 hr EEG monitoring results -follow up LP results -follow up cultures -continue Cipro 500mg q12H x 5 days for urinary tract infection to end on ___ -follow up with PCP regarding chronic hep c management and transaminitis. -follow up with PCP to ensure up to date on vaccinations such as tetanus -follow up with PCP regarding substernal goiter incidentally found on CTA neck -follow up with PCP regarding PFO found on echo Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN prn pain 2. ClonazePAM 0.5 mg PO BID plus 1 tab prn 3. LaMOTrigine 100 mg PO 1 TAB IN AM, 2 TABS IN ___ 4. Citalopram 20 mg PO DAILY 5. QUEtiapine Fumarate 100 mg PO QHS 6. Sumatriptan Succinate 100 mg PO PRN migraine 7. Cyclobenzaprine 10 mg PO HS:PRN muscle spasm 8. Omeprazole 20 mg PO DAILY 9. Ranitidine 300 mg PO HS 10. Pregabalin 200 mg PO TID joint pain 11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation prn: q4hr wheezing 12. Oxcarbazepine 300 mg PO Q24H Discharge Medications: 1. Citalopram 20 mg PO DAILY 2. LaMOTrigine 200 mg PO DAILY 3. Oxcarbazepine 300 mg PO DAILY 4. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days Day 1: ___ Last Dose ___ 5. Lidocaine Viscous 2% 15 mL PO TID:PRN tongue pain Patient instructed to hold other medications until follow up with primary care provider. This medication list likely not accurate. We were able to get medication lists from Pharmacy, Family, PCP and psych nurse and none of them matched. Discharge Disposition: Home Discharge Diagnosis: Stroke Possible drug induced seizure IV Drug use Urinary Tract Infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure participating in your care at ___ ___. You presented to our hospital because you were found unresponsive in your home and eventually transferred to us from an outside hospital for further evaluation and management of your care. During the hospitalization, imaging of your brain revealed that you had suffered a stroke in a small, deep structure in your brain called the striatum. This appears to have led to some impairment in your fine motor abilities in your R hand, which has improved somewhat over the course of the hospitalization. Our testing revealed that your blood contained evidence of cocaine and opiate use. You reported that you had injected adderall and possibly cocaine in the previous week. These drugs may have caused the blood vessels in your brain to spasm, causing decreased blood flow to your brain (a stroke) and the unresponsive episode. Please follow up with neurology, and see outpatient physical and occupational therapists. Your EEG results did not find any evidence of epileptic seizures. Your lumbar puncture did not find any evidence of infection thus far. Some additional tests on your spinal fluid are still pending. You were also diagnosed with a urinary tract infection. Please complete your current 5 day regimen of ciprofloxacin (last day ___. It is very important that you follow up with the following people as soon as possible: * Your primary care provider * Your psychiatrist * A neurologist * Your occupational therapist * A physical therapist * Your drug addiction counselor We wish you the best! Your ___ care team Followup Instructions: ___
10312715-DS-58	10,312,715	22,773,655	DS	58	2180-10-10 00:00:00	2180-10-10 21:25:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Mercaptopurine / Ketorolac / Ibuprofen / Flagyl / Reglan / Zofran / Gabapentin Attending: ___. Chief Complaint: Left abdominal pain and increased bowel movements Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ severe ___ Disease who failed multiple medical treatments (AZA, ___, remicaide, cimzia, and tysabri) s/p sub-total colectomy w/ ileorectal anastamosis (___) on chronic prednisone p/w increase in BM frequency and left back pain. . Patient has had multiple admission for abdominal pain (12 since ___. At last admission (___), he had increased BMs (40 daily) with severe LLQ abdominal pain and tenderness, as well as L flank pain. He had WBC 11, lactate 1.3, and a contraction alkalosis. Fecal cultures, O&P were negative. He was started on IV steroids and IV pantoprazole. His diet was advanced slowly with gradual improvement in his abdominal pain and BM frequency and he was discharged with a slow prednisone taper (60mg, now to 20mg). . Now he reports an increase in bowel movement frequency beginning 6 days PTA. The consistency was still his baseline 'soft-serve.' Then 2 days PTA, up until 3AM 1 day PTA, he began having BMs q20minutes that were completely watery. There was no change in the color of his stool -- some black, but not different from normal, and no bright blood. He had no bowel movements between 3AM on the day PTA until ~3pm today, when he had BMx1. He also reports some dull->sharp LLQ abdominal pain (___) that is slightly improved with bowel movements. . In the past week, he reports subjective fevers (Temp <= ___, nausea w/o emesis. There has been no change in his appetite, energy, weight, or activity. No recent travel, sick contacts, life stressors. Of note he has been slowly titrating down his po prednisone since last admission, most recently he was on 20mg po for 1 week. On ___ he increased this to 40mg po. He has also been smoking cig more frequently. . In terms of the back pain, he has noticed a "bump" in his lower left back for many months now and was mildly painful in ___. The discomfort is sharp at times and burning at times, > ___. He also feels associated dull discomfort in his hip. This pain is exacerbated by breathing and moving, does not radiate, and was improved for 20 minutes with morphine. He says the pain is similar to kidney stone pain he has had, but he denies dysuria or hematuria. No urinary incontinence, weakness. No recent trauma. . In the ED, initial vitals: pain ___, T 96.6, HR 84, BP 120/66, RR 18, O2 100% RA. He received 2 liters NS, Promethazine, Morphine 5 mg x2. Blood culture was sent. Labs revealed a WBC 8 (90% Neutrophils), Hct 47, and lactate of 2.5. GI was consulted. Chem7 revealed a non-anion gap acidosis, UA was negative, and CXR unremarkable. Vitals prior to transfer: 97.5 70 118/79 18 99% RA. . Currently, he is experiencing ___ back pain. . ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, constipation, BRBPR, hematochezia, dysuria, hematuria. Past Medical History: # Crohns disease (dx ___ - ileocolonic ___ disease with perianal abscesses and fistulas s/p subtotal colectomy with ileorectal anastamosis (___). He has failed azathioprine (ARF), ___ (allergy), Remicade (muscle spasm, rash), Cimzia (non-efficacious), Tysabri and is now steroid dependent. Has been evaluated by Dr. ___. He is hesitant for any further surgeries. # Atypical chest pain: neg stress ___, assocaited with "deep breathing" and his abd wall pain # Nephrolithiais: Last renal ultrasound ___: "Findings suggestive of nonobstructing nephrolithiasis in the right upper pole." # Back pain - MRI L spine (___) DJD (herniated disk); Spinal stenosis. Located over lower left back and radiates down lateral left leg to the knee. Occasional leg numbness. Left SI tenderness. # BMD nl ___ # L knee dislocation # Cataracts # Anemia # B12 deficiency: Monthly Vit-B12 1000ug injections at ___ ___. ___ come to ___ for these as well # s/p orchiectomy # latent TB treated with INH in ___ Social History: ___ Family History: Mother: died of ovarian cancer Father: died of throat cancer, asthma 1 Sister: ___ Disease (ileitis, colitis s/p end ileostomy) 1 Sister with T2DM Physical Exam: Admission Exam: VS - Temp 97.7F, 104/90 BP, 78 HR, 18 RR, O2-sat 98% RA GENERAL - Distressed, grimacing and clenching jaw periodically. Conversation. HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - Midline surgical scar, with a small ventral hernia, non-tender, and reducible. NABS, soft/ND. Tender throuhgout and especially in LLQ. No guarding. No rebound tenderness. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs). Increased sweat on the left. SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII intact. Moving all extremities spontaneously. Reflex 2+ patella, ankle. Parasthesia on the left. Strength ___ at hip flexor/extensor, ___ knee ext/flex, and ___ plantar ext/flex. Sensation grossly intact to light touch b/l in lower extremities. MSK - ROM (active/passive) at hip intact bilaterally, pain with left hip abduction and external rotation, as well as full flexion. Discharge Exam: VS - Temp 97.6F, 112/66 BP, 64 HR, 18 RR, O2-sat 95-98% RA GENERAL - Lying in bed asleep. Comfortable. NAD. HEENT - PERRLA, sclerae anicteric, MMM, OP clear NECK - supple, no LAD HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - Midline surgical scar, with a small ventral hernia, non-tender, and reducible. NABS, soft/ND. Non-tender. No guarding or rebound. BACK - Mild tenderness to palpation in back LLQ. no warmth or erythema. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radialis, DP). SKIN - no rashes or lesions NEURO - awake, CNs II-XII grossly intact. Moving all extremities spontaneously. MSK - ROM (active/passive) at hip intact bilaterally, pain in back with left hip at ~20 degrees extension or flexion. Pertinent Results: ___ 09:15AM BLOOD WBC-7.6 RBC-5.25 Hgb-15.4 Hct-46.8 MCV-89 MCH-29.3 MCHC-32.8 RDW-13.9 Plt ___ ___:33AM BLOOD WBC-11.7# RBC-4.59 Hgb-13.3* Hct-41.0 MCV-89 MCH-28.9 MCHC-32.4 RDW-13.9 Plt ___ ___ 04:55AM BLOOD WBC-10.8 RBC-4.78 Hgb-13.7* Hct-43.5 MCV-91 MCH-28.6 MCHC-31.4 RDW-13.7 Plt ___ ___ 06:05AM BLOOD WBC-10.8 RBC-4.71 Hgb-13.7* Hct-42.2 MCV-90 MCH-29.1 MCHC-32.5 RDW-14.0 Plt ___ ___ 09:15AM BLOOD Neuts-90.0* Lymphs-7.0* Monos-1.7* Eos-0.7 Baso-0.7 ___ 09:15AM BLOOD ESR-14 ___ 09:15AM BLOOD CRP-1.8 ___ 09:15AM BLOOD Glucose-99 UreaN-20 Creat-1.1 Na-140 K-4.6 Cl-109* HCO3-20* AnGap-16 ___ 09:55PM BLOOD UreaN-17 Creat-1.0 Na-135 K-4.3 Cl-107 HCO3-20* AnGap-12 ___ 05:33AM BLOOD Glucose-90 UreaN-14 Creat-0.9 Na-136 K-3.8 Cl-106 HCO3-22 AnGap-12 ___ 04:55AM BLOOD Glucose-142* UreaN-15 Creat-1.2 Na-138 K-4.1 Cl-103 HCO3-27 AnGap-12 ___ 06:05AM BLOOD Glucose-89 UreaN-14 Creat-1.2 Na-139 K-3.3 Cl-105 HCO3-23 AnGap-14 ___ 09:55PM BLOOD Phos-2.8 Mg-1.9 ___ 05:33AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.9 ___ 04:55AM BLOOD Calcium-9.2 Phos-2.0* Mg-2.1 ___ 06:05AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.7 ___ 09:55PM BLOOD ALT-19 AST-20 AlkPhos-50 TotBili-0.2 ___ 09:55PM BLOOD Lipase-30 ___ 09:28AM BLOOD Lactate-2.5* ___ 09:40AM URINE Color-Straw Appear-Clear Sp ___ ___ 09:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. Cryptosporidium/Giardia (DFA) (Final ___: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). Cryptosporidium/Giardia (DFA) (Final ___: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. Hip MR: IMPRESSION: 1. No evidence of avascular necrosis or fracture. 2. L5/S1 degenerative disc disease. L-spine MRI: IMPRESSION: 1. No evidence of epidural abscess. 2. Stable degenerative changes as described above. MR Enterography: IMPRESSION: 1. Evidence of acute on chronic ___ disease involving the distal ileum proximal to the ileorectal anastomosis with mucosal hyperenhancement, mesenteric hyperemia and mural thickening. 2. A new skip lesion is identified just proximal to a loop of dilated distal ileum within the right lower quadrant which also demonstrates mucosal hyperenhancement, mural thickening, and adjacent hyperemia. The remainder of the small bowel is mildly dilated. No abscess or fistula identified. 3. Bilateral subcentimeter renal cysts. KUB: IMPRESSION: Known dilated loop of neoterminal ileum in the pelvis is chronic. No evidence of new obstruction or free air. CXR: IMPRESSION: No acute cardiopulmonary process. No free air below the diaphragm. Brief Hospital Course: ___ w/ severe ___ s/p colectomy w/ ileorectal anastamosis (___) on chronic prednisone (failed prior steroid sparing therapy) and multiple recent hospital admissions p/w increased bowel movements, abdominal pain, and back pain likely a ___ flare and muscular back pain. . # Diarrhea, abdominal pain: Patient has severe ___ disease and the presentation on this admission was similar to that of previous admissions. MR enterography revealed chronic ___ changes, but not abscess or fistulizing disease. Abdominal films revealed no partial obstruction. Infection was unlikely, in that he remained afebrile, had no leukocytosis on admission, his stooling appeared dependent on intake, and stool studies and cultures were all negative. Bcx were pending on discharge. His ESR and CRP were wnl, but they have been in most previous admissions. His LFTs and lipase were wnl. He was initially kept NPO and started on IV steroids and IV pantoprazole. He was evaluated by GI who agreed this was consistent with his ___ flares. He was transitioned to a clear liquid diet and then to a lactose free/low residue free diet. He tolerated this well with gradual improvement in his abdominal pain back to his baseline. For pain he originally received IV dilaudid, followed by PO dilaudid, and then percocet. He was discharged on a one week course of percocet. He was transitioned to PO steroids and should work with Dr. ___ to taper this medication. He had < 8 BM's per day. . # ___ disease: Patient with a long history of ___ with ileorectal anastamosis and on chronic prednisone. He was started on vitamin D and should continue this along with calcium and vitamin B12 as an outpatient. . # Back pain: On admission, he reported lower left back pain and hip pain. Through the admission the hip pain resolved and the back pain became more focal. This pain is distinct from previous experiences with radicular pain. Most likely etiology is muscular. Abdominal plain films revealed no nephrolithiasis and UA was unremarkable. MR of hip revealed no evidence of AVN or fracture, but L5/S1 degenerative disc disease. MR of the spine revealed no evidence of epidural abscess or fracture, but stable degenerative changes. MRE revealed no fistulizing disease or abscess. Pain was controlled, as described above, with opioids and tylenol. For additional relief, patient was given lidocaine patches and started on flexeril. His pain was improved ___ -> ___ at the time of discharge. . # Non-gap acidosis: The patient developed a mild non-anion gap metabolic acidosis (AG 11, bicarb 20). This was likely due to contraction alkalosis from GI losses and resolved with volume resuscitation. . # Leukocytosis: Patient developed a mild leukocytosis (12->11->11). Likely due to steroids . #BILATERAL RENAL CYSTS WERE NOTED INCIDENTALLY ON IMAGING. . #PPX: heparin SQ. . TRANSITIONAL ISSUES: 1) Patient should increase prednisone dose to 55 mg daily and discuss tapering this medication with Dr. ___. 2) Patient was given a 1-wk course of percocet and flexeril for pain control. 3) Patient was started on Vitamin D because of chronic steroid use. 4) Patient should make sure he is getting 1000 mg of calcium carbonate daily because of chronic steroid use. 5) Patient should follow-up with GI. 6) BILATERAL RENAL CYSTS WERE NOTED INCIDENTALLY ON IMAGING Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from PatientwebOMR. 1. PredniSONE 20 mg PO DAILY Tapered dose - DOWN 2. Loperamide 8mg PO TID:PRN diarrhea 3. Calcium Carbonate 500 mg PO Frequency is Unknown 4. Cyanocobalamin 1000 mcg IM/SC monthly Discharge Medications: 1. Cyclobenzaprine 5 mg PO TID:PRN pain Duration: 1 Weeks hold for sedation RX cyclobenzaprine 5 mg three times a day Disp #21 Tablet Refills:0 2. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain Duration: 1 Weeks Do not exceed 6 doses per day and do not take any tylenol separately. RX Endocet 5 mg-325 mg ___ Disp #35 Tablet Refills:0 3. Omeprazole 20 mg PO BID 4. PredniSONE 55 mg PO DAILY Start: In am RX prednisone 20 mg daily Disp #40 Tablet Refills:0 RX prednisone 10 mg daily Disp #20 Tablet Refills:0 RX prednisone 5 mg daily Disp #20 Tablet Refills:0 5. Loperamide 8 mg PO BID:PRN diarrhea 6. Vitamin D 50,000 UNIT PO DAILY RX ergocalciferol (vitamin D2) 400 unit daily Disp #60 Tablet Refills:0 7. Calcium Carbonate 500 mg PO BID 8. Cyanocobalamin 1000 mcg IM/SC MONTHLY monthly Discharge Disposition: Home Discharge Diagnosis: ___ flare Muscular back 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. ___, It was a pleasure contributing to your care at ___. You were admitted to the hospital for abdominal pain, diarrhea, and back pain. Your MRI showed a new ___ lesion of your small bowel and we treated you with intravenous fluids, bowel rest, and steroids. Studies of your stool did not identify any signs of infection. The MRI of your abdomen did not show signs of fistulizing disease or infection. We also performed an MRI of your spine the revealed no evidence of epidural abscess or fracture and an MRI of your hip which did not show avascular necrosis of the hip. We have made the following changes to your medications: -Start: Prednisone 55 mg daily, please speak to your gastroenterologist regarding the tapering of this medication. -Start percocet 5mg/325mg at most every ___ hours for pain. This has Tylenol in it, do not exceed more than 2grams of tylenol a day. This also has oxycodone in it, which is a sedating medication. Do not take with alcohol or while operating a motor vehicle. -Start flexeril 5mg by mouth at most three times a day of pain or spasm. This is also a sedating medication, do not take with alcohol or while operating a motor vehicle. -Start ergocalciferol (Vit D) because you are on chronic steroids -Continue calcium carbonate 1000 mg daily because you are on chronic steroids Please see below for your follow up appointments. Followup Instructions: ___
10312715-DS-61	10,312,715	23,629,070	DS	61	2180-12-19 00:00:00	2180-12-19 23:11:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Mercaptopurine / Ketorolac / Ibuprofen / Flagyl / Reglan / Zofran / Gabapentin / Sulfasalazine / Sulfasalazine Attending: ___. Chief Complaint: Abd pain and diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMH of Crohns disease with perianal abscesses and fistulas s/p subtotal colectomy with ileorectal anastamosis (___), failed azathioprine (ARF), ___ (allergy), Remicade (muscle spasm, rash), Cimzia/certolizumab (non-efficacious), Tysabri/natalizumab and is now steroid dependent presents w/ abdominal pain consistent w/ previous ___ flares and increase of BM from 30x in 24 hours compared to baseline of ___ BM per day. The patient's most recent hospitalization was ___ for acute on chronic ___ disease- improved with IV solumedrol and then prednisone taper. He was currently on 45 mg of presdnisone once a day (down from 60 mg). 6 days PTA, patient noticed increasing knife like pain along the midline incision above the umbilicus consistent with previous adhesion pain. He describes this pain as persistent for the past year with flairs that last a week with ___ months of remission. This pain is worse with moving and was progrsesively worsening. 4 days PTA, the patient began noticing increased LLQ dull crampy pain consistent with his previous ___ flairups but with more severe pain. He attributes the ___ flair as secondary to his adhesion pain. 3 days PTA, the patient noticed an increase in his stooling (30x BM from ___ evening to ___ evening) that was above his baseline ___ BM a day). He describes the stool as watery, tan/greenish colored consistent with previous stool quality. The patient denies the appeance of melena or frank blood. No rectal bleeding although some blood with rectal exam in ED which pt believes was caused by digital exam itself. 1 day PTA, the patient had clam chowder which led to abdominal distension and worsening diarrhea. He attempted to try chicken soup later that day, but reported bowel movements within 20 minutes. He is currently not tolerating anything by mouth as he describes BM's but no nausea/vomiting within 20 minutes of ingestion. He endorses fevers/chills and sweating for the past 2 days but has not been febrile (temperatures 97). Patient denies vomiting, but has mild nausea. No lightheadness. He denies recent travel history, new pets, or close sick contacts. No recent dietary changes. He does fish but has not in the past week. Notes no muscle weakness or difficulty ambulating. Past Medical History: # Crohns disease (dx ___ - ileocolonic ___ disease with perianal abscesses and fistulas s/p subtotal colectomy with ileorectal anastamosis (___). He has failed azathioprine (ARF), ___ (allergy), Remicade (muscle spasm, rash), Cimzia (non-efficacious), Tysabri and is now steroid dependent. Has been evaluated by Dr. ___. He is hesitant for any further surgeries. # Atypical chest pain: neg stress ___, assocaited with "deep breathing" and his abd wall pain # Nephrolithiais: Last renal ultrasound ___: "Findings suggestive of nonobstructing nephrolithiasis in the right upper pole." # Back pain - MRI L spine (___) DJD (herniated disk); Spinal stenosis. Located over lower left back and radiates down lateral left leg to the knee. Occasional leg numbness. Left SI tenderness. # BMD nl ___ # L knee dislocation # Cataracts # Anemia # B12 deficiency: Monthly Vit-B12 1000ug injections at ___ ___. ___ come to ___ for these as well # s/p orchiectomy # latent TB treated with INH in ___ Social History: ___ Family History: Mother: died of ovarian cancer Father: died of throat cancer, asthma Sister: ___ Disease (ileitis, colitis s/p end ileostomy) Sister with T2DM, ?___ No h/i GI malignancy Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.1 121/66 P 65 RR 18 97% RA General: Well-appearing man in pain HEENT: NC/AT, sclerae anicteric, MMM, OP clear, no oral lesions Neck: supple, no cervical lymphadenopathy Lungs: CTAB CV: RRR, no m/r/g, nl S1-S2 Abdomen: well healed midline surgical scar, +BS in all 4 quadrants. RUQ soft, with no rebound or guarding. Tender in LLQ and region midline along surgical scar above umbilicus on deep palpation of RUQ. No heptaosplenomegaly. Tender region midline along surgical scar above umbilicus on deep palpation of RLQ. No heptaosplenomegaly. LUQ and LLQ not palpated due to patient pain and discomfort. Extremities: WWP, 2+ peripheral pulses. No edema noted. Neuro: AOx3. MMT equal on lower extremities. No paresthesias, numbness in lower extremities. Skin: multiple 1cm erythematous papules noted over chest and arms (stable for past years), multiple tattoos Rectal: + multiple skin tags,+erythema externally, red raised tender abscess on left side of preianal region with no discharge noted DISCHARGE PHYSICAL EXAM VS Tmax: 97.9 Tcurr: 97.6 BP 108/60 HR 70 RR 20 O2 98%/RA General: Well-appearing man HEENT: No oral lesions , NC/AT, sclerae anicteric, MMM Neck: supple, no cervical lymphadenopathy Lungs: CTAB CV: RRR, no m/r/g, nl S1-S2 Abdomen: Well healed midline surgical scar, +BS in all 4 quadrants. Non-distended. RUQ and RLQ soft, with no rebound or guarding, minimal tenderness on palpation. LUQ and LLQ soft, with no rebound or guaridng, mininimally tender. No heptaosplenomegaly. Tender midline region to palpation along surgical scar above umbilicus. Discomfort midline on palpation of left side. Extremities: WWP, 2+ peripheral pulses. No edema noted. Neuro: AOx3. No sensory or motor deficits on either leg. Skin: resolving erythematous papules noted over chest, no drainage or discharge. Multiple tattoos. Rectal: + multiple skin tags, +erythema externally, red raised tender abscess on left side of perianal region with no discharge Pertinent Results: ___ 11:14AM LACTATE-2.1* ___ 11:00AM URINE HOURS-RANDOM ___ 11:00AM URINE GR HOLD-HOLD ___ 11:00AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 11:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG ___ 10:46AM GLUCOSE-114* UREA N-21* CREAT-0.9 SODIUM-141 POTASSIUM-4.9 CHLORIDE-111* TOTAL CO2-18* ANION GAP-17 ___ 10:46AM estGFR-Using this ___ 10:46AM ALT(SGPT)-26 AST(SGOT)-18 ALK PHOS-52 TOT BILI-0.2 ___ 10:46AM ALBUMIN-4.3 ___ 10:46AM WBC-8.7 RBC-4.66 HGB-13.6* HCT-41.4 MCV-89 MCH-29.3 MCHC-33.0 RDW-14.7 ___ 10:46AM NEUTS-89.1* LYMPHS-6.2* MONOS-3.8 EOS-0.7 BASOS-0.3 ___ 10:46AM PLT COUNT-160 ABD KUB Supine and Erect on ___ FINDINGS: Upright and supine views of the abdomen and pelvis were performed. Comparison is made to previous exam from ___ and CT scan from ___. Mildly prominent loop of bowel seen in the left lower quadrant, which appears less dilated than it did on previous exam. Elsewhere, there is overall paucity of bowel gas in the abdomen. No air-fluid levels identified. No free air is seen below the diaphragm. Osseous structures are unremarkable. IMPRESSION: Nonspecific bowel gas pattern without evidence of obstruction. MR ENTEROGRAPHY ___ Final Read FINDINGS: The study is limited due to motion artifact and inadequate post contrast scanning phasing. Allowing for these limitations: The patient is status post colectomy with ileorectal anastomosis. The region of the anastomosis appears intact. Just upstream to the anastomosis at the level of the neo-terminal ileum there is a persistent segment of abnormal mucosal enhancement, mural thickening and mesenteric hyperemia which appears to have less sharply defined serosal margins (14:45) compared to prior study but similar to ___. There is also persistent dilatation of the small bowel upstream to this area (8:10) involving an ileal segment of approximately 22 cm. The dilatation of this bowel loop is slightly improved compared to prior study (3.6 cm vs 4.6 cm in ___. A small area of abnormal enhancement is also noted in the motion-corrupted post contrast images in the mid abdomen just to the right of midline (1301:65). However, no abnormality in that region is observed in the non contrast images as well as in the recent CT, suggesting that this might be an area of bowel collapse with multiple adjacent mucosal surfaces rather than abnormal enhancement. No other skip lesions are identified. The visualized portions of the liver are normal in appearance. There is no intrahepatic biliary duct dilatation. The pancreas, spleen, and adrenal glands are unremarkable. The kidneys enhance and excrete contrast symmetrically. There are bilateral punctate cystic lesions without concerning features. No other focal lesions are noted. The visualized vascular structures are unremarkable. There is no retroperitoneal or mesenteric lymphadenopathy. There is no ascites or abdominal wall hernia. The urinary bladder, prostate, rectum, and anus are normal in appearance. There is no pelvic free fluid. IMPRESSION: 1. Persistent area of abnormal enhancement in the distal ileum just proximal to the ileorectal anastamosis with slightly more inflammation compared to ___, consistent with acute on chronic ___ disease. 2. Small area of abnormal enhancement just to the right of mid abdomen likely represents collapsed bowel rather than a skip lesion. Brief Hospital Course: ___ with PMH of Crohns disease with perianal abscesses and fistulas s/p subtotal colectomy with ileorectal anastamosis (___), failed azathioprine (ARF), ___ (allergy), Remicade (muscle spasm, rash), Cimzia/certolizumab (non-efficacious), Tysabri/natalizumab and is now steroid dependent (on 45 mg prednisone per day taper) presents w/ abdominal pain consistent w/ previous ___ flares and increase of BM from 30x in 24 hours compared to baseline of ___ BM per day. # ___ Flare: Patient presented to the floor with severe abdominal pain and frequent watery stools. On admission, the patient noted a ___ pain along his vertical midline incision that he described as stabbing and unremitting. This pain has been ongoing for the past year to which he attributed to abdominal adhesions caused by his previous abdominal surgeries. In addition, he noted LLQ crampy dull pain ___ consistent with his previous Crohn flares. Furthermore, on admission his stooling frequency had increased (30x in 24 hours) from baseline ___ in 24 hours). We opted to keep him NPO for the first 48 hours, providing IVF. GI was consulted and provided recommendations for IV salumedrol 20 mg TID. Pain control was achieved with IV Dilaudid 1.5-2 mg Q3H:PRN. MRI was performed on ___ which showed acute on chronic ___ disease as well as a portion of collapsed bowel. On ___, his abdominal pain had improved enough from pt to be ready to transition to PO analgesics, prednisone, and advancing diet. On ___ pt advanced diet to regular and tolerated without nausea/vomiting. His stool samples were negative for infectious agents (C. diff, E.coli, Ova & parasites, Salmonella/Shigella/Campylobacter). On day of discharge, patient reported formed stools overnight with frequency similar to his baseline. Moreover, abdominal pain was back to baseline and pt was able to ambulate without difficulty. He was discharged with instructions to taper Prednisone 60mg by 5mg weekly until he followsup with his gastroenterologist in ___. Pt also has f/u appts with PCP and ___ general surgeon to discuss surgical options in alleviating his abdominal pain. He was also discharged with oxycodone, Bactrim for PCP prophylaxis, PPI (preadmission med), and Citracal. #Back pain: Pt complains of acute on chronic back pain during hospital course and attributes this to muscle spasms. Upon discharge, pt was complaining of continued back pain in addition to mild abdominal pain. He was discharged with Flexeril TID x 3 days. #Psychosocial Issues: Patient exhibited significant frustration and anger towards medical care and the lack of surgical options for his adhesion pain. The patient was informed that he was not a good surgical candidate given his multiple surgeries per Dr. ___. Social work consult was offered and refused. Pt's agitation escalated to point where he needed to be frequently redirected and required diazepam on multiple occasions. Given his considerable desire for surgical intervention for his adhesion's pain despite being a poor surgical candidate, we opted to set up an outpatient surgical appointment to more clearly lay out his options. #Smoking: Patient has a greater than ___ year pack history. On admission, he reported smoking ___ cigarettes per day. Nicotine patch was provided throughout hospital course. Smoking cessation was encouraged. Transitional issues --Pt was given Oxycodone(10 mg) Q4H:PRN for two weeks, may need an earlier appointment for refill if pain continues --Pt is to continue the following while on steroids: PCP prophylaxis with ___ SS daily, PPI and Citracal --Patient will follow up with GI specialists, Dr. ___ Dr. ___ in ___ and ___ --Follow up with surgery, Dr. ___, to discuss treatment options for chronic abdominal pain on ___ --Pt is to followup with Dr. ___ in ___ --Pt is to taper by the following instructions: --PredniSONE 60 mg PO daily Duration: 7 Days Start: In am --PredniSONE 55 mg PO daily Duration: 7 Days Start: After 60 mg tapered dose. --PredniSONE 50 mg PO daily Duration: 7 Days Start: After 55 mg tapered dose. --PredniSONE 45 mg PO daily Duration: 7 Days Start: After 50 mg tapered dose. --PredniSONE 40 mg PO daily Duration: 7 Days Start: After 45 mg tapered dose. --PredniSONE 35 mg PO daily Duration: 7 Days Start: After 40 mg tapered dose. --PredniSONE 30 mg PO daily Duration: 7 Days Start: After 35 mg tapered dose. --PredniSONE 25 mg PO daily Duration: 7 Days Start: After 30 mg tapered dose. --PredniSONE 20 mg PO daily Duration: 7 Days Start: After 25 mg tapered dose. --PredniSONE 15 mg PO daily Duration: 7 Days Start: After 20 mg tapered dose. --PredniSONE 10 mg PO daily Duration: 7 Days Start: After 15 mg tapered dose. --PredniSONE 5 mg PO daily Duration: 7 Start: After 10 mg tapered dose. Medications on Admission: - Prednisone 45mg daily - Omeprazole 20mg PO BID - Loperamide 8mg PO TID PRN - Vitamin B12 monthly - Tums - Ciprofloxacin (periodically as a prophylaxis) Discharge Medications: 1. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:0 2. PredniSONE 60 mg PO DAILY 3. Cyanocobalamin 1000 mcg IM/SC ONCE Duration: 1 Doses monthly 4. Loperamide 4 mg PO TID:PRN diarrhea 5. Omeprazole 20 mg PO DAILY 6. Cyclobenzaprine 10 mg PO TID:PRN back pain RX cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day Disp #9 Tablet Refills:0 7. Citracal + D NF (calcium citrate-vitamin D3;<br>calcium phosphate-vitamin D3) 315-200 mg-unit Oral BID RX calcium citrate-vitamin D3 [Citracal + D] 315 mg-200 unit 2 tablet(s) by mouth twice a day Disp #120 Tablet Refills:0 8. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain RX oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours Disp #84 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: ___ disease flare 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 caring for you at the ___. You were admitted to the hospital for severe abdominal pain and diarrhea which was consistent with an acute ___ disease flare. You received IV steroids and IV pain medications until you were able to advance your diet and you did well on oral pain medications and oral prednisone. Your MRI showed acute inflammation on top of chronic inflammation that was consistent with your ___ disease. Please complete the steroid taper starting from 60 mg daily and make sure you communicate with your GI doctor as you taper the prednisone. You will need close follow-up with your GI specialists and your primary care doctor. Followup Instructions: ___
10312715-DS-62	10,312,715	20,700,054	DS	62	2181-02-09 00:00:00	2181-02-11 22:06:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Mercaptopurine / Ketorolac / Ibuprofen / Flagyl / Reglan / Zofran / Gabapentin / Sulfasalazine / Sulfasalazine Attending: ___ Chief Complaint: Abdominal pain. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. ___ is a ___ year old male with a history of severe, refractory ___ Disease (17 admissions for this since ___, nephrolithiasis who presents with acute worsening of his chronic abdominal pain. He states that this feels like prior ___ exacerbations, but feels like this is the worst one he has had in "at least a year." He reports that he usually has ___ loose bowel movements per day at baseline but began experiencing increasing frequency to ___ per day on ___ and ___. Over the weekend, they increased to ___ per day and severe abdominal pain started. He states that it was worst in the LLQ but had pain in his entire abdomen. It felt sharp and stabbing and was associated with abdominal distention, nausea and dry heaving but no emesis. He denies fevers, chills, muscle aches, URI symptoms, diet changes, recent travel, and sick contacts. By ___ and ___ he was having 30 bowel movements per day and felt that he was "putting out twice as much" as he was taking in by mouth. He reports being scheduled for a colonoscopy on ___ with initiation of methotrexate therapy afterward. He relates extreme frustration with his medical care and inability to find a definitive solution. He has repeatedly pursued surgical intervention, but has been found to be a poor surgical candidate given the lack of potential benefit in the absence of obstruction. He was scheduled to get a second opionion from a surgeon at ___ yesterday "Dr. ___ but his "records were never sent" and he was unable to be seen. He endorses two episodes of suicidal ideation in the last six months without plans. He denies current suicidal ideation or homocidal ideation or feelings of wanting to hurt himself or others. REVIEW OF SYSTEMS: Postive as per HPI. Denies denies headache, cough, chest pain, shortness of breath, dysuria, frequency, hematochezia, melena, fevers, chills, unintentional weight changes, suicidal ideation, homocidal ideation, new rashes, new visual changes. RECENT HOSPITALIZATIONS: ___: ___ flare - Improved with IV solumedrol and then prednisone taper. Pain was was controlled initially with IV IV Dilaudid 1.5-2 mg Q3H:PRN and was transitioned to PO oxycodone. ___: ___ flare - Given IV solumedrol then transitioned to PO prednisone. Pt was interested in surgery but surgery did not feel it was warranted. He had surgery follow up outpatient. ___: Met outpatient with gen surgery who did not think he was surgical candidate, nor did they think surgery was warranted. Pt planning to get second opinion with ___ surgeon. ___: saw Dr ___ doctor, planned to start methotrexate and folic acid following colonoscopy on ___: Scheduled to see ___ surgeon for second opionion but "records were never sent." In the ED, initial vitals 98.4 78 121/76 20 97 Given dilaudid 1mg IV in ED. Currently, Mr. ___ reports being in ___ abdominal pain and states that the hydromorphone in the ED helped but did not completely relieve pain. He thinks that he has an acute exacerbation of ___ disease and has done this "many times before." He believes he needs bowel rest, steroids, and pain control while he stabilizes. Past Medical History: MEDICAL HISTORY: - Crohns disease (dx ___ - ileocolonic ___ disease with perianal abscesses and fistulas s/p subtotal colectomy with ileorectal anastamosis (___). He has failed azathioprine (___), ___ (allergy), infliximab [Remicade] (muscle spasm, rash), certolizumab [Cimzia] (non-efficacious), natalizumab [Tysabri] and is now steroid dependent. Has been evaluated by Dr. ___ Dr. ___ general surgery who do not believe surgical intervention is warranted. Patient requested ___ opinion at ___. Scheduled to start methotrexate therapy following colonoscopy ___ - Atypical chest pain: neg stress ___, associated with "deep breathing" and his abd wall pain - Nephrolithiais: Last renal ultrasound ___: "Findings suggestive of nonobstructing nephrolithiasis in the right upper pole." - Back pain - MRI L spine (___) DJD (herniated disk); Spinal stenosis. Located over lower left back and radiates down lateral left leg to the knee. Occasional leg numbness. Left SI tenderness. - BMD nl ___ - L knee dislocation - Cataracts - Anemia - B12 deficiency: Monthly Vit-B12 1000ug injections at ___ ___. ___ come to ___ for these as well - s/p orchiectomy - latent TB treated with INH in ___ Social History: ___ Family History: - Mother: died of ovarian cancer - Father: died of throat cancer, asthma - Sister: ___ Disease (ileitis, colitis s/p end ileostomy) - Sister with T2DM, ?___ - No h/i GI malignancy Physical Exam: PHYSICAL EXAM: VS - T 97.1 BP 111/65 HR 65 RR 18 SaO2 97% on RA GENERAL - Toxic appearing man who appears in distress, holding abdomen. HEENT - EOMI. No thyromegaly. Oropharynx clear without apthous ulcerations. NECK - No JVD. No LAD. LUNGS - CTAB, no accessory muscle use. HEART - RRR, no m/r/g. ABDOMEN - Well healed midline incision. Bowel sounds hyperactive. Non distended. Guarding without rigidity. No rebound tenderness. Pain to light palpation in all quadrants, worst in LLQ. Unable to palpate deeply for masses due to patient discomfort. No costovertebral angle tenderness. SKIN - Multiple areas of hypopigmentation over chest. Healed excoriations on chest arms and legs. Multiple tattoos. EXTREMITIES - Warm, well perfused. Nonedematous. NEURO - Alert & oriented x 3. Moving all four limbs spontaneously. Follows commands. RECTAL - Patient refused exam. DISCHARGE PHYSICAL EXAM: VS - T 98.8 BP 122/76 HR 61 RR 18 SaO2 99% on RA UOP 700ml since midnight. GENERAL - Middle aged man who appears anxious and agitated but less so than prior examinations. HEENT - EOMI. No thyromegaly. Oropharynx clear without apthous ulcerations. NECK - No JVD. No LAD. LUNGS - CTAB, no accessory muscle use. HEART - RRR, no m/r/g. ABDOMEN - Well healed midline incision. Bowel sounds hyperactive. Non distended. Minimal guarding. No rigidity. No rebound tenderness. Pain to light palpation in lower quadrants only. Unable to palpate deeply for masses due to patient discomfort. No costovertebral angle tenderness. SKIN - Multiple areas of hypopigmentation over chest. Healed excoriations on chest arms and legs. Multiple tattoos. EXTREMITIES - Warm, well perfused. Nonedematous. NEURO - Alert & oriented x 3. Moving all four limbs spontaneously. Follows commands. Pertinent Results: ___ 05:35PM BLOOD WBC-8.1 RBC-4.09* Hgb-12.2* Hct-35.9* MCV-88 MCH-29.9 MCHC-34.0 RDW-14.0 Plt ___ ___ 07:30AM BLOOD WBC-7.4 RBC-4.13* Hgb-12.3* Hct-36.7* MCV-89 MCH-29.8 MCHC-33.6 RDW-14.3 Plt ___ ___ 07:20AM BLOOD WBC-7.1 RBC-3.89* Hgb-11.5* Hct-34.7* MCV-89 MCH-29.6 MCHC-33.1 RDW-14.4 Plt ___ ___ 07:00AM BLOOD WBC-8.7 RBC-3.95* Hgb-11.9* Hct-35.1* MCV-89 MCH-30.1 MCHC-33.9 RDW-14.2 Plt ___ ___ 06:50AM BLOOD WBC-13.5# RBC-4.50 Hgb-13.6* Hct-40.6 MCV-90 MCH-30.3 MCHC-33.6 RDW-14.2 Plt ___ ___ 08:00AM BLOOD WBC-13.9* RBC-5.06 Hgb-15.2 Hct-45.5 MCV-90 MCH-30.0 MCHC-33.3 RDW-14.2 Plt ___ ___ 07:30AM BLOOD ESR-7 ___ 05:35PM BLOOD Glucose-90 UreaN-22* Creat-1.0 Na-144 K-3.9 Cl-112* HCO3-22 AnGap-14 ___ 07:30AM BLOOD Glucose-109* UreaN-22* Creat-1.1 Na-141 K-3.8 Cl-109* HCO3-21* AnGap-15 ___ 07:00AM BLOOD Glucose-141* UreaN-11 Creat-1.0 Na-138 K-4.1 Cl-105 HCO3-24 AnGap-13 ___ 08:00AM BLOOD Glucose-90 UreaN-21* Creat-1.2 Na-136 K-4.4 Cl-99 HCO3-25 AnGap-16 ___ 07:30AM BLOOD CRP-1.7 ___ 02:50PM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-POS amphetm-NEG mthdone-NEG ___ 10:01 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool MORE THAN 12 HRS OLD. *FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Reported to and read back by ___ ___ 2:30PM. 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. CT ABDOMEN & PELVIS: 1. Mildly stenosed wall thickening and mild stranding of the distal ileum before its ileorectal anastamosis with a stable eccentric nodular focus. This may represent subacute ___ inflammation. 2. No evidence of nephrolithiasis or obstructive uropathy. Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION ================================== #) ___ FLARE & C. DIFF COLITIS: Mr. ___ primary issue was severe abdominal pain. Given his history of numerous admissions for ___ exacerbation and extremely refractory disease (multiple failed biological agents), we considered this as our primary differential. He was treated with bowel rest, IV fluid rescusitation, analgesia (hydromorphone, cyclobenzaprine, and lorazepam), and IV methylprednisolone with minimal improvement in abdominal pain or stool output initially. CT scan failed to demonstrate obstruction, nephrolithiasis, or other acute process to suggest an alternative diagnosis. Stool cultures were negative but PCR revealed toxigenic C. diff. After initiating PO vancomycin his symptoms improved dramatically. GI was consulted, (and know this patient well) and assessed that his symptoms were likely better explained by C. diff infection rather than ___ flare given normal ESR and CRP. Of note, he had been taking ciprofloxacin chronically as an outpatient. GI recommended against immediate endoscopic investigation since he was improving clinically. His diet was advanced and medications transitioned to PO, including analgesia, with continued clinical improvement. His steroids were tapered and he was discharged with instructions to taper to pre-admission levels. His admission occurred in a context of his disease course (refractory ___, frequent admissions) which was understandably frustrating to Mr. ___. After failing numerous agents for his ___ disease he has sought surgical intervention on several occasions at ___ and he was felt not to be a good candidate for surgery given lack of obstruction. He was even set to get a second opinion with a surgeon at ___. #) AGITATION & SUICIDAL IDEATION: From records, appears to be a common behavior pattern when he is overwhelmed and having difficulty coping. Mr. ___ was significantly agitated during this admission especially early on when he reported to be and appeared to be in severe pain. He shouted at staff members, refused certain treatments (ex. subcutaneous heparin), and expressed extreme frustration with ___ and threatened to "call the local news" about his "horrible care" he received here. Patient services were notified and spoke with the patient. In the midst of his frustration he stated that he wanted to "go home and end it all" and threatened to sign out AMA. Psychiatry was consulted and felt his suicidal ideation was transient and related to his underlying medical problems. His agitation declined as his pain became better controlled. A urine tox screen revealed cocaine, which could also have partially explained his behavior on admission and his improvement after abstinence. #) COCAINE ABUSE: Possibly contributed to abdominal symptoms via mesenteric ischemia. Patient denied current use of ilicits and reported a distant history of cocaine use. His urine toxicology revealed cocaine but he continued to vehemently deny using. His theory was that he had "shared a Pepsi with someone" who may have been doing cocaine and this had yielded a false-positive. TRANSITIONAL ISSUES =================== - Address cocaine abuse and its contribution to his abdominal pain - Close follow-up with GI - Consider development of a care plan with PCP (see WebOMR note from Dr. ___ details) - Consider work-up of "A stable nodular focus of eccentric heterogeneity is noted along the lateral wall of the mid sigmoid colon measuring 1.3 x 1 cm." seen on CT scan here. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 2. PredniSONE 40 mg PO DAILY 3. Cyanocobalamin 1000 mcg IM/SC ONCE Duration: 1 Doses monthly 4. Loperamide 8 mg PO BID diarrhea 5. Omeprazole 20 mg PO DAILY 6. Cyclobenzaprine 10 mg PO TID:PRN back pain 7. Citracal + D NF* (calcium citrate-vitamin D3;<br>calcium phosphate-vitamin D3) 315-200 mg-unit Oral BID Discharge Medications: 1. Cyclobenzaprine 10 mg PO TID:PRN back pain 2. Omeprazole 20 mg PO DAILY 3. 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 4. Bacitracin Ointment 1 Appl TP QID 5. Nicotine Patch 14 mg TD DAILY Nicotine Withdrawal RX nicotine 14 mg/24 hour Apply to skin once daily Daily Disp #14 Transdermal Patch Refills:0 6. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN Pain Hold for sedation, RR < 12. RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:0 7. Vancomycin Oral Liquid ___ mg PO Q6H RX vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours Disp #40 Capsule Refills:0 8. Citracal + D NF (calcium citrate-vitamin D3;<br>calcium phosphate-vitamin D3) 315-200 mg-unit Oral BID 9. Cyanocobalamin 1000 mcg IM/SC ONCE Duration: 1 Doses monthly 10. PredniSONE 30 mg PO BID RX prednisone 10 mg 4 tablet(s) by mouth twice a day Disp #30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Clostridium difficule colitis ___ disease exacerbation 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 ___ ___. I'm very sorry that you have had such difficulty with your ___ Disease over the years. While here, you had very severe pain in your abdomen which was poorly controlled by pain medications. We also found an infection your intestines called Clostridium difficile colitis ("C-Diff") which we treated with antibiotics (vancomycin by mouth.) You remained without a fever and your conditioned improved such that you could continue your treatment at home. Followup Instructions: ___
10312715-DS-63	10,312,715	20,195,820	DS	63	2181-03-07 00:00:00	2181-03-16 20:20:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Mercaptopurine / Ketorolac / Ibuprofen / Flagyl / Reglan / Zofran / Gabapentin / Sulfasalazine / Sulfasalazine Attending: ___. Chief Complaint: ___ flare Major Surgical or Invasive Procedure: none History of Present Illness: ___ with a history of ___ disease s/p total colectomy and ileostomy reversal presenting with abdominal pain. Patient states that he underwent a flex-sigmoidoscopy today and began experiencing ___ LLQ abdominal pain following the procedure now presenting to the ED concerned for possible Crohns flare. He states that he had been on a liquid diet for three days in anticipation of the procedure as he is unable to tolerate the prep. He had been experiencing increased ___ RLQ pain and ___ LLQ pain since beginning the liquid diet three days ago. He endorses chronic abdominal pain but states that the recent increase in pain had him concerned that he might have a ___ flare. He also reports increased diaphoresis in the last three days, which is also a typical sign of an oncoming ___ flare, which occur approximately every 2 months. Of note, he relates extreme frustration with his medical care and inability to find a definitive solution. He has repeatedly pursued surgical intervention, but has been found to be a poor surgical candidate given the lack of potential benefit in the absence of obstruction. He has previously endorsed two episodes of suicidal ideation and been evaluated by psychiatry. Per Outpatient GI Dr. ___ note, pt plan to start methotrexate after flex sig today. Prednisone has been tapered to 30mg daily for swelling with plan to decrease in increments of 5mg as tolerated. Also had intake appt with ___ surgeon from the Pelvic Floor Service, Dr. ___, who is going to review his CTs and MRI and decide on whether he should have surgery. In the ED, initial VS were 97.7 74 118/100 18 96%. CT Abdomen: Short 4 cm length of focal sigmoid colon wall thickening which is under distended. It is unclear if this correlates with the area of edematous and erythematous mucosa seen on this morning's flexible sigmoidoscopy. No evidence of perforation. Labs notable for Wbc 8.1, Hct 39, and normal chemistry panel. LFTs and lactate not checked. Vitals prior to transfer 97 °F (36.1 °C), Pulse: 71, RR: 18, BP: 124/75, O2Sat: 98, O2Flow: RA, Pain: 10. On arrival to the floor, pt confirms the above story. He has felt unwell since ___ and notes increased stool (baseline BM 18 small per 24h period) now increased to ___ per day despite loperamide. Abd pain is chronic but worsened significantly after sigmoidoscopy. He feels dehydrated and c/o generalized abd pain. Denies nausea, vomiting, fever, chills, dizziness, chest pain, BRBPR, melena, dysuria or hematuria. Endorses chronic scabbing rash over torso and extremities attributed to prednisone. Completed course of po vancomycin 2 weeks ago (10 day course). REVIEW OF SYSTEMS: (+) (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, nausea, vomiting, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: MEDICAL HISTORY: - Crohns disease (dx ___ - ileocolonic ___ disease with perianal abscesses and fistulas s/p subtotal colectomy with ileorectal anastamosis (___). He has failed azathioprine (___), ___ (allergy), infliximab [Remicade] (muscle spasm, rash), certolizumab [Cimzia] (non-efficacious), natalizumab [Tysabri] and is now steroid dependent. Has been evaluated by Dr. ___ Dr. ___ general surgery who do not believe surgical intervention is warranted. Patient requested ___ opinion at ___. Scheduled to start methotrexate therapy following colonoscopy ___ - Atypical chest pain: neg stress ___, associated with "deep breathing" and his abd wall pain - Nephrolithiais: Last renal ultrasound ___: "Findings suggestive of nonobstructing nephrolithiasis in the right upper pole." - Back pain - MRI L spine (___) DJD (herniated disk); Spinal stenosis. Located over lower left back and radiates down lateral left leg to the knee. Occasional leg numbness. Left SI tenderness. - BMD nl ___ - L knee dislocation - Cataracts - Anemia - B12 deficiency: Monthly Vit-B12 1000ug injections at ___ ___. ___ come to ___ for these as well - s/p orchiectomy - latent TB treated with INH in ___ Social History: ___ Family History: - Mother: died of ovarian cancer - Father: died of throat cancer, asthma - Sister: ___ Disease (ileitis, colitis s/p end ileostomy) - Sister with T2DM, ?___ - No h/i GI malignancy Physical Exam: PHYSICAL EXAM: VS - 97.7 124/73 78 20 98/RA GENERAL - hcronically ill appearing man lying in bed appears anxious and tearful but cooperative and conversational HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, oral mucosa pink/dry, OP clear no lesions 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, diffusely tender to palpation EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - multiple small punctate erythematous lesions over torso and extremities NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout Pertinent Results: ___ 06:00PM GLUCOSE-85 UREA N-16 CREAT-1.1 SODIUM-142 POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-24 ANION GAP-14 ___ 06:00PM ALT(SGPT)-25 AST(SGOT)-22 ALK PHOS-48 TOT BILI-0.2 ___ 06:00PM PHOSPHATE-3.2 ___ 06:00PM CRP-1.2 ___ 06:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 06:00PM WBC-8.1 RBC-4.44* HGB-13.0* HCT-39.2* MCV-88 MCH-29.3 MCHC-33.2 RDW-14.2 ___ 06:00PM NEUTS-85.4* LYMPHS-10.4* MONOS-3.6 EOS-0.4 BASOS-0.2 ___ 06:00PM PLT COUNT-___bd/Pelvis ___: Short 4 cm length of focal distal ileum wall thickening which is under distended. This area is similar in appearance to CT ___. It is unclear if this correlates with the area of edematous and erythematous mucosa seen on this morning's flexible sigmoidoscopy. No evidence of perforation. Brief Hospital Course: ___ with a history of ___ disease s/p total colectomy and ileostomy with reversal presenting with abdominal pain following flex sig ___. # Abdominal pain: Hx of refractory ___ with chronic abdominal pain and frequent hospital admissions presenting with acute worsening of abdominal pain after flex sig, also reporting RLQ discomfort consistent with prior abscess. No evidence of perforation or abscess on contrast enhanced CT. LFTs wnl. Given evidence of thickening of distal ileum on imaging and increased abdominal pain and stool frequency, presentation was most consistent with ___ flare. He was kept NPO overnight and started on IV methylprednisolone and IV hydromorphone. The following day, he tolerated PO intake and was transitioned to PO prednisone and pain medication. After conversation with his outpatient GI doctors, Drs. ___ was discharged home on 40mg daily prednisone with plan for him to follow up in GI clinic ___ and start methotrexate. # Diarrhea: Pt reported increased stool frequency for several days prior to admission, likely due to ___ flare as above. Pt had hx of C difficile colitis s/p tx with po vancomycin and was previously on long term oral abx. C diff this admission was negative. # Immune suppression: Pt has failed multiple prior ___ medication and was steroid dependent on admission and anticipating MTX therapy upon discharge. He was discharged on high dose predisone. PCP prophylaxis may be considered for him in the future. # Skin lesions: Pt with multiple skin ulcerations across chest and arms which he reports as chronic and secondary to frequent radiation exposure from CT imaging for ___ disease. No HIV test documented in our system. HIV testing should be considered as an outpatient. # Substance abuse: Patient has distant history of cocaine use but denies currently and insists prior positive ___ screens have been false-positives from passive cocaine exposure from his neighbors. ___ positive for cocaine, opiates, benzos. Transitional Issues: -may consider PCP prophylaxis in the future given continued immune suppression for ___ -discharged on 40mg prednisone daily with plan to follow up with GI ___ with plan to start methotrexate -Outpatient HIV testing Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 35 mg PO DAILY 2. Omeprazole 20 mg PO BID 3. Loperamide 8 mg PO TID:PRN diarrhea 4. Calcium Carbonate 500 mg PO QID:PRN indigestion 5. Cyanocobalamin 1000 mcg IM/SC MONTHLY Discharge Medications: 1. Calcium Carbonate 500 mg PO QID:PRN indigestion 2. Omeprazole 20 mg PO BID 3. PredniSONE 40 mg PO DAILY RX prednisone 10 mg 4 tablet(s) by mouth Daily Disp #120 Tablet Refills:0 4. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain RX oxycodone 10 mg 1 tablet(s) by mouth every 4 hours Disp #36 Tablet Refills:0 5. Cyanocobalamin 1000 mcg IM/SC MONTHLY 6. Loperamide 8 mg PO TID:PRN diarrhea Discharge Disposition: Home Discharge Diagnosis: Luminal ___ Flare Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ becase you had a worsening of your ___ disease following a recent endoscopy. A CT scan of your abdomen showed inflammation but no evidence of abscess (localized infection) or perforation (hole in your bowel). We have given you intravenous steroids and transitioned you to steroids by mouth. Your pain and diarrhea have improved. You should follow up in GI clinic with Dr. ___ as scheduled on ___. You should continue to take all of your medications as prescribed with the following changes: INCREASE Prednisone to 40mg daily START Oxycodone for pain Followup Instructions: ___
10312715-DS-66	10,312,715	20,439,688	DS	66	2181-05-21 00:00:00	2181-05-24 20:18:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Mercaptopurine / Ketorolac / Ibuprofen / Flagyl / Reglan / Zofran / Gabapentin / Sulfasalazine / Sulfasalazine Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ with a PMH of ___ disease s/p subtotal colectomy with ileo-rectal anastomosis, also s/p multiple failed therapies (currently on prednisone & MTX) who is presenting with 5 days of worsening diarrhea and abdominal pain. His abdominal pain started on ___, a couple days after tapering from prednisone 30mg to 25mg. Initially, he experienced diffuse abdominal pain, worse on the left side. His BMs increased in frequency from ___ soft, small volume BMs to >20 by ___. BMs were without blood or mucous. He also experienced nausea, no vomiting. Also decreased po intake. After calling his PCP, he increased his prednisone dose to 40mg on ___, however his symptoms persisted. This morning he continued to have frequent small volume BMs and came to the ED because of unbearable left-sided sharp ___ abdominal pain. No fevers/chills. No rashes or new oral lesions. Importantly, he started taking Bactrim for PCP ___ 1 week ago. Of note, his ___ was diagnosed in ___ and led to ___ requiring subtotal colectomy with ileo-rectal anastomosis in ___. He has failed multiple treatments including immunomodulator therapy with thiopurines as well as multiple anti-TNFs and Tysabri either due to med intolerance/adverse reactions or ineffectiveness. He has had numerous admissions for abdominal pain/diarrhea that resulted from tapering off prednisone. Most recently he has been on methotrexate. Also had an episode of C. difficile. His last lower endoscopy in early ___ (also with biopsy) showed severe chronic active colitis and MRE showed acute on chronic CD in the ileum near the ileo-rectal anastomosis. In the ED, initial vitals were 96.6 61 120/76 18 98% RA. Initial labs without leukocytosis. CT abd/pelvis which, on wet read, showed "5 cm segment of distal ileum with wall thickening and prominent vasa recta, may represent active ___ disease, this is unchanged compared to ___. No abscess, no fistula. No free air" He received total of Dilaudid 2.5mg IV and 2L NS fluid. He did not receive antibiotics, antiemetics or additional prednisone in the ED. On arrival to the floor, initial vital signs were 97.4 119/84 64 16 98RA. He was very agitated and complaining of ___ abdominal pain that is diffuse, but worse in the lower left quadrant. He is requesting pain meds. REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. All other 10-system review negative in detail. Past Medical History: - ___ disease (diagnosed ___: ileocolonic ___ disease with perianal abscesses and fistulas s/p subtotal colectomy with ileorectal anastomosis (___). He has failed azathioprine (ARF), ___ (allergy), Remicade (muscle spasm, rash), Cimzia (non-efficacious), Tysabri and is now steroid dependent. Has been evaluated by Dr. ___. He is hesitant for any further surgeries. - Degenerative Disc Disease (Disc protrusion): MRI lower spine (___) showed spinal stenosis; pain is felt over lower left back and radiates down lateral left leg to knee with occasional numbness. - Nephrolithiais: Last renal ultrasound ___: nonobstructing nephrolithiasis in the right upper pole - Atypical chest pain: neg stress ___, associated with "deep breathing" and his abd wall pain - Left knee dislocation - Cataracts - Anemia - Vitamin B12 deficiency: monthly vitamin B12 1000 ug injections taken at ___; occasionally comes to ___ for injections - History of C. diff positive stools - latent TB treated with INH in ___ PSH: - subtotal colectomy ___ - ileorectal anastamosis ___ - surgery for "collapsed colon" ___ - several lysis of adhesions operations ___ - L orchiectomy ___ Social History: ___ Family History: Father died of throat cancer in ___ (heavy smoker/drinker). Mother died of ovarian cancer in ___. Grandmother passed away of complications from diabetes. Has 4 sisters, one with ___ also (recently had ostomy), one with diabetes. One brother in good health. Physical Exam: ADMISSION PHYSICAL EXAM: VS 97.4 119/84 64 16 98RA GEN Alert, oriented, in distress regarding abdominal pain HEENT NCAT MMM EOMI sclera anicteric, OP clear, no oral erosions NECK supple, no JVD, no LAD PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, no mrg ABD: well healed veritcal midline and small RLQ surgical scar, soft, mild distention, hypoactive BS, tender to palpation throughout, most especially in LLQ. No rebound or guarding. EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN He has multiple tattoos on his forearms bilaterally. Also has ___ subcentimeter erythematous papules on his chest. DISCHARGE PHYSICAL EXAM: VS 98.0/98.2 61 108/66-110s/70s 18 96-98%RA GEN Alert, oriented, NAD HEENT NCAT MMM EOMI, OP clear, no oral erosions NECK supple, no JVD, no LAD PULM Good aeration, CTAB ___: RRR normal S1/S2, no mrg ABD: well healed vertical midline and small RLQ surgical scar, soft, ND, BS normoactive, no tinkling sounds. tender to palpation on RLQ. No rebound or guarding. EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN He has multiple tattoos on his forearms bilaterally. Also has ___ subcentimeter erythematous papules on his chest. Pertinent Results: ================================ ADMISSION LABS: ___ 09:50AM BLOOD WBC-8.4 RBC-4.36* Hgb-13.2* Hct-40.1 MCV-92 MCH-30.2 MCHC-32.8 RDW-15.4 Plt ___ ___ 09:50AM BLOOD Neuts-92.0* Lymphs-5.4* Monos-2.0 Eos-0.3 Baso-0.3 ___ 09:50AM BLOOD Glucose-114* UreaN-26* Creat-0.8 Na-142 K-3.9 Cl-113* HCO3-19* AnGap-14 ___ 09:50AM BLOOD ALT-33 AST-23 AlkPhos-50 TotBili-0.1 ___ 08:20AM BLOOD CRP-2.3 ___ 08:20AM BLOOD ESR-8 DISCHARGE LABS: ___ 08:00AM BLOOD WBC-9.2# RBC-4.27* Hgb-13.6* Hct-39.5* MCV-93 MCH-31.9 MCHC-34.5 RDW-15.6* Plt ___ ___ 08:00AM BLOOD Glucose-100 UreaN-16 Creat-1.2 Na-140 K-3.9 Cl-102 HCO3-28 AnGap-14 ___ 08:00AM BLOOD Calcium-9.6 Phos-3.3 Mg-2.0 ================================ URINE: ___ 09:50AM URINE Color-Yellow Appear-Clear Sp ___ ___ 09:50AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 09:50AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG ================================ Blood Culture: no growth x72 hours ================================ ___ 7:10 pm STOOL C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. ================================ CT ABDOMEN/PELVIS without contrast FINDINGS: The lung bases are clear. The visualized heart and pericardium are unremarkable. The liver enhances homogeneously and there are no focal liver lesions. The gallbladder is normal. The portal vein is patent. The pancreas is normal. The spleen is normal. The adrenal glands are normal. The kidneys enhance and excrete contrast symmetrically. There is no mesenteric or retroperitoneal lymphadenopathy. Patient is status post subtotal colectomy with ileorectal anastomosis. Again seen is an approximately 5 cm length of focal distal ileum thickening just before the rectal anastomosis. This is unchanged compared to ___. Remainder of the small bowel is unremarkable. No evidence of stranding surrounding this area. No evidence of fistula or abscess. No free air. Incidental note of an uncomplicated paraduodenal internal hernia, unchanged. No evidence of obstruction. PELVIS: The bladder and terminal ureters are normal. The prostate and seminal vesicles are normal. The rectum is normal. There is no free fluid in the pelvis. There is no pelvic or inguinal lymphadenopathy. The aorta is normal in caliber. The intra-abdominal vasculature is patent. BONES: No acute bony abnormality. IMPRESSION: 5-cm in length of distal ileum with wall thickening is unchanged compared to ___. No evidence of perforation, abscess or fistula. ================================ ECGStudy Date of ___ 11:44:20 AM Sinus bradycardia. Mild Q-T interval prolongation. Since the previous tracing of ___ the rate is slower. Otherwise, no change. IntervalsAxes ___ ___ ================================ Brief Hospital Course: ___ with a PMH of ___ disease s/p subtotal colectomy with ileo-rectal anastomosis s/p multiple failed therapies now on prednisone and MTX who was admitted with worsening abdominal pain and diarrhea. ACUTE ISSUES: # Presumed Ileus with possible Crohns flare: His clinical presentation of frequent episodes of watery diarrhea, abdominal pain and inability to tolerate po intake in the setting of tapering his prednisone dose (from 40mg to 25mg) was consistent with previous ___ flares. There was no evidence of fistula/abscess/SBO on CT abd pelvis. C. diff and stool culture was negative. His symptoms improved after 5 days of pred 40mg (on hospital D2 because he resumed pred40 3 days prior to admission). He received IVF, IV pain control with Dilaudid, and tizanidine. On discharge, he was able to tolerate full po solids/liquids with po pain control and pred40mg daily. He also continued his MTX25mg q weekly regimen. CHRONIC ISSUES: # Substance abuse: He has a long history of substance abuse including cocaine. Urine tox was negative and he denied recent use of illicits. # Vit B12 deficiency: He received his B12 injection on this admission. # PCP ___: He continued Bactrim SS daily given his chronic steroids. # GERD: continued omeprazole TRANSITIONAL ISSUES: - Former patient of Dr. ___. He will be transitioning care to ___ because of her leave. - HCP ___ (Aunt) ___ Cell: ___ - Full Code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cyanocobalamin 1000 mcg IM/SC ONCE Duration: 1 Doses 2. Omeprazole 20 mg PO DAILY 3. FoLIC Acid 5 mg PO QTHUR 4. Loperamide 2 mg PO QID:PRN diarrhea 5. Methotrexate 25 mg PO 1X/WEEK (TH) take with 5mg folate 6. PredniSONE 40 mg PO DAILY Tapered dose - UP 7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Discharge Medications: 1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:*0 2. FoLIC Acid 5 mg PO QTHUR 3. Loperamide 2 mg PO QID:PRN diarrhea 4. Methotrexate 25 mg PO 1X/WEEK (TH) take with 5mg folate 5. Omeprazole 20 mg PO DAILY 6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 7. Cyanocobalamin 1000 mcg IM/SC ONCE Duration: 1 Doses 8. PredniSONE 40 mg PO DAILY Tapered dose - UP Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - Acute ___ disease flare Secondary diagnoses: - GERD, prior substance 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 the hospital because you were having abdominal pain and increased frequency of bowel movements, similar to your prior ___ disease flares. You had a CT scan of your abdomen which showed inflammation likely due to ___, but did not show any other concerning findings. You were continued on your steroids and methotrexate and your symptoms improved. Your diet was advanced to a soft diet and you should continue to advance as you are able to tolerate. We did not make any changes to your medications. Followup Instructions: ___
10312715-DS-72	10,312,715	25,743,352	DS	72	2183-04-23 00:00:00	2183-04-30 18:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Mercaptopurine / Ketorolac / Ibuprofen / Flagyl / Reglan / Gabapentin / Sulfasalazine Attending: ___. Chief Complaint: diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M w/ hx of Crohn's disease status post subtotal colectomy and ileorectal anastomosis as well as frequent admissions for chronic abdominal pain p/w diarrhea. He states that since ___ he has had increase in number of bowel movements from normal 8x/day to every 30 minutes. Stools are watery and vary from small to about 600cc as measured in hat in ED. He denies blood in stool. He notes some nausea and emesis over the last few days and some chills/sweat but denies fevers. He now feels bloated and states that stool frequency has reduced to every hour. He has some anal irritation from frequent wiping. He also notes "L kidney pain" saying it does not feel like kidney stones he has had in past and states he had some hard time urinating today. He states that he went to a broth diet but has bad willpower so finds he needs to come to hospital for bowel rest and would have gone home if he had a ride. He states that he has had no instigating factors such as change in diet or exposures but does note drinking eggnog today. He states that his abdominal pain is always present and not very different that usual. He notes that he has trouble making it to pain mangement appointments and his new PCP reduced his oxycodone dose but he has continued to take old dose, leading him to finish his meds early. Of note, he reduced his prednisone dose from 10 to 5mg per Dr. ___ on ___ and finished a course of PO vanc for C. diff on ___. Per OMR, the patient has been admitted very frequently for possible Crohn's flare, treated with bowel rest, IVF, IV pain medications and slow reinstatement of his home medications. During ___ and early ___ he received most of his care at ___ ("the surgeons here didn't want to operate on me") where the remainder of his ileum was apparently resected; however, he has recently re-established care here at ___. He was most recently admitted twice in ___ then again in ___ first, for C. Diff and then (___) for ongoing diarrhea which was attributed to recurrence of C. Diff (thought less likely to be Crohn's flare d/t normal inflammatory markers). He was most recently discharged at the end of ___ and discharged on slow C. Diff taper to end ___. He was advised to taper prednisone slowly (5mg q2 weeks) and referred to pain management clinic for management of chronic pain with opiate dependence. In the ED initial vitals were: 97.6 110 ___ 96% RA - Labs were significant for Lactate 2.9, K 3.6, Cr 1.7 with BUN 20 (baseline Cr 1.1), Glu 156, Bicarb 23 with AG 14, ALT 44 AST 38, lipase 26, AP 52, Tbili 0.3, CRP 6.0 (up from 0.8 ___, WBC 8.2 with 77%PMN, H/H 15.4/42.1 Plt 147, UA with few bact, WBC 4, 9 hyaline casts - Patient was given 1mg IV hydromorphone x3, 4mg IV ondansetron x2, 3L NS, PO famotidine x1. Vitals prior to transfer were: 98.4 82 ___ 100% RA On the floor, patient notes that he "wants doctors to ___ from him", which he has stated on past admissions. Review of Systems: As per HPI, otherwise negative Past Medical History: Crohn's Disease: - dx ___ - ileocolonic disease c/b perianal abscesses and fistulas - s/p subtotal colectomy with ileorectal anastomosis ___ resection of remaining distal colon/rectum (___) - partial SBO requiring ex-lap (___), ex-lap w/ LOA (___) - medical management: failed azathioprine (ARF), ___ (allergy), infliximab (muscle spasm, rash), Cimzia (certolizumab) (non-efficacious), Tysabri (natalizumab) and is now steroid dependent (prednisone 10 is lowest) # Vitamin B12 deficiency: IM replacement # Depression # Degenerative Disc Disease (Disc protrusion): MRI lower spine (___) showed spinal stenosis; pain is felt over lower left back and radiates down lateral left leg to knee with occasional numbness. # Nephrolithiais: Last renal ultrasound ___: non-obstructing nephrolithiasis in the right upper pole # Atypical chest pain with neg stress ___ # Cataracts: ___ longstanding steroid use # latent TB treated with INH in ___ # L orchiectomy ___ Social History: ___ Family History: Father died of throat cancer in ___ (heavy smoker/drinker). Mother died of ovarian cancer in ___. Maternal grandmother has ___ ___ grandmother had lung cancer Sister has colitis, ileitis Physical Exam: ADMISSION: Vitals - T: 97.7 BP: 126/82 HR: 74 RR: 18 02 sat: 99%RA GENERAL: Mildly uncomfortable appearing but pleasant man lying in bed in NAD HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, dry MM NECK: no elevated JVP CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: soft, nondistended, +BS, midline surgical scar, mild tenderness to palpation in LUQ, no rebound/guarding EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact,AAOX3, motor and sensory exam grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes RECTAL: Skin tags present around anus, dark lesion present on anus at 8 o'clock position consistent with patient description of fistula, normal rectal tone, no stool in vault, no blood DISCHARGE: normal, stable vital signs GENERAL: comfortable appearing middle-aged man lying in bed in NAD HEENT: anicteric sclera, moist MM NECK: no elevated JVP CARDIAC: normal rate, regular rhythm, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: soft, nondistended, +BS. midline surgical scar, mild tenderness to palpation in LUQ, no rebound/guarding EXTREMITIES: no edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact,AAOX3, motor and sensory exam grossly intact SKIN: scattered excoriated papules RECTAL: firm, hyperpigmented skin on left lateral aspect of anus, minimally tender to palpation. Pertinent Results: ADMISSION: ___ 09:15PM BLOOD WBC-8.2# RBC-4.77 Hgb-15.4# Hct-42.1 MCV-88 MCH-32.4* MCHC-36.6* RDW-14.6 Plt ___ ___ 09:15PM BLOOD Neuts-78.6* Lymphs-13.5* Monos-5.2 Eos-2.3 Baso-0.4 ___ 10:20AM BLOOD ___ PTT-31.8 ___ ___ 09:15PM BLOOD Glucose-156* UreaN-20 Creat-1.7* Na-142 K-3.6 Cl-105 HCO3-23 AnGap-18 ___ 09:15PM BLOOD ALT-44* AST-38 AlkPhos-52 TotBili-0.3 ___ 09:15PM BLOOD Albumin-4.7 ___ 09:28PM BLOOD Lactate-2.9* ___ 09:15PM BLOOD CRP-6.0* ___ 09:15PM URINE Color-Yellow Appear-Clear Sp ___ ___ 09:15PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG ___ 09:15PM URINE RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-0 ___ 09:15PM URINE CastHy-9* DISCHARGE: ___ 05:31AM BLOOD WBC-6.2 RBC-4.27* Hgb-13.6* Hct-38.5* MCV-90 MCH-31.8 MCHC-35.3* RDW-14.4 Plt ___ ___ 05:31AM BLOOD Glucose-96 UreaN-11 Creat-1.4* Na-139 K-3.9 Cl-103 HCO3-21* AnGap-19 ___ 10:20AM BLOOD ALT-37 AST-28 AlkPhos-40 TotBili-0.4 ___ 05:31AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0 MICRO: ___ 10:20 am Immunology (CMV) FINAL REPORT ___ CMV Viral Load (Final ___: CMV DNA not detected. Performed by Cobas Ampliprep / Cobas Taqman CMV Test. Linear range of quantification: 137 IU/mL - 9,100,000 IU/mL. Limit of detection 91 IU/mL. This test has been verified for use in the ___ patient population. ___ CT ABD/PELVIS: IMPRESSION: No acute intra-abdominal process. No fluid collection or fistula. No obstruction. STOOL: ___ 9:54 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. Brief Hospital Course: ___ yo M w/ longstanding hx of Crohn's disease s/p total colectomy w/ ileorectal anastamosis; and multiple failed medical regimens presenting with worsening of diarrhea. ACTIVE ISSUES: # Abdominal pain and diarrhea: Improved after IV fluids and pain medications. Etiology was concerning for Crohn's flare given his known chronic severe Crohn's, temporal association with down-tapering of prednisone, and identical symptoms as prior flares. His inflammatory markers were not very high, though notably they have not been elevated in prior flares either. C-diff was negative. Relative opiate withdrawal was also considered since he just recently ran out of his home oxycodone, though he did deny other symptoms of this including rhinorrhea, yawning, etc and his symptoms began prior to his running out. Given his complicated Crohn's history, GI was consulted, and his prednisone was restarted back at 10mg daily. His symptoms significantly improved with this treatment. He had a mild ___ as well which remained stable with IV fluids. He was counseled on maintaining adequate po intake, and he should have labs checked at his next outpatient appointment. # Acute kidney injury: Improved with IV fluids though not back to his baseline. He understood the importance of maintaining adequate salt and fluid intake and following up with his outpatient doctors for further ___. # Crohn's disease and pain management: He recently re-established care w/ GI (Dr. ___ with a plan was for slow taper of prednisone with continuation of azathioprine 100mg daily. His GI providers have been reluctant to provide ongoing prescriptions for opiate pain management and referred him to pain management clinic, where he has not yet been able to establish care due to transportation issues. Given that he has been unable to do so and given his high risk of recurrent GI symptom and pain flare, he was provided with an additional prescription for oxycodone as a bridge to his upcoming GI and PCP ___. He will need to establish care with the pain management clinic for further management. CHRONIC ISSUES: # Vitamin B12 deficiency: IM replacement as outpatient prn. # Depression: No home medications. # Degenerative Disc Disease: Not active. # Nephrolithiais: No recent flare, no dysuria/hematuria. # Atypical chest pain with neg stress ___: Not active. # Latent TB treated with INH in ___: No pulm symptoms. # GERD: Continue home famotidine. # Code: full confirmed # Emergency Contact: Aunt ___ HCP ___, ___. Per pt, do not call after 9PM. TRANSITIONAL ISSUES: - continue 10mg prednisone with plan for very slow down-taper by 1mg per week - dietary changes as follows: limit intake that is high in osmolarity (juice, concentrated sweets), increase sodium intake and water to prevent dehydration, restrict lactose - apply zinc oxide topically to perianal area daily to help with skin irritation - Pain plan - given his acute worsening of pain with simultaneous down-tapering of prednisone and oxycodone, he was prescribed a bridging course of oxycodone 5mg ___ tabs) q6-8h prn pain. He has been trying to arrange for transportation to be seen by the Pain clinic to assist with management, so this should be pursued for further management - consider PCP prophylaxis given his steroid-dependency - check basic chemistries at his upcoming appointment to ensure improved or stable renal function Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Azathioprine 100 mg PO DAILY 2. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain 3. PredniSONE 5 mg PO DAILY Tapered dose - DOWN 4. Famotidine 20 mg PO Q12H 5. Cyanocobalamin 1000 mcg IM/SC MONTHLY 6. LOPERamide 8 mg PO QAM 7. LOPERamide 12 mg PO QPM 8. Vitamin D 50,000 UNIT PO 1X/WEEK (___) Discharge Medications: 1. Azathioprine 100 mg PO DAILY 2. Famotidine 20 mg PO Q12H 3. OxycoDONE (Immediate Release) 5 mg PO EVERY ___ HOURS as needed for breakthrough pain RX oxycodone 5 mg ___ tablet(s) by mouth Every ___ hours Disp #28 Tablet Refills:0 4. PredniSONE 10 mg PO DAILY RX prednisone 1 mg 10 tablet(s) by mouth Once a day Disp #60 Tablet Refills:0 5. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 6. Cyanocobalamin 1000 mcg IM/SC MONTHLY 7. LOPERamide 8 mg PO QAM 8. LOPERamide 12 mg PO QPM 9. zinc oxide 10 % topical Twice a day Apply to irritated ___ skin. RX zinc oxide 20 % Apply to irritated ___ skin. Twice a day Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Probable mild Crohn's flare Secondary Diagnosis: Mild acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you during your hospitalization. You were admitted on ___ for worsening abdominal pain and diarrhea. You underwent a work-up that fortunately didn't identify any new infections. Your pain was most likely caused by your underlying Crohn's disease after reducing your prednisone dose and pain medications. You were given IV fluids and pain medications, and your condition improved. You are now safe to be discharged home. Please be sure to follow-up with Dr. ___ Dr. ___ as scheduled. Please be sure to keep up with your fluid intake and take your medications as prescribed. We hope you enjoy the rest of the holidays! Your ___ care team Followup Instructions: ___
10312715-DS-73	10,312,715	23,979,215	DS	73	2183-06-15 00:00:00	2183-06-16 15:04:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Mercaptopurine / Ketorolac / Ibuprofen / Flagyl / Reglan / Gabapentin / Sulfasalazine Attending: ___. Chief Complaint: back pain and abdominal pain/diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ yo male w/ a hx of Crohn's disease s/p colectomy w/ ileorectal anastamosis and hx of frequent admissions for chronic abdominal pain and DJD/spinal stenosis w/ chronic lumbar back pain who presents with 4 days of progressive nausea/vomiting/diarrhea and back pain. Pt reports that ___ he was shoveling snow, and after a particular heavy thrust over shoulder he started experiencing intense back pain. He described the feeling as if he had a painful (___) bulge coming out of his back with pins and needles going all the way down his left leg. He has a history of spinal stenosis and DJD, w/ flare-ups leading to back pain radiating from the lower back around the side of his belly, but he says the sensation has not extended down his lateral thigh previously. That same night his back pain began he started experiencing similar symptoms to his Crohn's flare-ups, with frequent bowel movements and abdominal pain. He describes his pain as a ___ LUQ and LLQ sharp abdominal pain with an additional dull pain radiating down to groin. He feels slightly bloated and feels as if his old incisions are stretching. He describes his baseline as ___ BMs regular per day, though over the past few days there have been as many as 30 per day, which he describes as watery and non-bloody. Although stools have been non-bloody he sees blood on toilet paper, which he thinks may be an aggravation of his skin tag/left sided abscess. He has measured temperatures up to 98-99 up from his usual baseline of 96. Called PCP on ___. Had appointment on ___ at primary care. Was found to have no neurologic compromise or weakness. Was given ___ referral and prescriptions for cyclobenzaprine/duloxetine. He has been unable to eat since ___. This morning his stomach and back pain were reportedly 10 times worse. BMs have continued though have been watery. Vomiting has been watery, nonbloody, with occasional minimal greenish tinge. Patient called GI doctor on call (sees Dr. ___ ___, and was advised to present to ED for evaluation. Pt notably has extensive Crohn's history, including colectomy w/ ileorectal anastamosis, and recent ileal resection in ___ at ___. Recently reestablished care at ___ w/ Dr. ___. Patient has regular flare-ups of his Crohn's disease and has a history of multiple admissions for bowel rest. Last flare was on ___, when he presented similarly with increased bowel movements. He has continued his attempt to taper his prednisone given multiple longstanding issues secondary to steroid use (cataracts in eyes, rotten teeth) - currently on 4 mg once a day, down from 120 mg at one point. Steroid tapering in the past has been associated with worsening of patient's diarrhea. At time of last admission he was taking 10 mg prednisone qd. Pain management has been a struggle previously. Opioids are prescribed by PCP, though has been beginning to attend pain management clinic. Due to concern regarding poor coping, agreed to see a clinical social worker regarding long term management of his abdominal and back pain. In the ED, initial vital signs were: T97.4 HR98 BP120/80 RR18 O2 sat 97%. Exam was notable for LUQ and LLQ pain. Labs were notable for nl LFTs, WBC 5.7, bicarb 19, lactate 1.9, CRP 1.8. CT abdomen showed no acute CT findings to explain the patient's pain. No signs of intraabdominal infection or abscess. Patient was given morphine 5 mg x 2, zofran, and Dilaudid. On Transfer Vitals were: T97.3 HR68 BP101/59 RR16 O2 sat 97% RA. Past Medical History: Crohn's Disease: - dx ___ - ileocolonic disease c/b perianal abscesses and fistulas - s/p subtotal colectomy with ileorectal anastomosis ___ resection of remaining distal colon/rectum (___) - partial SBO requiring ex-lap (___), ex-lap w/ LOA (___) - medical management: failed azathioprine (ARF), ___ (allergy), infliximab (muscle spasm, rash), Cimzia (certolizumab) (non-efficacious), Tysabri (natalizumab) and is now steroid dependent (prednisone 10 is lowest) # Vitamin B12 deficiency: IM replacement # Depression # Degenerative Disc Disease (Disc protrusion): MRI lower spine (___) showed spinal stenosis; pain is felt over lower left back and radiates down lateral left leg to knee with occasional numbness. # Nephrolithiais: Last renal ultrasound ___: non-obstructing nephrolithiasis in the right upper pole # Atypical chest pain with neg stress ___ # Cataracts: ___ longstanding steroid use # latent TB treated with INH in ___ # L orchiectomy ___ Social History: ___ Family History: older sister w/ ___ and collitis/ostomy. Sister w/ diabetes. Paternal grandmother w/ lung cancer. Maternal grandmother died of diabetes. Mother died of ovarian cancer. Father died of throat cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T97.3 HR68 BP101/59 RR16 O2 sat 97% RA General: NAD. lying comfortably in bed. HEENT: NC/AT. no scleral icterus. Lymph: No LAD. CV: RRR. no r/m/g. Lungs: CTAB. no w/r/r Abdomen: well healed ex-lap incision. Hypoactive BS. ND. Soft. Sharp TTP LUQ, Mild TTP LLQ. no rebound/guarding. Back: TTP most pronounced around L4-L5 w/ pain radiation around left side. GU: uncircumcised. no rashes or other lesions noted. Rectal: Anal skin tag noted. L sided perianal abscess. normal rectal tone/anal wink. Ext: WWP. No C/C/E. 2+ ___. Neuro: Awake, alert, oriented to person, place and time. Able to coherently relay history. Slight loss of light touch around L4-L5 distributions on lateral thigh and calf. patellar/Achilles reflexes 1+ b/l symmetric. ___ motor exam full and symmetric. No saddle sensory loss. Skin: multiple punctate crusted lesions noted across anterior calves. DISCHARGE PHYSICAL EXAM: Vitals: Tm 98.3 Tc 97.9 HR63 BP102/64 RR18 SaO2 98 RA General: no acute distress. lying in bed HEENT: NC/AT. no scleral icterus. Lymph: No LAD. CV: RRR. no r/m/g. Lungs: CTAB. no w/r/r Abdomen: well healed ex-lap incision. Hypoactive BS. mild TTP LUQ/LLL. Back: mild TTP over spine at level of L4-L5 Ext: WWP. No C/C/E. 2+ ___. Neuro: Awake, alert, oriented to person, place and time. Able to coherently relay history. ___ motor exam full and symmetric. Skin: multiple punctate crusted lesions noted across anterior calves. Pertinent Results: ___ 09:05AM BLOOD WBC-5.7 RBC-4.59* Hgb-14.2 Hct-40.3 MCV-88 MCH-30.9 MCHC-35.2* RDW-14.5 Plt ___ ___ 09:05AM BLOOD Neuts-78.3* Lymphs-12.0* Monos-7.1 Eos-2.1 Baso-0.4 ___ 09:05AM BLOOD ___ PTT-32.7 ___ ___ 09:05AM BLOOD Plt ___ ___ 09:05AM BLOOD Glucose-96 UreaN-20 Creat-1.2 Na-140 K-3.6 Cl-109* HCO3-19* AnGap-16 ___ 09:05AM BLOOD ALT-26 AST-26 AlkPhos-56 TotBili-0.4 ___ 09:05AM BLOOD Lipase-35 ___ 09:05AM BLOOD Albumin-4.1 Calcium-9.7 Phos-3.4 Mg-1.8 ___ 09:18AM BLOOD Lactate-1.9 ___ 09:05AM BLOOD CRP-1.8 ___ C. difficile DNA amplification assay (Final ___: 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. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI 0157:H7 FOUND. ___ L-SPINE (AP & LAT) 11:30 AM Intervertebral disc spaces, and alignment are essentially within normal limits with mild hypertrophic spurring especially at L5-S1. There is contrast material within the gallbladder. This may be a sign of vicarious excretion if there is any evidence of underlying renal disease. A less likely possibility could be fistulization of contrast related to the known underlying Crohn's disease. ___ CT ABD & PELVIS WITH CONTRAST FINDINGS: THORAX: The visualized lung bases are clear with no pleural effusions, pneumothorax or focal opacities. The visualized heart and pericardium are normal. Atelectasis is noted in the left lung. A 3 mm left lower lobe pulmonary nodule is noted (2:5). IMPRESSION: 1. No acute CT findings to explain the patient's pain. No signs of intra-abdominal infection or abscess. 2. 3 mm left lower lobe pulmonary nodule. If the patient has risk factors such as smoking history or history of malignancy, recommend follow-up CT in 12 months to assess stability. ___ ECG Study Date Sinus rhythm. Normal ECG. Compared to the previous tracing of ___ the rate has increased. Otherwise, no diagnostic interim change. Brief Hospital Course: This is a ___ year old male with past medical history of ileocolonic crohns on azathioprine and chronic steroids s/p multiple surgeries admitted ___ w diarrhea and back pain, found to have c.diff colitis, no focal neurologic processes identified, with improved frequency of stooling, able to ambulate now ready for discharge home on a 14 day regimen of PO vancomycin and planned GI follow-up. ACUTE ISSUES: # Cdiff Coliits / Crohns Disease - patient w Crohns Disease presenting with increasing abdominal pain and diarrhea; found to have C.Diff colitis. No concern for active inflammatory disease as well. Patient treated with PO Vancomycin 250mg Q6H with resolution of symptoms to his baseline of 8 bowel movements per day. Planned for 2 week course (day ___, end date ___ as well as outpatient GI follow-up to consider MRE and/or flex sig. # Incidental finding - on CT scan, found to have "3 mm left lower lobe pulmonary nodule. If the patient has risk factors such as smoking history or history of malignancy,recommend follow-up CT in 12 months to assess stability." # Acute on Chronic Lower Back pain: pt long history of lower back pain in the lumbar area who presented with lower back pain radiating down left leg. No focal neurologic deficits or warning signs for cord compression. Felt potentially consistent w/ L4-L5 radiculopathy, though no motor weakness noticed. Patient seen by chronic pain service, treated with Acetaminophen 650 mg PO/NG Q8H; OxycoDONE 10 mg PO Q6H and Oxycodone 10mg BID:PRN, lidocaine patch, trial of cyclobenzaprine. Has outpatient f/u w/ chronic pain service scheduled. # GERD: Toward end of hospitalization patient reported discomfort with reflux refractory to calcium carbonate. Decision was made to initiate treatement with famotidine 20 mg over PPI due to increased risk of recurrent C diff with the latter. CHRONIC ISSUES: # Vitamin B12 deficiency: continue IM replacement as outpatient prn. # Nephrolithiais: No recent flare, no dysuria/hematuria. # Atypical chest pain with neg stress ___: Not active. EKG in house reassuring. TRANSITIONAL ISSUES: - Rec repeat CT chest 12 months given smoking history and incidental finding of 3 mm left lower lobe pulmonary nodule. - Outpatient GI follow-up evaluation scheduled regarding need for MRE or flexible sigmoidoscopy. - Outpatient chronic pain evaluation scheduled for ___. # Code: Full (confirmed w/ pt) # Emergency Contact: ___ (aunt) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Azathioprine 100 mg PO DAILY 2. Cyanocobalamin 1000 mcg IM/SC QMONTH 3. LOPERamide 8 mg PO BID diarrhea 4. PredniSONE 4 mg PO DAILY Tapered dose - DOWN 5. Duloxetine 20 mg PO DAILY 6. Cyclobenzaprine 5 mg PO DAILY 7. OxycoDONE (Immediate Release) 5 mg PO EVERY ___ HOURS as needed for breakthrough pain 8. Famotidine 20 mg PO Q12H Discharge Medications: 1. Azathioprine 100 mg PO DAILY 2. Duloxetine 20 mg PO DAILY 3. Famotidine 20 mg PO Q12H 4. PredniSONE 4 mg PO DAILY Tapered dose - DOWN 5. Acetaminophen 650 mg PO Q8H RX acetaminophen 650 mg 1 tablet(s) by mouth every eight (8) hours Disp #90 Tablet Refills:0 6. Cyanocobalamin 1000 mcg IM/SC QMONTH 7. Vancomycin Oral Liquid ___ mg PO Q6H RX vancomycin [Vancocin] 125 mg 1 capsule(s) by mouth every six (6) hours Disp #44 Capsule Refills:0 8. Lidocaine 5% Patch 1 PTCH TD DAILY RX lidocaine 5 % (700 mg/patch) Apply one patch to back daily Daily Disp #30 Patch Refills:0 9. Cyclobenzaprine 10 mg PO TID RX cyclobenzaprine 10 mg 1 tablet(s) by mouth Three times a day Disp #60 Tablet Refills:1 10. OxycoDONE (Immediate Release) 10 mg PO Q6H RX oxycodone 10 mg 1 tablet(s) by mouth every six (6) hours Disp #100 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Clostridium difficile Lower back pain Secondary Diagnosis: Crohn's Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital after you presented with several days of abdominal pain, back pain, and diarrhea. After evaluating you with bloodwork, stool studies, and imaging, it was determined that your abdominal pain was most likely caused by infection with a certain kind of bacteria called clostridium difficile. You were started on an antibiotic regimen and your diarrhea and abdominal pain improved. Based on the story of how your back pain started, it was thought that this was caused by shoveling, for which the best treatment is pain management and continued mobility as this should resolve with some time. There was no evidence on x-ray of any other abnormalities involving your spinal cord. Based on the story and your symptoms, management of your pain for the next ___ months is the most appropriate course of action and your pain should resolve within that time frame. Please take all medications as prescribed and keep all scheduled appointments. Should you develop a severe worsening of symptoms, experience any of the warning signs listed below, or have any any other symptoms that concern you please seek medical attention. You have a lung nodule seen on imaging which is unlikely to be concerning but should be followed up by your primary care doctor. It was a pleasure taking care of you! Your ___ Team Followup Instructions: ___
10312715-DS-74	10,312,715	23,217,947	DS	74	2183-07-22 00:00:00	2183-07-30 16:19:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Mercaptopurine / Ketorolac / Ibuprofen / Flagyl / Reglan / Gabapentin / Sulfasalazine Attending: ___. Chief Complaint: Abdominal ___ Major Surgical or Invasive Procedure: ___ Flexible sigmoidoscopy History of Present Illness: Mr. ___ is a ___ gentleman with a history of Crohn's disease s/p colectomy w/ ileorectal anastamosis, frequent admissions for chronic abdominal ___, and recent admission for c. diff colitis. He presents with 10 days of worsening diarrhea and abdominal ___, which feels similiar to his Crohn's flares. He states that he was recently on a prednisone taper which was stopped on ___. Around ___, he reports a significant increase in the number of his bowel movements, for which Dr. ___ 30 mg of prednisone. Patient reports subjective fevers, chills, nausea, rhinorrhea, and dry cough over the last few days. He otherwise denies chest ___, shortness of breath, dysuria, or new rash. He states that he has not had any loose bowel movements recently which he relates to his poor PO intake. He presented to the ED, In the ED, initial vitals: 10 98.6 75 ___ 97% RA. Labs notable for H/H 13.2/37.8, plt 128, LFT's PENDING, lactate 1.4, UA negative, FluA/B PCR negative. C. dif PENDING. He was made NPO and received IV morphine, IV dilaudid, 2L NS, benzonatate, guaifenesin-dextromethorphan, ondansetron. Vitals prior to transfer: 0 98.6 62 104/56 16 98% RA. He was admitted for ___ control and follow-up of c. dif. Currently, patient feels anxious and agitated about his ___ medications. He states that if his requests for IV dilaudid, including early doses are not met, he "will just get up and start punching through walls." On further ROS, he does endorse significan rectal ___ on R. This feels different than prior fissures, feels he does have an active fissure on L at around 9 o'clock. Has been wiping more due to diarrhea. Has not noticed any drainage. ROS: Please refer to HPI for pertinent positives and negatives. 10 point ROS is otherwise negative. Past Medical History: Crohn's Disease: - dx ___ - ileocolonic disease c/b perianal abscesses and fistulas - s/p subtotal colectomy with ileorectal anastomosis ___ resection of remaining distal colon/rectum (___) - partial SBO requiring ex-lap (___), ex-lap w/ LOA (___) - medical management: failed azathioprine (ARF), ___ (allergy), infliximab (muscle spasm, rash), Cimzia (certolizumab) (non-efficacious), Tysabri (natalizumab) and is now steroid dependent (prednisone 10 is lowest) # Vitamin B12 deficiency: IM replacement # Depression # Degenerative Disc Disease (Disc protrusion): MRI lower spine (___) showed spinal stenosis; ___ is felt over lower left back and radiates down lateral left leg to knee with occasional numbness. # Nephrolithiais: Last renal ultrasound ___: non-obstructing nephrolithiasis in the right upper pole # Atypical chest ___ with neg stress ___ # Cataracts: ___ longstanding steroid use # latent TB treated with INH in ___ # L orchiectomy ___ Social History: ___ Family History: older sister w/ ___ and collitis/ostomy. Sister w/ diabetes. Paternal grandmother w/ lung cancer. Maternal grandmother died of diabetes. Mother died of ovarian cancer. Father died of throat cancer. Physical Exam: ADMISSION PHYSICAL EXAM ================================= Vitals: 98 142/89 20 98% RA General: AAOx3, appeared comfortable from the door, began writhing on bed when I entered the room HEENT: NCAT, EOMI, PERRL. Sclera anicteric, conjunctiva pink. MMM. Neck: supple, no LAD, no JVP elevation Lungs: CTAB, no w/r/r CV: RRR, normal S1 and S2, no m/g/r Abdomen: Soft, TTP diffusely, most in RLQ. Patient does have rebound when asked if pressing or pulling away hurts more, but objectively appears more uncomfortable with palpation and when distracted by talking he tolerates hard bump into bed without ___. Bowel sounds are hyperactive, abd tympanic. No palpable masses or HSM appreciated. Negative ___. No fluid wave or shifting dullness. Rectal: Multiple skin tags. Tenderness and ? fissure at 9 o'clock, unable to tolerate close inspection of skin. Perirectal area at ___ o'clock markedly tender, tenderness extends 5 cm outward from anal verge, no visible fistula, sinus tract not palpated, but this area reliably more tender than surrounding tissue. Mild erythema throughout perirectal area, no ulcerations. Limited internal exam with ___ digit without obvious fistula, mass, internal hemorrhoid, though exam very limited by ___. GU: no foley Ext: WWP. 2+ peripheral pulses. No edema. Neuro: CNs II-XII intact. MAEE. Grossly normal strength and sensation. PSYCH: Labile, mood "anxious and angry," affect congruent DISCHARGE PHYSICAL EXAM ======================================== Vitals: 98.1 100/56 18 96% RA General: AAOx3, lying in bed, eating a breakfast sandwich HEENT: NCAT, EOMI. Sclera anicteric. MMM. Neck: supple, no LAD, no JVP elevation Lungs: CTAB, no w/r/r CV: RRR, normal S1 and S2, no m/g/r Abdomen: Soft, TTP diffusely, most in LLQ. No rebound or guarding. Bowel sounds are normoactive. No palpable masses or HSM appreciated. No fluid wave or shifting dullness. GU: no foley Ext: WWP. 2+ peripheral pulses. No edema. Neuro: Grossly normal strength and sensation. A&O x 3. PSYCH: Labile, mood "anxious," affect congruent Pertinent Results: ADMISSION LABS ========================== ___ 10:25AM BLOOD WBC-5.7 RBC-4.33* Hgb-13.2* Hct-37.8* MCV-87 MCH-30.4 MCHC-34.9 RDW-14.7 Plt ___ ___ 10:25AM BLOOD Neuts-78.8* Lymphs-9.6* Monos-8.9 Eos-2.5 Baso-0.4 ___ 10:25AM BLOOD Glucose-81 UreaN-16 Creat-1.2 Na-140 K-3.4 Cl-107 HCO3-21* AnGap-15 ___ 10:25AM BLOOD ALT-21 AST-24 AlkPhos-66 TotBili-0.4 ___ 10:25AM BLOOD Lipase-27 ___ 10:25AM BLOOD Albumin-4.0 ___ 10:37AM BLOOD Lactate-1.4 ___ 11:05AM URINE Color-Yellow Appear-Clear Sp ___ ___ 11:05AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 11:05AM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 DISCHARGE/PERTINENT LABS ========================== ___ 05:27AM BLOOD WBC-4.5 RBC-4.16* Hgb-12.5* Hct-36.6* MCV-88 MCH-30.1 MCHC-34.2 RDW-14.3 Plt ___ ___ 05:18AM BLOOD Glucose-98 UreaN-13 Creat-1.1 Na-139 K-3.5 Cl-107 HCO3-21* AnGap-15 ___ 05:14AM BLOOD ALT-21 AST-26 AlkPhos-66 TotBili-0.5 ___ 05:18AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.2 ___ 05:14AM BLOOD CRP-19.5* ___ 05:14AM BLOOD HIV Ab-NEGATIVE ___ 05:14AM BLOOD HCV Ab-NEGATIVE MICRO ========================= __________________________________________________________ Time Taken Not Noted Log-In Date/Time: ___ 11:19 am STOOL CONSISTENCY: WATERY Source: Stool. FINAL REPORT ___ FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI 0157:H7 FOUND. __________________________________________________________ ___ 5:00 pm Immunology (CMV) FINAL REPORT ___ CMV Viral Load (Final ___: CMV DNA not detected. Performed by Cobas Ampliprep / Cobas Taqman CMV Test. Linear range of quantification: 137 IU/mL - 9,100,000 IU/mL. Limit of detection 91 IU/mL. This test has been verified for use in the ___ patient population. __________________________________________________________ ___ 10:23 am BLOOD CULTURE *FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. IMAGING ======================== MRE IMPRESSION: 1. Status post total colectomy, without evidence of active Crohn disease, definite enteroenteric fistula, or intra-abdominal abscess. 2. No perianal fistula identified. GI REPORTS ======================= ___ Flexible Sigmoidoscopy Findings: Other Ileo-rectal anastomosis was encounted consistent with history of subtotal colectomy. Mild patchy erythema was noted in the neoterminal ileum. Two aphthous ulcers were seen at the ileo-rectal anastomosis. Small erosion in anal canal. Cold forceps biopsies were performed for histology at the rectum. Cold forceps biopsies were performed for histology at the Neo-terminal ileum. Impression: Ileo-rectal anastomosis was encounted consistent with history of subtotal colectomy. Mild patchy erythema was noted in the neoterminal ileum. Two aphthous ulcers were seen at the ileo-rectal anastomosis. Small erosion in anal canal. (biopsy, biopsy) Otherwise normal sigmoidoscopy to splenic flexure CARDIOLOGY ========================================== Cardiovascular Report ECG Study Date of ___ 8:55:30 AM Artifact is present. Sinus rhythm. Probably normal ECG. Compared to the previous tracing of ___ there is probably no significant change. Intervals Axes Rate PR QRS QT/QTc P QRS T 79 160 90 ___ 49 ___ 42 Brief Hospital Course: Mr. ___ is a ___ man with a history of Crohn's disease, recent c. dif colitis, and chronic abdominal/back ___ ___ on chronic narcotics who presented with abdominal and rectal ___ due to suspected viral gastroenteritis. # Abdominal/Rectal ___ and Dirrhea: He has a history of Crohn's, however his acute ___ was most likely due to gastroenteritis in the setting of multiple bowel resections. He had viral URI symptoms ___ days prior to the onset of his diarrhea. Rectal ___ most likely due to erosions from frequent diarrhea. See below for negative work up of crohn's as possible etiology. C. diff PCR was negative. He was initially treated with bowel rest and IV dilaudid. There were several confrontations between Mr. ___ and the nursing staff and medical team regarding his narcotic regimen. He said that not getting additional breakthrough IV dilaudid made him want to "punch through the wall" and at one point he reported it made him feel like "killing" one of his physicians, however he immediately recanted when it was made clear that threatening behavior would not be tolerated. After 2 days, he was transitioned to an oral narcotic regimen of oxycodone with an equivalent daily dose (30 mg PO oxycodone daily, spaced out to 5 mg q4h instead of 10 mg PO q8h to minimize breakthrough periods). Plan to follow up with PCP and the ___ clinic as previously scheduled. # Crohn's Disease: After a thorough evaluation, it was concluded that his crohn's disease was not active and unlikely to be the source of his ___. He underwent an MRE which did not reveal fistulas or abscesses, CRP was 19.5 (felt to be most likely related to viral illness), ESR was WNL, and flex sig (2 small apthous ulcers and a mild erosion, not felt to be consistent with active disease). He was followed by the GI service, who advised decreasing prednisone to 20 mg daily and follow-up as an outpatient. Of note, he is followed at ___ by Dr. ___, who has not seen him in clinic in ___ years. # Thrombocytopenia: Has been intermittently low in past but persistently thrombocytopenic over past 3 months. Prior coags, including last admission, were within normal limits. Hep A/B/C negative on prior testing. Given normal synthetic function, liver failure less likely etiology. HIV/HCV negative. # GERD: Continued famotidine. # Pulmonary Nodule: Last admission, CT scan showed incidental "3 mm left lower lobe pulmonary nodule. Given smoking history, he was felt to need a repeat CT in ___ for follow-up. This was discussed with Mr. ___, and he was given a copy of the report. He states that he has known about these nodules for years and that they have not changed. # B12 deficiency: Continue outpatient IM repletion # CODE STATUS: Full # CONTACT: ___ (aunt) ___ TRANSITIONAL ISSUES - Patient will hit two weeks of >/= 20 mg prednisone daily prior to his next appointment, so he was started on atovaquone for PCP ___. Please consider discontinuing as prednisone dose is tapered. - Follow-up with ___ Clinic as scheduled - Follow-up pending stool cultures - Follow-up pending CMV viral load - Follow-up mucosal biopsy (to be discussed at next GI appointment) - Needs repeat CT chest in ___ for monitoring of lung nodule - Consider Hep A/B immunization as outpatient (non-immune) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Azathioprine 100 mg PO DAILY 2. Famotidine 20 mg PO BID 3. PredniSONE 30 mg PO DAILY 4. Acetaminophen 650 mg PO Q8H:PRN ___ 5. Cyclobenzaprine 10 mg PO TID:PRN muscular back ___ 6. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN ___ 7. Calcium Carbonate Dose is Unknown PO DAILY Discharge Medications: 1. Vitamin D 1000 UNIT PO DAILY RX ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Calcium Carbonate 1000 mg PO DAILY RX calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 2 tablet(s) by mouth daily Disp #60 Tablet Refills:0 3. Acetaminophen 650 mg PO Q8H:PRN ___ 4. Azathioprine 100 mg PO DAILY 5. Cyclobenzaprine 10 mg PO TID:PRN muscular back ___ 6. Famotidine 20 mg PO BID 7. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN ___ 8. PredniSONE 20 mg PO DAILY RX prednisone 20 mg 1 tablet(s) by mouth daily Disp #15 Tablet Refills:0 9. Atovaquone Suspension 1500 mg PO DAILY RX atovaquone 750 mg/5 mL 10 mL by mouth daily Refills:0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ------------------- Chronic abdominal ___ SECONDARY DIAGNOSIS -------------------- Crohn's 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 caring for you during your admission to ___ ___. As you know, you came in because of abdominal ___. You had a flexible sigmoidoscopy and an MRE that did not show active Crohn's, a fistula, or an abscess. You will follow-up with Dr. ___ on ___ for ongoing management of your Crohn's disease. You and Dr. ___ discussed a slow taper strategy, so we are starting you on a medicine called Atovaquone to prevent a specific type of pneumonia ("PCP ___ that can happen to patients on prednisone. You should be able to stop Atovaquone when your prednisone dose goes below 20 mg daily, but please talk about this with Dr. ___. During your last admission, a lung nodule was seen on your CT scan. Because of your smoking history, we need to follow this to make sure it is not cancer. You need a repeat CT chest in ___ to monitor your lung nodule. Please follow-up with your PCP and the ___ Clinic as scheduled. We wish you the best of luck, Sincerely, Your Medical Team Followup Instructions: ___
10312715-DS-76	10,312,715	24,038,327	DS	76	2183-11-11 00:00:00	2183-11-14 12:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Mercaptopurine / Ketorolac / Ibuprofen / Flagyl / Reglan / Gabapentin / Sulfasalazine Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of Crohn's disease s/p total colectomy with ileorectal anastomosis and multiple flares in the past, recurrent C. difficile infeciton, and depression who presents with diffuse abdominal pain, worse in the LLQ. Of note, the patient was recently admitted to ___ ___ for multiple, watery, non-bloody diarrhea and exacerbation of his chronic LLQ abdominal pain. KUB negative for toxic megacolon, abdominal exam benign. Patient tested positive for C. Diff. Started on PO Vancomycin for 14 days ___, end date ___. He has been admitted monthly since ___, which have been attributed to Crohn's flares and C. difficile colitis. Since then, patient reports feeling well until this ___ when he developed increased watery consistency of his stools. On ___, began having pain sharp, knife-like in the epigastrum just below the sternum and left lower area just above the inguinal region. This pain he attributes to adhesions, given that he has this pain before. Pain is steady and non-radiating. He also describes a crampy intermittent abdominal, similar to previous Crohn's flares, which is accompanied with ___ episodes of watery diarrhea. Has had NBNB emesis x 2, unrelated to meals. Last meal was 2 days ago. In the ED, initial vitals 97.7 80 111/70 16 94%RA. Labs were significant for WBC 6.3, Cr 0.8, Bicarb 20, Cl 110, lactate 1.4. CT abd/pelvis was negative for obstruction or inflammation. Ileocecal anastomosis was unremarkable. He was given 1L IVF, zofran, and IV dilaudid 1 mg x2. Vitals prior to transfer 97.3 73 120/84 18 100% RA. He is now admitted to Medicine for further management of abdominal pain and potential Crohn's flare. Currently, patient is severe discomfort, laying in awkward positions, as tolerable. Otherwise able to recount history and is a good historian. Denies fever, chills, nausea, vomiting. Denies CP, palpiations, fever, dysuria, jaundice, rashes, vision changes. Past Medical History: Crohn's Disease: - dx ___ - ileocolonic disease c/b perianal abscesses and fistulas - s/p subtotal colectomy with ileorectal anastomosis ___ resection of remaining distal colon/rectum (___) - partial SBO requiring ex-lap (___), ex-lap w/ LOA (___) - medical management: failed azathioprine (ARF), ___ (allergy), infliximab (muscle spasm, rash), Cimzia (certolizumab) (non-efficacious), Tysabri (natalizumab) and is now steroid dependent (prednisone 10 is lowest) # Vitamin B12 deficiency: IM replacement # Depression # Degenerative Disc Disease (Disc protrusion): MRI lower spine (___) showed spinal stenosis; pain is felt over lower left back and radiates down lateral left leg to knee with occasional numbness. # Nephrolithiais: Last renal ultrasound ___: non-obstructing nephrolithiasis in the right upper pole # Atypical chest pain with neg stress ___ # Cataracts: ___ longstanding steroid use # latent TB treated with INH in ___ # L orchiectomy ___ # CLOSTRIDIUM DIFFICILE ENTEROCOLITIS: Three episodes in past year Social History: ___ Family History: older sister w/ ___ and collitis/ostomy. Sister w/ diabetes. Paternal grandmother w/ lung cancer. Maternal grandmother died of diabetes. Mother died of ovarian cancer. Father died of throat cancer. Physical Exam: ON ADMISSION ============ VS: 97.8 124/72 66 20 100% RA GEN: Alert, lying in bed, severe distress HEENT: Tacky MM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD PULM: Generally CTA b/l without wheeze or rhonchi COR: RRR (+)S1/S2 no m/r/g ABD: Soft, +TTP epigastrum and LLQ, +BS, no rebound tenderness, voluntary guarding, no rigidity RECTAL: miltiple skin tags, no significant edema/erythema or purulent drainage, no palpable masses, no fissures noted EXTREM: Warm, well-perfused, no edema NEURO: CN II-XII grossly intact, motor function grossly normal SKIN: multiple scattered violaceous-red papules, many with hemorrhagic crust and exoriations on the face, arms, and legs ON DISCHARGE ============ VS: 97.8 124/72 66 20 100% RA GEN: Alert, lying in bed, severe distress HEENT: Tacky MM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD PULM: Generally CTA b/l without wheeze or rhonchi COR: RRR (+)S1/S2 no m/r/g ABD: Soft, +TTP epigastrum and LLQ, +BS, no rebound tenderness, voluntary guarding, no rigidity RECTAL: miltiple skin tags, no significant edema/erythema or purulent drainage, no palpable masses, no fissures noted EXTREM: Warm, well-perfused, no edema NEURO: CN II-XII grossly intact, motor function grossly normal SKIN: multiple scattered violaceous-red papules, many with hemorrhagic crust and exoriations on the face, arms, and legs Pertinent Results: LABS ==== ___ 04:20AM BLOOD WBC-6.3 RBC-4.45* Hgb-13.4* Hct-40.3 MCV-91 MCH-30.1 MCHC-33.3 RDW-13.7 RDWSD-45.7 Plt ___ ___ 04:20AM BLOOD Neuts-72.5* Lymphs-12.5* Monos-9.2 Eos-4.6 Baso-0.6 Im ___ AbsNeut-4.56 AbsLymp-0.79* AbsMono-0.58 AbsEos-0.29 AbsBaso-0.04 ___ 04:20AM BLOOD Glucose-86 UreaN-25* Creat-0.8 Na-139 K-3.7 Cl-110* HCO3-20* AnGap-13 ___ 04:42AM BLOOD Lactate-1.7 ___ 04:20AM BLOOD ALT-20 AST-23 AlkPhos-72 TotBili-0.2 CRP: 1.4 IMAGING ======= ___ CT A/P W/ CON: No acute abnormality identified including no evidence of bowel obstruction, free intraperitoneal air, or adjacent inflammatory changes. Patient is post total colectomy with an unremarkable ileorectal anastomosis. MICRO ===== ___: C. difficile negative ___: Blood cultures pending Brief Hospital Course: ___ M with Crohn's disease s/p total colectomy with ileorectal anastomosis, and previous LOA, admitted multiple times over 6 months for chronic LLQ pain and increased frequency of watery BM attributed to Crohn's flares and surgical adhesions, who p/w abdominal pain and increased BMs. # Abdominal pain: Patient is s/p total colectomy with multiple episodes of Crohn's flare and 3 episodes of C. diff recently. :abs were reassuring (LFTs and lipase normal, Cr normal) and Abdominal/Pelvic CT scan was conducted and negative for acute intraabdominal process. The GI team saw the patient and thought that Crohn's flare was unlikely given normal CRP, lack of leukocytosis, normal lactate. The patient was admitted to Medicine for further pain management. He was placed on PO hydromorphone 2mg Q6H PRN and Tylenol ___ Q6H PRN. He felt that his symptoms were being inadequately controlled left AGAINST MEDICAL ADVICE. The patient was educated regarding the risks of leaving the hospital AMA, including infection, worsening abdominal pain, and even death. # Crohn's disease: GI was consulted and felt that Crohn's flare was unlikely given negative CT and normal CRP. We continued his home azathioprine. . #elevated triglycerides-returned after pt left AMA. **THE PATIENT LEFT AGAINST MEDICAL ADVICE on ___ at 8PM** Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Azathioprine 50 mg PO DAILY 2. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia 3. famotidine 20 mg oral BID 4. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain 5. Vitamin D 50,000 UNIT PO EVERY 4 WEEKS (___) 6. LOPERamide 8 mg PO BID:PRN diarrhea Discharge Medications: 1. Azathioprine 50 mg PO DAILY 2. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia 3. famotidine 20 mg oral BID 4. LOPERamide 8 mg PO BID:PRN diarrhea 5. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain 6. Vitamin D 50,000 UNIT PO EVERY 4 WEEKS (___) Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS SECONDARY DIAGNOSIS Crohn's Disease Adhesions 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 abdominal pain. Your labs were reassuring and you had a CT scan that was without evidence of anything dangerous in your abdomen. Because you reported ongoing pain, you were admitted to Medicine. The GI doctors saw ___ and were reassured that there unlikely to be a Crohn's flare. They also think that infection is less likely, and we sent stool tests for this. We treated your pain with oral hydromorphone and Tylenol. You are now leaving AGAINST MEDICAL ADVICE. We talked to you about different means to address your symptoms but you decided to leave. You were told the risks of leaving the hospital including worsening abdominal pain, infection, and even death. Followup Instructions: ___
10312772-DS-18	10,312,772	22,110,933	DS	18	2115-11-04 00:00:00	2115-11-04 16:19:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Melena Major Surgical or Invasive Procedure: EGD ___ History of Present Illness: ___ without significant PMH presenting with melena and lightheadedness. Patient initially presented to ___, with reports of melena on ___, with associated weakness and lightheadedness. Patient describes large black loose stool on the morning of ___. He took Pepto-Bismol with some relief. Since that time, he noted dyspnea on exertion and associated lightheadedness. On the day of presentation, he had an episode of presyncope with associated diaphoresis, without chest pain or palpitations. He endorses an upper respiratory illness one week prior to presentation which has since fully resolved. He has no known history of ulcer disease. He endorses drinking ___ beers per night ___ times per week, ___ cups of coffee per day, does not believe he has a history of liver disease. He has no history of alcohol withdrawal symptoms, has gone weeks without drinking in the past. He also takes 2 Aleve every morning for years. He denies abdominal pain, nausea, fevers, chills, chest pain, lower extremity edema. In the ___: Vital signs 98.5, 116, 129/82, 100% on room air Rectal exam at ___ was notable for melena. Hemoglobin there was 7.6. ALT 22, AST 20, Alk phos 39, Tbili 0.4 He received 2 units of packed red blood cells, IV PPI, and reportedly had an episode of coffee-ground emesis prior to transfer. Patient was transferred from ___ to ___ as there was no gastroenterologist on call at that time. In the ___ ED: Vital signs 98.5, 109, 118/80 Exam notable for benign abdomen Labs notable for WBC 15.5, hemoglobin 9.1, platelets 232, BUN 36, creatinine 0.7, INR 1.2, PTT 21.8 Chest x-ray unremarkable Case was reviewed with GI consult service, recommended IV fluids, IV PPI, maintain n.p.o. with plan for EGD, admit to floor unless change in clinical status On arrival to the floor, patient endorses mild nausea without abdominal pain. He states that he feels significantly better compared to original presentation. Denies lightheadedness, chest pain. He does endorse feeling warm since episode of melena. ROS: 10 point review of system reviewed and negative except as otherwise described in HPI Past Medical History: Chronic bilateral knee pain Social History: ___ Family History: Sister with lupus Physical Exam: EXAM ON ADMISSION - UNCHANGED AT DISCHARGE VS: 98.6 PO 147 / 90 99 18 98 RA Orthostatic VS Lying 129/86, 96; Standing 127/83, 117 GEN: alert and interactive, comfortable, no acute distress HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without lesion or exudate, moist mucus membranes LYMPH: no anterior/posterior cervical, supraclavicular adenopathy CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, or gallops LUNGS: clear to auscultation bilaterally without rhonchi, wheezes, or crackles GI: soft, nontender, without rebounding or guarding, nondistended with normal active bowel sounds, no hepatomegaly, negative fluid wave, no bulging flanks EXTREMITIES: no clubbing, cyanosis, or edema GU: no foley SKIN: no rashes, petechia, lesions, or echymoses; warm to palpation NEURO: Strength grossly intact, alert and oriented PSYCH: normal mood and affect Pertinent Results: LABS ON ADMISSION ___ 08:15PM BLOOD WBC-15.5* RBC-3.17* Hgb-9.1* Hct-28.0* MCV-88 MCH-28.7 MCHC-32.5 RDW-15.2 RDWSD-48.5* Plt ___ ___ 08:15PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+* Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Burr-1+* ___ 10:59PM BLOOD ___ PTT-21.8* ___ ___ 08:15PM BLOOD Glucose-110* UreaN-36* Creat-0.7 Na-142 K-4.4 Cl-109* HCO3-23 AnGap-10 LABS ON DISCHARGE ___ 12:50PM BLOOD WBC-10.6* RBC-2.82* Hgb-8.3* Hct-25.1* MCV-89 MCH-29.4 MCHC-33.1 RDW-16.3* RDWSD-50.7* Plt ___ ___ 09:05AM BLOOD ___ PTT-24.3* ___ ___ 09:05AM BLOOD Glucose-106* UreaN-28* Creat-0.8 Na-143 K-4.2 Cl-106 HCO3-25 AnGap-12 ___ 09:05AM BLOOD ALT-18 AST-15 AlkPhos-42 TotBili-0.2 ___ 09:05AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.0 EGD REPORT Impression: Small hiatal hernia. Esophagitis in the lower third of the esophagus and gastroesophageal junction compatible with reflux esophagitis and ulcerations. Erythema in the pre-pyloric region and antrum. Ulcer in the antrum (biopsy). Recommendations: - Antireflux regimen: Avoid chocolate, fatty foods, peppermint, caffeine, onions, garlic, beer, alcohol and soft drinks with gas. Elevate the head of the bed at least 3 inches. Go to bed with an empty stomach. - Exclude H Pylori - PPI BID - Followup with a GI doctor; recommend EGD in 2 months, to exclude ___ as well and confirm healing of noted lesions Brief Hospital Course: ___ without significant PMH presenting with melena and acute blood loss anemia. He was transfused two units at ___ and then transferred to ___ for further care. Here he remained stable and did not require further transfusion. He was treated with IV PPI, and taken for EGD which showed findings as outlined above, ulcerative esophagitis and gastritis, likely source of his bleeding. After procedure he successfully advanced diet, ambulated about the unit, and had negative orthostatic blood pressures. He was discharged with an followup plan including GI and PCP at ___ nearby his home. # Melena # Presyncope # Orthostatic hypotension # Acute blood loss anemia # Upper GI bleed # GERD # Ulcerative esophagitis # Gastritis with antral ulcer - Avoid alcohol, NSAIDs - Adhere to anti-reflux regimen: Avoid chocolate, fatty foods, peppermint, caffeine, onions, garlic, beer, alcohol and soft drinks with gas. Elevate the head of the bed at least 3 inches. Go to bed with an empty stomach. - Follow up pending laboratory/microbiology tests to exclude H pylori - PPI BID until GI followup and repeat endoscopy, then can taper - Carafate QID for 2 weeks - Followup with a GI doctor; recommend EGD in 2 months, to exclude ___ as well and confirm healing of noted lesions. Scheduled at discharge. # Alcohol abuse: Pt acknowledges drinking as many as 40 beers per week. No history of EtOH withdrawal symptoms, does not drink daily. He had no withdrawal symptoms here. He was counseled on alcohol avoidance. Advance Care Planning/Code status: FULL - presumed Contact: ___, wife, ___ For billing purposes, >30 minutes spent coordinating discharge home Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain 2. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet(s) by mouth twice daily Disp #60 Tablet Refills:3 3. Sucralfate 1 gm PO QID Duration: 2 Weeks RX sucralfate 1 gram 1 tablet(s) by mouth four times daily Disp #56 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: ___ Acute blood loss anemia GERD Esophagitis with ulceration Gastritis with ulceration Alcohol abuse Discharge Condition: Ambulating without difficulty, tolerating a regular diet. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ with dark/tarry stools (___), lightheadedness, sensation you were going to pass out (presyncope). You were found to be quite anemic. You were given a blood transfusion, and you were brought to ___ in ___ for further evaluation. You were treated with potent acid reducing medications. You underwent upper endoscopy which showed irritation and ulceration of the esophagus and the stomach. This most likely developed due to esophageal reflux disease (GERD), alcohol use, and NSAID medication use. You should (1) quit drinking and avoid alcohol entirely for the next several months at least (2) avoid all NSAID type medications (Alieve, Motrin, Advil, naproxen, ibuprofen, diclofenac, etc). You need to follow up closely with a primary care doctor and also a GI doctor. You should have a repeat endoscopy to make sure your stomach and esophagus are healing with treatment. Followup Instructions: ___
10312901-DS-6	10,312,901	22,961,879	DS	6	2122-12-28 00:00:00	2122-12-29 19:28:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old female with no significant past medical history presents with abdominal/flank pain. Started with suprapubic pain and dysuria on ___. She was evaluated on ___ and diagnosed with a UTI and started on Macrobid (2 doses). She presented to the ED with fevers, nausea/vomiting and persistent abdominal pain and new flank pain. Denies diarrhea, vaginal bleeding or discharge. In the ED, initial VS were T98.3 HR 109 BP 142/95 RR15 SpO2 100% RA Labs showed WBC 12.1, creatinine 0.8. U/A with no bacteria, 48 WBCs, mod leuks, 5 epis. uHCG negative. CT abd/pelvis showed no acute abdominal or pelvic abnormality identified. No perinephric fluid collection or radiographic evidence to explain patient's symptomatology. She was given Zofran x3, morphine 5mg x4, 4L NS, started on cipro and CTX and admitted for with a presumptive diagnosis of pyelonephritis. Transfer VS were 98.2 135/77 80 18 99% RA Decision was made to admit to medicine for further management. On arrival to the floor, patient reports continued severe R side abdominal pain radiating to her flank. She is sexually active. Last period was ___ weeks ago. No vaginal bleeding/discharge. No dysuria, fevers/chills. Unable to tolerate po without severe nausea. Reports a bowel movement this morning. REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. All other 10-system review negative in detail. Past Medical History: chlamydia, treated with azithromycin in ___ Social History: ___ Family History: noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: VS - 98.0 80 123/65 20 100% RA GENERAL: appears very uncomfortable, writhing in pain, AOx3 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, diffusely tender most pronounced over RUQ and RLQ. no rebound; mild voluntaryguarding, no hepatosplenomegaly, + R CVAT EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM VS - 97.6, 112/48 69 16 100% RA GENERAL: appears very uncomfortable, writhing in pain, AOx3 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, diffusely tender most pronounced over RUQ and RLQ. no rebound; no guarding, no hepatosplenomegaly, + R CVAT, neg Rovsing's EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: LABS ============= ___ 04:50AM BLOOD WBC-12.1* RBC-4.40 Hgb-11.7 Hct-35.8 MCV-81* MCH-26.6 MCHC-32.7 RDW-14.2 RDWSD-41.4 Plt ___ ___ 04:55PM BLOOD WBC-9.8 RBC-4.17 Hgb-11.1* Hct-34.5 MCV-83 MCH-26.6 MCHC-32.2 RDW-14.3 RDWSD-42.6 Plt ___ ___ 07:00AM BLOOD WBC-7.4 RBC-3.75* Hgb-9.9* Hct-31.2* MCV-83 MCH-26.4 MCHC-31.7* RDW-14.2 RDWSD-43.4 Plt ___ ___ 04:50AM BLOOD Neuts-70.8 ___ Monos-7.0 Eos-0.7* Baso-0.4 Im ___ AbsNeut-8.55* AbsLymp-2.52 AbsMono-0.85* AbsEos-0.08 AbsBaso-0.05 ___ 04:50AM BLOOD Glucose-113* UreaN-11 Creat-0.8 Na-139 K-4.0 Cl-105 HCO3-22 AnGap-16 ___ 04:55PM BLOOD Glucose-87 UreaN-5* Creat-0.8 Na-137 K-4.1 Cl-101 HCO3-24 AnGap-16 ___ 07:00AM BLOOD Glucose-82 UreaN-5* Creat-0.8 Na-138 K-4.0 Cl-106 HCO3-25 AnGap-11 ___ 04:55PM BLOOD ALT-11 AST-18 LD(LDH)-152 AlkPhos-74 TotBili-0.3 ___ 04:55PM BLOOD Calcium-9.4 Phos-3.6 Mg-1.9 ___ 06:20AM URINE RBC-8* WBC-48* Bacteri-FEW Yeast-NONE Epi-5 TransE-1 ___ 01:40PM URINE RBC-6* WBC-13* Bacteri-NONE Yeast-NONE Epi-5 ___ 06:20AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD ___ 06:20AM URINE Color-Yellow Appear-Clear Sp ___ ___ 01:40PM URINE Color-Straw Appear-Clear Sp ___ ___ 06:20AM URINE Mucous-RARE ___ 06:20AM URINE UCG-NEG MICRO ============= Time Taken Not Noted Log-In Date/Time: ___ 12:48 pm URINE TAKEN SPECIMEN ___ @ 1247. *FINAL REPORT ___ URINE CULTURE (Final ___: <10,000 organisms/ml. ___ 9:10 am URINE Site: CLEAN CATCH Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Pending): IMAGING ============== ___ CT Abdomen/Pelvis FINDINGS: Chest: The bases of the lungs are clear. Visualized heart and pericardium are unremarkable. Abdomen: The liver appears homogeneous in attenuation with no focal lesion identified. There is no intrahepatic biliary duct dilation. The portal veins are patent. The gallbladder is without radiopaque cholelithiasis. The pancreas is homogeneous in attenuation without a focal lesion or pancreatic duct dilation. The spleen is normal in size and attenuation. Bilateral adrenal glands are normal. The kidneys present symmetric nephrograms and excretion of contrast. No focal lesion is identified. There is no hydronephrosis. No perinephric fluid collection or stranding is identified. Opacified ureters are without a filling defect. The stomach, duodenum, and loops of small bowel are grossly normal in appearance. No evidence of obstruction. The appendix is not well visualized though no inflammatory changes are identified to suggest acute appendicitis. The colon is unremarkable. There is no abdominal free fluid or air. The aorta is normal in caliber without aneurysmal dilatation. There is no retroperitoneal or mesenteric adenopathy. Pelvis: The bladder is well distended and grossly unremarkable. There is no adnexal mass. There is no pelvic free fluid, inguinal, or pelvic sidewall adenopathy. Osseous structures: No suspicious lytic or blastic lesions are identified. IMPRESSION: No acute abdominal or pelvic abnormality identified. Specifically no perinephric fluid collection or intra-abdominal or intrapelvic abscess. Brief Hospital Course: Ms. ___ is a healthy ___ woman with a history of chlamydia in ___ who presented with abdominal/flank pain, nausea, and vomiting, concerning for pyelonephritis. # Early Pyelonephritis: Patient was admitted given concern for pyelonephritis and started on IVF, zofran, morphine, and IV ciprofloxacin 400mg q12h. A CT scan did not show perinephric stranding or other evidence of pyelonephritis. Appendicitis was considered given the clinical history of periumbilical pain migrating to RLQ, however, Rovsing's sign was negative and patient was afebrile without CT findings of appendicitis. LFTs were WNL, urine hCG negative, and patient did not have cervical motion tenderness or vaginal discharge to suggest PID. Ruptured ovarian cyst was considered, though significant pelvic free fluid was not seen. Patient improved rapidly on ciprofloxacin and an early pyelonephritis (in spite of negative imaging) vs. severe cystitis was ultimately considered most likely. Pain controlled, afebrile, leukocytosis downtrending and tolerating diet on discharge to continue ciprofloxacin for 7 day course with PCP ___. # Miscellaneous: continued on home OCP Transitional: - cont ciprofloxacin 500mg po q12 for total of 7 days (last day ___ - establish care with PCP at ___ - f/u CT (low suspicion given lack of vaginal discharge/symptoms and grossly normal pelvic exam without CMT) : THIS RETURNED NEGATIVE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ___ Fe (norethindrone-e.estradiol-iron) 1 mg-20 mcg (21)/75 mg (7) oral DAILY Discharge Medications: 1. ___ Fe (norethindrone-e.estradiol-iron) 1 mg-20 mcg (21)/75 mg (7) oral DAILY 2. Acetaminophen 1000 mg PO Q8H RX acetaminophen [Acetaminophen Pain Relief] 500 mg 2 tablet(s) by mouth three times daily as needed Disp #40 Tablet Refills:0 3. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice daily Disp #10 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID:PRN constipation RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily as needed Disp #10 Capsule Refills:0 5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN breakthrough pain hold for sedation, resp rate<10 RX oxycodone 5 mg 1 capsule(s) by mouth every 6 hours Disp #15 Capsule Refills:0 6. Senna 8.6 mg PO BID:PRN constipation RX sennosides [senna] 8.6 mg 1 capsule by mouth twice daily as needed Disp #10 Capsule Refills:0 7. Simethicone 40-80 mg PO QID:PRN cramping RX simethicone [Bicarsim] 80 mg 1 tablet by mouth four times daily as needed Disp #10 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Abdominal pain Discharge Condition: Stable, improved AOx3 Ambulates Discharge Instructions: Ms. ___, You were seen and evaluated at ___ for your abdominal pain. You were given antinausea medication (Zofran), IV pain control, 4 liters of normal saline and started on antibiotics for a presumptive diagnosis of kidney infect (pyelonephritis). You had an elevated white blood cell count (12) that improved with fluids and antibiotics. A CT scan did no show any acute abnormalities to explain your pain. Your urine culture was negative and your other labs were all very reassuring. You were observed overnight and continued on ciprofloxacin for presumed gastroenteritis. You symptomatically improved with normal labs and normal exam and will be discharged to finish a course of antibiotics. It was a pleasure taking care of you during your stay at ___- we wish you all the best in your recovery! -Your ___ Team Followup Instructions: ___
10312961-DS-16	10,312,961	29,940,806	DS	16	2115-03-11 00:00:00	2115-03-11 17:12:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Toe infection Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M w/ hx of peripheral vascular disease (s/p bilateral ___ ray amputations) insulin-dependent DM (well-controlled), MI s/p CABG (___), HTN and TIA presenting with diabetic foot infection (non-healing right ___ toe ulcer). The ulcer has been present for the past 4 months, but was initially clean, painless and asymptomatic. Over the past two weeks, it has become increasingly symptomatic. It was debrided by his podiatrist in ___ 2 weeks ago. Four days prior to discharge he was again seen by his podiatrist in ___ who prescribed bactrim due to concern for superficial infection (painful, red, serosanguinous drainage). He was again seen in ___ on the day of presentation (___) for podiatric follow-up; reportedly, his podiatrist felt a surgical intervention might be warranted and referred him to ___. Throughout this time he denies systemic symptoms (no F/C, anorexia/N/V) and complains primarily of pain with ambulating. In the ED initial vitals were: 98.7 92 169/95 18 97% - Labs were significant for WBC 12.4, u/a normal, chemistries with Cr 1.5 (b/l 0.9), lactate 4.0 -> 1.3 on recheck. Plain film of foot showed no evidence of acute osteo. Podiatry was consulted recommended no acute surgical intervention admit for ___. - Patient was given vanc, cefazolin, and bactrim. Past Medical History: PMH: DM x ___ years, PVD, HTN, MI s/p CABG ___, HLD, CAS s/p stroke (___), diabetic retinopathy, PAD PSH: RLE angio (___), R ___ met resection (___), hernia repair Social History: ___ Family History: Diabetes mellitus Physical Exam: ADMISSION, ___: V:98.7 92 169/95 18 97% ___: ___: dopplerable, protective sensation diminished. muscle strength ___. active and passive ROM intact. POP to ___ digit R foot. Skin well coapted from prior surgery. R foot ___ digit dorsal lesion with minimal erythema. no streaking, tracking, fluctuance malodor, or drainage. Stable. DISCHARGE, ___: VS - 98.3; BP 164/73; HR 88; 97% on RA Gen - pleasant middle-aged gentleman in NAD; at times appears on the verge of tears when discussing recent setbacks in his health (i.e. ulcers which limit walking) HEENT - MMM no OP lesions Cor - RRR no MRG; well-healed sternotomy scars Pulm - Clear througout Abd - obese, soft, NT/ND, NABS Extrem - no edema RLE - Brawny discoloration (mild) ___ pulses non-palpable (dopplerable) ___ digit: 5mm superficial dorsal ulcer w/ dried blood/crust. 1cm ulceration in the interspace between the ___ and ___ digit; medially granular base with red eschar. No purulence or expressable drainage. Pertinent Results: LABS of NOTE ======================== 132 98 12 ------------< 217 (___) 4.9 21 0.9 136 98 13 ------------< 144 (___) 5.0 24 1.5 10.7 > 14.___ / 43.0 < 214 (___) 12.4 > 15.7 / 46.1 < 289 (___) Diff: 63%N; 24%L CRP: 35 (___) ESR: PENDING Lactate: 1.3 ___, 11pm s/p 1L IVF) <- 4.0 ___, 7pm) UA: trace blood, nitrite neg, <1 RBCs BLOOD CULTURES ======================== ___: NGTD ___: NGTD STUDIES OF NOTE ======================== 2+ View Right Toe X-Ray (___): - Soft tissue swelling about the ___ digit - No obvious fracture or dislocation - Slight buckling along the dorsal surface of the middle phalanx is indeterminate for fracture - No definite bone destruction, however there is slight indistinctness of cortex along the alteral aspect of the distal phalanx (which is new compared with ___. The possibility of early erosion in this location cannot be excluded. Otherwise, no erosion is identified. Foot AP/Lat/Oblique Right (___): - Vascular calcifications present - S/p amputation of the ___ ray beyond the level of the mid ___ metatarsal - No evidence for fracture or bony lysis - Soft tissues diffusely thickened, particularly the hindfoot - No findings suggestive of active osteomyelitis Brief Hospital Course: ___ yo M w/ hx of peripheral vascular disease (s/p bilateral ___ ray amputations) insulin-dependent DM (well-controlled), MI s/p CABG (___), HTN and TIA presenting with diabetic foot infection (non-healing right ___ toe ulcer). #DIABETIC FOOT ULCER: - Evaluated by podiatry; no acute surgical intervention warranted. - Initial plain films (Foot AP/Lat) without findings suggestive of active osteo; however, on exam it was unclear whether the dorsal ulcer probed to bone, raising concern for chronic osteo. Dedicated ___ right toe film was equivocal for early erosion. Elevated CRP (35) non-specific for deep soft tissue infection. - Discharged on amox-clavulanate 875 BID to complete 7-day course (last dose ___ - Will have close follow-up with podiatry at which point further surgical management (ray amputation) will be considered - Tramadol as needed for pain control #Hx PAD: - Revascularization of RLE attempted previously but unfortunately unsuccessful - Continues on anti-platelet and high-dose statin #DM: - Excellent control; continue current regimen TRANSITIONAL ISSUES: - Continue augmentin 875 BID for one week until next seen by podiatry - At podiatry follow-up (___), will be evaluated for further surgical intervention Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atorvastatin 80 mg PO DAILY 2. BusPIRone 10 mg PO BID 3. Carvedilol 12.5 mg PO BID 4. detemir 10 Units Breakfast detemir 20 Units Bedtime Insulin SC Sliding Scale using novolog Insulin 5. Lisinopril 20 mg PO DAILY 6. Aspirin 325 mg PO DAILY 7. Sulfameth/Trimethoprim DS 1 TAB PO BID Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. BusPIRone 10 mg PO BID 4. Carvedilol 12.5 mg PO BID 5. detemir 10 Units Breakfast detemir 20 Units Bedtime Insulin SC Sliding Scale using novolog Insulin 6. Amoxicillin-Clavulanate Susp. 875 mg PO BID Continue taking until you see your podiatrist on ___. 7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain Take every 6 hours as needed for pain. 8. Lisinopril 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: ACUTE: Diabetic foot infection CHRONIC: Peripheral arterial disease Insulin dependent diabetes mellitus Discharge Condition: Appropriate mental status Independent Discharge Instructions: Dear Mr. ___, You were admitted to the hospital due to an infection on your toe. The podiatrists evaluated you here in the hospital and thought that there was no need for urgent surgery on your toe. However, they want to see you again in one week to re-evaluate whether or not you may need surgery on that toe in the future. We were initially concerned about your kidney function but on repeat bloodwork your kidney function was normal. It seems like the problem with your kidney function that was seen on your first set of labs was probably a side effect from the antibiotic you had been taking in the 4 days before coming to the hospital. You will be discharged on a different antibiotic called amoxicillin-clavulanic acid (also called Augmentin). Take this medication twice a day every day for the next week. Continue taking the medication until you see the podiatrist again. We made an appointment for you to see Dr. ___ on ___, ___ at 9:50am. Please continue to apply betadine and dry gauze to the wound on your foot, at least once daily. We expect that some of your pain should improve with treatment of the infection. In the meantime, take tramadol 50mg every 6 hours as needed for pain. Please take this medication instead of ibuprofen/Advil/motrin (medications which can hurt your kidney function). It was a pleasure taking care of you and we wish you all the best. Sincerely, Your ___ Team Followup Instructions: ___
10312961-DS-17	10,312,961	24,500,567	DS	17	2115-04-24 00:00:00	2115-04-24 15:40:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PODIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right fourth digit infection Major Surgical or Invasive Procedure: ___: R ___ digit amputation ___: R ___ digit amputation site debridement and closure History of Present Illness: ___ PMHx IDDM, CAD s/p CABG, PVD, chronic R ___ toe ulcer p/w worsening pain and drainage to R ___ digit. Pt states he has had the ulcer for over 5 months. He has known PVD without any vascular intervention to his right leg. Dr. ___ him recently and had him continue his oral abx with a tentatively planned amputation ___ the early new year. Pt states that a few days ago, his pain increased and his toe bled more. He is still changing his bandage daily. Pt denies N/V/f/SOB/CP but admits to a decrease ___ appetite. Past Medical History: PMH: DM x ___ years, PVD, HTN, MI s/p CABG ___, HLD, CAS s/p stroke (___), diabetic retinopathy, PAD PSH: RLE angio (___), R ___ met resection (___), hernia repair Social History: ___ Family History: Diabetes mellitus Physical Exam: Admission PE: 10 98.8 94 187/107 16 98% ra ___: ___: dopplerable, protective sensation diminished. Gangrenous distal ___ digit. Significant POP to ___ digit distal eschar. There is a small area at the dorsal lateral aspect of wound that has purulent drainage. Interdigitally there was also some purulence over the eschar but not an open area from which is was coming from. No appreciable fluctuance or significant erythema. Foot was more warm than leg. Discharge PE: VSS Gen: NAD RLE focused exam: sutures intact to prior amputation site, no acute signs of infection. ___ dopplerable. No protective sensation to the R forefoot. Muscularly intact. Pertinent Results: Admission labs: ___ 01:25PM URINE HOURS-RANDOM ___ 01:25PM URINE HOURS-RANDOM ___ 01:25PM URINE GR HOLD-HOLD ___ 01:25PM URINE GR HOLD-HOLD ___ 01:25PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 01:25PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 01:25PM URINE RBC-<1 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 ___ 01:25PM URINE HYALINE-1* ___ 12:59PM LACTATE-2.3* ___ 12:50PM GLUCOSE-162* UREA N-12 CREAT-0.8 SODIUM-130* POTASSIUM-5.5* CHLORIDE-91* TOTAL CO2-25 ANION GAP-20 ___ 12:50PM estGFR-Using this ___ 12:50PM WBC-14.8* RBC-5.37 HGB-16.3 HCT-46.6 MCV-87 MCH-30.3 MCHC-34.9 RDW-13.0 ___ 12:50PM NEUTS-75.9* LYMPHS-13.0* MONOS-9.0 EOS-1.8 BASOS-0.3 ___ 12:50PM PLT COUNT-322 ___ 06:02AM BLOOD WBC-9.7 RBC-4.53* Hgb-13.5* Hct-38.4* MCV-85 MCH-29.8 MCHC-35.2* RDW-12.6 Plt ___ ___ 06:02AM BLOOD Plt ___ ___ 05:50AM BLOOD Glucose-85 UreaN-11 Creat-0.7 Na-136 K-4.3 Cl-100 HCO3-26 AnGap-14 ___ 06:02AM BLOOD CRP-38.1* Imaging: ___ R foot xrays FINDINGS: The patient is status post amputation of the fourth digit phalanges. There is a soft tissue defect ___ this region. The patient also has had a prior amputation of the midshaft of the fifth metatarsal. There is no acute fracture. Vascular calcifications are appreciated. ___ R foot MRI: Wet Read by ___ on ___ ___ 9:04 AM Findings compatible with distal fourth digit osteomyelitis ___ the right clinical setting. Diffuse edema throughout the soft tissues of the foot, without drainable abscess. ___: R foot xray: Wet Read by ___ on ___ ___ 4:24 ___ Lucency within the fourth proximal phalanx at the interphalangeal joint concerning for infectious process. No evidence of subcutaneous emphysema. Unchanged appearance of fifth metatarsal amputation site. No fracture or dislocation is seen. Micro: ___ 12:42 pm SWAB Source: R ___ digit ulcer. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Preliminary): GRAM NEGATIVE ROD(S). SPARSE GROWTH. STAPH AUREUS COAG +. MODERATE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Preliminary): RESULTS PENDING. Path: pending Brief Hospital Course: The patient presented to Emergency Room on ___. After thorough evaluation, it was deemed necessary to admit the patient to the podiatric surgery service. Broad spectrum IV antibiotics were given and a culture was taken. The vascular team was consulted due to concern for adequacy of blood flow for healing after the planned fourth digit amputation. Noninvasive arterial studies were ordered to be performed on ___. MRI ___ to rule out abscess due to pain being out of proportion to exam as well as the presence of edema and erythema to the midfoot. Patient was kept NPO with IVF at midnight for a right fourth digit amputation/foot debridement on ___. Pt was evaluated by anesthesia and taken to the operating room. There were no adverse events ___ the operating room; please see the operative note for details. Afterwards, pt was taken to the PACU ___ stable condition, then transferred to the ward for observation. Later that day, patient had noninvasive arterial studies performed to evaluated blood flow and healing potential of amputation site. The vascular team did not do any further vascular intervention. Post-operatively, the patient remained afebrile with stable vital signs; pain was well controlled with IV pain medication that was then transitioned into an entirely oral pain medication regimen on a PRN basis. The patient remained stable from both a cardiovascular and pulmonary standpoint. Urine output remained adequate throughout the hospitalization. The patient received subcutaneous heparin throughout admission; early and frequent ambulation were strongly encouraged while ___ the forefoot using ___ wedge shoe. The Infectious Disease service was consulted and managed the IV antibiotics and will have a planned 6 weeks. The patient was subsequently discharged to home on ___. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: ___: 1. Atorvastatin 80 mg PO DAILY 2. BusPIRone 10 mg PO BID 3. Carvedilol 12.5 mg PO BID 4. detemir 10 Units Breakfast detemir 20 Units Bedtime Insulin SC Sliding Scale using novolog Insulin 5. Lisinopril 20 mg PO DAILY 6. Aspirin 325 mg PO DAILY 7. Sulfameth/Trimethoprim DS 1 TAB PO BID Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. BusPIRone 10 mg PO BID 4. Carvedilol 25 mg PO DAILY 5. Fluoxetine 40 mg PO DAILY 6. Glargine 10 Units Breakfast Glargine 24 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Lisinopril 20 mg PO DAILY 8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth q4-6h Disp #30 Tablet Refills:0 9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 10. CefePIME 2 g IV Q12H RX cefepime [Maxipime] 2 gram 1 IV twice a day Disp #28 Vial Refills:2 11. MetRONIDAZOLE (FLagyl) 500 mg PO TID RX metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three times a day Disp #42 Tablet Refills:*2 Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Right fourth digit infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted ___ due to a right fourth digit infection. Over the weekend, you were started on IV antibiotics and your pain was controlled with narcotics. On ___, ___, you underwent a right fourth digit amputation that was left open due to the presence of purulence. On ___, ___, your open incision was closed. You will be sent home on pain medications and antibiotics. Please, see the discharge instructions below: Discharge Instructions: Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, severe increase ___ pain to operative site or pain unrelieved by your pain medication, nausea, vomiting, chills, foul smelling or colorful drainage from your incisions/wounds, redness or swelling around your incisions, or any other symptoms which are concerning to you. Diet: ___ regular diet Medication Instructions: Resume your home medications. You will be starting some new medications: 1. You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. 2. If you were prescribed antibiotics, it is critical for you to take them as prescribed and for the full course of the regimen. Activity: Please, remain nonweightbearing to your right forefoot ___ your special forefoot ___ wedge shoe. This is crucial to increase healing potential. Wound Care: You may shower but please keep dressings clean, dry, and intact. Do not submerge your foot/leg ___ water. Please call the doctor or page the ___ pager, if you have increased pain, swelling, redness, or drainage to the operative sites. Followup Instructions: ___
10313068-DS-16	10,313,068	28,722,585	DS	16	2140-12-31 00:00:00	2141-01-01 17:21:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Neurontin / naproxen Attending: ___. Chief Complaint: Subarachnoid hemorrhage s/p fall from wheelchair Major Surgical or Invasive Procedure: None History of Present Illness: ___ man with PMH of TBI, CVA, and right-carotid dissection presented with altered mental status s/p fall from wheelchair. Mr. ___ was in his usual state of health when he fell from his wheelchair on evening prior to day of admission, landed on his left side, and hit his head on the curb. According to bystanders, he did not lose consciousness. He was transported by ambulance to ___ and then transferred to ___ ___ due to suspicion of intraparenchymal bleed on CT. In the ___, initial vital signs were Tmax 102.4 102 129/80 14 97% RA. He was found to be awake, restless, with facial abrasions, left knee and hand abrasions. Patient was agitated, pulling at his cervical collar. Required frequent redirection. He was alert to self and place. He was sent to CT, found to have increased lethargy upon return. Pt grew increasingly disoriented throughout overnight observation in ___. Was oriented to self and place on arrival to ___, then self only, then completely disoriented within 7 hours of arrival to ___. Exam notable for A&Ox2 upon arrival, became A&Ox0 by time of admission to ___ 5. Labs were notable for WBC 15.7 (79% polys 12.4 absolute polys, 7% monos 1.1 absolute monos) at ___ evening prior to admission (20:04) and WBC 20.3 (79.4% polys 16.07 absolute polys, 8% monos 1.63 absolute monos) in ___ ___ evening prior to admission (23:20). Patient was given buspirone 30 mg PO BID, duloxetine 90 mg PO DAILY, furosemide 20 mg PO, omeprazole 40 mg PO BOD, baclofen ___ mcg/hr IT INFUSION, rosuvastatin calcium 40 mg PO QPM, acetaminophen 1000 mg PO ONCE, azithromycin 500 mg IV ONCE, ceftriaxone 1 g IV ONCE, levetiracetam 1000 mg IV ONCE. ASA discontinued. On Transfer Vitals were 98.5 76 119/72 16 98% RA. Upon arrival to the floor, Mr. ___ was found to be in no pain, reported no concerns. Established his basline with family: A&Ox3, able to ambulate with cane/walker but prefers wheelchair, can hold a conversation, may be easily distractible but usually holds attention, responds appropriately to questions. At time of interview, patient was oriented to self. He believed he was at the ___ building and did not know the year. Patient is an unreliable historian. He stated that he did not know why he was at ___ and did not remember falling or being in either ___. He denied headache, vision changes, hearing changes, fluid from ears, head pain, neck pain, shoulder pain, left arm pain, fever, chills, and rash. He reported that he had constipation for 3 days, dark stools, and chronic dry cough daily. Past Medical History: CVA - right ICA dissection w/ residual left hemiparesis (___) GERD Pneumonia Gastric ulcers HLD Depression Substance Abuse ADHD Social History: ___ Family History: Unable to be obtained. Physical Exam: ON ADMISSION: Vitals: 98.1 74 135/90 20 98% RA General: Pleasant, restless, easily distracted man sitting in bed in no acute distress. Able to be redirected, but difficult to hold attention. HEENT: Normocephalic, facial abrasion noted over left zygomatic - nontender to touch. Extraocular movements in tact, no nystagmus, pupils PERRLA. No oral ulcers, normal hearing bilaterally. Lymph: No cervical LAD, no thyromegaly. CV: Diminished heart sounds, unable to appreciate rubs, gallops, or murmurs. Lungs: Clear to auscultation bilaterally, no wheezes, crackles, or coarse breath sounds. Abdomen: Soft, tender, nondistended. Noted surgical scar in RLQ with hard mass underneath - felt like an implanted device. GU: Not performed Ext: Warm, well-perfused. Unable to appreciate lower extremity pulses but upper extremity pulses were ___ bilaterally. ___ contracted. Difficult to flex left leg or passively move left arm. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to self, ___", and ___. Believes ___ is president. Language: Speech fluent with good comprehension and repetition. Often inappropriate response to questions - Difference between an apple and orange is "push buttons". Naming intact. No dysarthria. Unable to say months or days of the week backwards. Unable to perform serial subtraction - "100, 93, 93, help on the veranda". Able to follow commands that involve movement across midline. Memory ___ at 5 minutes. Cranial Nerves: I: Not assessed II: Pupils equally round and reactive to light. Visual fields difficult to assess due to patient moving eyes during exam. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial sensation in tact bilaterally in all three trigeminal branches. Able to grimace, puff out cheeks, and clench eyes shut tightly. VIII: Hearing in tact. IX, X: Palatal elevation symmetrical. XI: Unable to shrug left shoulder. XII: Tongue midline without fasciculation. Motor: Normal bulk and tone on R extremities, strength ___ throughout. L extremities had decreased tone and contraction. Unable to dorsiflex L ankle or flex L knee, L hip flexors ___ and L hip extension ___. L hand grip ___, unable to flex/extend L wrist, unable to extend L elbow, unable to move L shoulder. Sensation: Intact to light touch throughout on right side. Left leg and left arm insensitive to deep palpation and pinching. Felt pain upon manipulating left arm at site of abrasion. Skin: Abrasions on left hand, wrist, and forearm. Ecchymosis on left shoulder. Palpable mass overlying left side of chest between ___ and 4th ribs, no pain to palpation, immobile. No rashes or other lesions. ON DISCHARGE: VS: 97.7 75 113/68 16 95% RA GEN: Pleasant, slightly distractible man sitting in bed in NAD. Easily redirected. HEENT: Normocephalic, facial abrasion noted over left zygomatic, nontender. Pupils PERRLA. EOMI. No oral ulcers, even palatal rise normal hearing to voice. LYMPH: No cervical LAD, no thyromegaly, no tenderness. CV: Normal S1, S2 with no M/R/G. Flat JVP, no peripheral edema. PULM: CTAB, no wheezes, crackles, or coarse breath sounds. GI: Soft, tender, nondistended. No hepatosplenomegaly, normoactive bowel sounds. EXT: Warm, well-perfused. Right radial pulse was ___, unable to check left radial pulse due to short cast. Unable to appreciate lower extremity pulses. Left extremities both contracted. NEURO: Mental status: Awake and alert, cooperative with exam, normal affect. Easier to hold attention and more talkative than previous days. Oriented to self, ___", and ___. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria. Able to say days of the week forward and backwards quickly. Improved serial subtraction - "___-81" quickly. Able to follow commands that involve movement across midline. Immediate recall of objects and abstract (honesty) ___, delayed recall ___ at 5 minutes, ___ with hints. Able to remember local sports teams, that ___ is the ___ (continued improvement). CN: I: Not assessed II: Pupils equally round and reactive to light. III, IV, VI: Extraocular movements in tact. V, VII: Facial sensation in tact. Able to show teeth, puff out cheeks, and clench eyes shut tightly on R side, moderate impairment on left side. VIII: Hearing in tact to voice. IX, X: Palatal elevation symmetrical. XI: Unable to shrug left shoulder. XII: Tongue midline without fasciculation. MOTOR: Normal bulk and tone on R extremities, strength ___ throughout. Left extremities are contracted. Unable to appreciate dorsiflexion of L ankle ___ knee flexion, L hip flexion ___ and L hip extension ___. L hand grip ___, unable to flex/extend L wrist, unable to extend L elbow, unable to move L shoulder. SENSATION: Intact to light touch throughout on right side. Unable to thoroughly assess L side due to possible confabulation. SKIN: Abrasions on left hand, wrist, and forearm, R wrist. Ecchymosis on left shoulder, left hand, right wrist. No rashes/lesions, no pressure sores/ulcers, no skin/hair abnormalities. Pertinent Results: ON ADMISSION: ___ 11:20PM BLOOD WBC-20.3* RBC-4.49* Hgb-13.1* Hct-40.2 MCV-90 MCH-29.2 MCHC-32.6 RDW-14.0 RDWSD-45.3 Plt ___ ___ 11:20PM BLOOD Neuts-79.4* Lymphs-10.2* Monos-8.0 Eos-1.3 Baso-0.6 Im ___ AbsNeut-16.07* AbsLymp-2.06 AbsMono-1.63* AbsEos-0.27 AbsBaso-0.12* ___ 11:20PM BLOOD ___ PTT-30.7 ___ ___ 11:20PM BLOOD Glucose-97 UreaN-11 Creat-0.9 Na-141 K-4.0 Cl-104 HCO3-22 AnGap-19 ON DISCHARGE: ___ 06:00AM BLOOD WBC-7.7 RBC-4.50* Hgb-13.1* Hct-41.1 MCV-91 MCH-29.1 MCHC-31.9* RDW-13.6 RDWSD-45.9 Plt ___ ___ 06:00AM BLOOD Glucose-107* UreaN-12 Creat-0.7 Na-142 K-4.1 Cl-107 HCO3-29 AnGap-10 ___ 06:00AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.3 RELEVANT LABS: ___ 06:36AM BLOOD ALT-25 AST-36 LD(LDH)-341* AlkPhos-68 TotBili-0.5 ___ 06:45AM BLOOD VitB12-583 Folate->20 ___ 06:45AM BLOOD TSH-0.77 ___ 06:45AM BLOOD HIV Ab-Negative ___ 11:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 10:20AM BLOOD Lactate-1.2 ___ 06:45AM BLOOD VITAMIN B1-WHOLE BLOOD-PND MICROBIOLOGY: ___ 04:30AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 04:30AM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ___ 06:20PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 06:20PM URINE RBC-0 WBC-3 Bacteri-NONE Yeast-NONE Epi-0 ___ Blood cultures NGTD x2 Urine culture negative RPR negative OTHER STUDIES: ___ CT HEAD W/O CONTRAST: 1. Subarachnoid hemorrhage overlying the bilateral frontal lobes and left temporal lobe. No recent priors are available in our system to compare for interval change. 2. Encephalomalacia of the right frontal and parietal lobes consistent with old infarct. ___ CT C-SPINE W/O CONTRAST: No evidence of fracture or traumatic malalignment. ___ GLENO-HUMERAL SHOULDER: A deformity of the humeral head and neck may be chronic, however a fracture cannot be excluded. If there is continued clinical suspicion for fracture a dedicated CT or MR is recommended for further evaluation. ___ CT HEAD W/O CONTRAST: 1. Study is severely degraded by motion. There is a 6 mm focus of hemorrhage overlying the left frontal lobe, left sylvian fissure, and trace ventricular hemorrhages are grossly similar to prior. Otherwise, comparison and evaluation of previously seen hemorrhage is virtually impossible due to patient motion. 2. Repeat imaging is recommended. ___ CHEST (PORTABLE AP): No focal consolidation concerning for pneumonia. ___ CT HEAD W/O CONTRAST: 1. Interval improvement of subarachnoid hemorrhage involving with no evidence of new hemorrhage. 2. Development of mild edema surrounding the left frontal hematoma, likely a hemorrhagic contusion. 3. Encephalomalacia of the right frontal and parietal lobes consistent with old infarct. ___ WRIST(3 + VIEWS) LEFT: Mildly displaced fracture of the fifth metacarpal base. Brief Hospital Course: ___ man with history of left sided hemiparesis s/p CVA from R ICA rupture, ADHD, hyperlipidemia and depression who initially presented to ___ with altered mental status s/p fall from wheelchair, transferred to ___ due to suspicion of intraparenchymal bleed on CT. CT head here showed subarachnoid hemorrhage overlying bilateral frontal lobes and L temporal lobe. He spiked temperatures and had leukocytosis, but this was thought to be stress response as he had no clinical signs of infection. Neurosurgery evaluated him and determined no acute surgical intervention was needed. He was started on keppra; neuro exam was monitored every 4 hours and labetalol was used to maintain SBP <140. Neurology was consulted and performed EEG, which was negative for seizure activity. Repeat head imaging showed improvement in bleed. His mental status gradually improved during admission. #Urinary ___ hospital course was complicated by acute urinary retention, thought to be secondary to outflow obstruction (BPH although no diagnosis) vs. effect of SAH. He was started on tamsulosin but continued to require intermittent catheterization. He should have follow-up with urology as an outpatient. Please intermittently straight cath patient as needed. Tamsulosin can be discontinued if patient voiding freely. #Left metacarpal fracture - diagnosed on xray he was seen by orthopedics and placed in short arm splint. He is to have f/u with orthopedics in ~2 weeks #Chronic Spasms- Baclofen pump in place. Pain services were consulted and recommended continued use of pump. Patient will have pump refilled as documented below in transitional issues. CHRONIC ISSUES: #L shoulder deformity: Patient had no complaints of shoulder pain but does have pain with abduction past 60 degrees. Likely chronic condition from repeated falls at home. #Previous CVA: Continued on home Baclofen Pump. ASA was initially held given SAH but resumed later in hospital course #Gastric Ulcers: Continued on home omeprazole 40 mg PO DAILY #Chronic cough: Continued on home Tiotropium 1 INH DAILY #HLD: Continued on home Rosuvastatin 40 mg PO QHS #GERD: Continues on Omeprazole 40 mg PO DAILY #Depression: Continue on home Bupropion 150 mg PO BID, Duloxetine 90 mg PO DAILY, and Buspirone 30 mg PO BID #ADHD: Continued on home Amphetamine-Dextroamphetamine 15 mg PO BID TRANSITIONAL ISSUES: - Patient to complete 7 day course of keppra, last day ___. Please give one dose tonight (___) - Other new medications: Tamsulosin (can be discontinued if urinary retention resolves), folic acid, thiamine - Patient's baclofen pump was interrogated on ___: Pump Model 8637-40 40ml Baclofen 1000mcg/ml Dose per day is 849mcg/day Reservoir Volume 17.5ml Low Reservoir Alarm Volume 4ml Refill Interval is 15 days Low Reservoir Alarm Date ___ THUS AS ABOVE THE PUMP NEEDS TO BE REFILLED ON ___. - Please maintain SBP <160. ___ use labetalol 100mg. - Please monitor neuro exam BID. Low threshold for head CT if changes in neuro exam - Please bladder scan q6h for urinary retention and straight cath with urojet prn - Patient had left wrist fracture from the fall and was placed in short arm splint. He is to have f/u with orthopedics in ~2 weeks - Patient with chronic changes on left shoulder however could rule out acute fracture, if patient has worsening pain consider CT scan/further imaging - Code status: Full - Emergency Contact: ___ (___). ___ (___). ___ (___) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Rosuvastatin Calcium 40 mg PO QPM 2. DULoxetine 90 mg PO DAILY 3. Furosemide 20 mg PO EVERY OTHER DAY 4. Omeprazole 40 mg PO DAILY 5. Guaifenesin 5 mL PO Q4H:PRN cough 6. Tiotropium Bromide 1 CAP IH DAILY 7. Multivitamins 1 TAB PO DAILY 8. Cyanocobalamin 100 mcg PO DAILY 9. Cetirizine 10 mg PO DAILY 10. calcium citrate (calcium citrate-vitamin D2) 750 mg oral DAILY 11. Vitamin D ___ UNIT PO DAILY 12. teriparatide 20 mcg/dose - 600 mcg/2.4 mL subcutaneous QAM 13. Aspirin 325 mg PO DAILY 14. BuPROPion 150 mg PO BID 15. Baclofen 35 mcg/hr IT INFUSION 16. BusPIRone 30 mg PO BID 17. Amphetamine-Dextroamphetamine 15 mg PO BID Discharge Medications: 1. Amphetamine-Dextroamphetamine 15 mg PO BID 2. Aspirin 325 mg PO DAILY 3. Vitamin D ___ UNIT PO DAILY 4. Tiotropium Bromide 1 CAP IH DAILY 5. Omeprazole 40 mg PO DAILY 6. Rosuvastatin Calcium 40 mg PO QPM 7. Guaifenesin 5 mL PO Q4H:PRN cough 8. Multivitamins 1 TAB PO DAILY 9. DULoxetine 90 mg PO DAILY 10. BuPROPion 150 mg PO BID 11. Cyanocobalamin 100 mcg PO DAILY 12. BusPIRone 30 mg PO BID 13. calcium citrate (calcium citrate-vitamin D2) 750 mg oral DAILY 14. teriparatide 20 mcg/dose - 600 mcg/2.4 mL subcutaneous QAM 15. Acetaminophen 650 mg PO Q6H:PRN pain 16. FoLIC Acid 1 mg PO DAILY 17. Thiamine 100 mg PO DAILY 18. Tamsulosin 0.4 mg PO QHS 19. LevETIRAcetam 500 mg PO BID Duration: 4 Days Last day ___ Please administer one dose tonight ___ at 8pm 20. Furosemide 20 mg PO EVERY OTHER DAY 21. Baclofen 35 mcg/hr IT INFUSION 22. Heparin 5000 UNIT SC BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: Subarachnoid hemorrhage Acute urinary retention Left wrist fracture SECONDARY: Prior cerebrovascular accident Attention deficit/hyperactivity disorder Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___. You were admitted because you fell and suffered a head bleed (subarachnoid hemorrhage). You had some confusion after the fall. Fortunately, imaging of your brain showed that the bleed is stable. Your confusion gradually improved during your hospital course. You have a wrist splint because you fractured your left wrist during the fall. You also required intermittent catheterizations as you were retaining urine. These issues will continue to be monitored at your rehab facility, where you will be going to increase your strength and mobility. Please continue to take your medications as prescribed. Your rehab facility will help schedule your follow-up with your PCP. Your follow-up appointments with urology, orthopedics, and neurology have been scheduled for you, see below. We wish you the best, Your ___ Care Team Followup Instructions: ___
10313172-DS-18	10,313,172	27,410,597	DS	18	2171-10-28 00:00:00	2171-10-29 07:28:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain with nausea/vomiting Major Surgical or Invasive Procedure: ___ 1. Exploratory laparotomy. 2. Extensive lysis of adhesions. 3. Freeing of adhesive band causing small bowel obstruction. 4. Enteroenterostomy to bypass area of stricture secondary to fibrosis. History of Present Illness: History obtained from patient with assistance from pt's nephew. Mr. ___ is a ___ man, ___ only, with history significant for stage IIIB (pT3, pN3a, cM0) gastric cancer s/p total gastrectomy (___), on ___ cycle chemotherapy, who presents with abdominal pain a/w nausea and vomiting. ___ General Surgery was consulted out of concern for bowel obstruction. He was in his usual state of health until yesterday morning when he felt nauseated after returning from chemotherapy. He would normally feel occasionally nauseated on chemo but he was concerned that he vomited "a few times" all day, with saliva-appearing emesis. That night, he developed a constant abdominal pain located in the substernal region of his gastrectomy scar. The pain did not radiate. His last bowel movement was at 10am this morning, with well formed stools. Denies passing flatus today (last passed flatus was yesterday). His appetite is unchanged; last meal at noon today. Of note, he recalls having a similar abdominal pain in ___, which resolved after 15 days with pain medications only. He presented to ___ this afternoon for persisting abdominal pain. At ___, he was given pain medication, CT scan of abdomen and pelvis was obtained, and NG tube was placed. It is unclear how much secretions came out of the NG tube. He was told he had "obstruction" and was referred to present to ___ ED for possible surgical evaluation. Past Medical History: PMH (per OMR): 1) Gastric cancer 2) Hepatitis B carrier - ___ HBsAg positive, ___ HBeAg negative, ___ HBV DNA detected, less than 20 IU/mL 3) chronic low back pain 4) latent TB s/p treatment 5) hypertension 6) allergic rhinitis 7) DJD ONCOLOGIC HISTORY (Per OMR): ___: EGD with a single 24 mm ulcer in the fundus at the cardia, biopsy with moderately differentiated adenocarcinoma. ___: CT torso with: enhancing AP window lymph node measuring 1 x 1.5 cm, 2 mm RUL nodule. No abdominal findings suggestive of metastatic disease. ___: Total gastrectomy and extended lymphadenectomy by Dr. ___ of J tube. Pathology with 2.5 cm adenocarcinoma at fundus, grade 2, pT3. 11 of 50 lymph nodes positive (pN3a). Margins negative. Lymphatic and perineural invasion present. ___: repeat CT chest with decrease in size of AP window lymph node now 0.8 x 1.2 cm, not suggestive of metastatic disease. ___: C1D1 epirubicin (50 mg/m2), oxaliplatin (130 mg/m2), capecitabine (1000 mg bid x14 days) ___: chemoradiation with capecitabine 1000 mg bid ___: C2D1 adjuvant oxaliplatin (130 mg/m2), capecitabine (1000 mg bid x 14 days) PSH: Roux-en-y gastrectomy for gastric adeno in ___ Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T98.0 HR 91 BP 142/94 RR 16 Sats 99% RA Gen: Comfortable, in NAD HEENT: sclerae anicteric, mucus membranes moist, no lymphadenopathy. NG tube draining 250cc blood tinged clear secretions CV: RRR, nl S1 and S2, no M/R/G. 2.5cm well-healed scar on right upper chest, with subdermally imbedded port. Pulm: Non-labored breathing. Clear anteriorly. No wheeze/rales/rhonchi. Abdomen: 12cm vertical midline scar running from substernal to umbilicus, well-healed. Hypoactive bowel sounds. Mildly tympanitic on auscultation. Mildly distended. TTP on substernal area only. No rebound tenderness or rigidity. Extremities: Cool, but well perfused, ___ pulses 2+, no edema. DISCHARGE PHYSICAL EXAM: AFVSS Gen: AAO, NAD ___: RRR, S1S2, no M/R/G Pulm: CTABL, no wheezes, rhonchi or rales Incisions: C/D/I, no drainage, slight erythema at inferior aspect, steristrips in place Abd: +BS, nontender, nondistended Ext: No edema, palpable pulses Pertinent Results: ADMISSION LABS: ___ 11:30PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 11:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 11:30PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 11:20PM LACTATE-3.5* ___ 08:45PM GLUCOSE-184* UREA N-11 CREAT-0.9 SODIUM-135 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-20* ANION GAP-19 ___ 08:45PM WBC-9.9# RBC-4.11* HGB-12.3* HCT-38.6* MCV-94 MCH-29.8 MCHC-31.8 RDW-15.2 ___ 08:45PM NEUTS-88.5* LYMPHS-4.4* MONOS-6.0 EOS-0.8 BASOS-0.4 IMAGING STUDIES: CT ABD & PELVIS WITH CONTRAST ___ IMPRESSION: 1. Findings consistent with closed loop obstruction of small bowel with a transition point in the midline abdomen near the level of the aortic bifurcation likely due to an adhesion or mesenteric defect. Proximal small bowel is obstructed at the transition, and a long abnormal segment of bowel grouped in the right lower pelvis exits very close to the same place. Mild-moderate amount of mesenteric fluid and hyperemia and bowel wall thickening of small bowel loops clustered in the right lower quadrant suggesting a closed loop obstruction are concerning for congestion or even ischemia of the mesentery or associated small bowel. 2. Hypoattenuation of the left hepatic lobe is likely secondary to oncology treatment. 3. Left upper pole 1.2 x 1.3 x 1.3 cm hyperdense renal cyst, previously characterized as a hemorrhagic cyst. DISCHARGE LABS: ___ 08:02AM BLOOD WBC-5.0 RBC-3.11* Hgb-9.5* Hct-29.4* MCV-95 MCH-30.6 MCHC-32.4 RDW-14.4 Plt Ct-88* ___ 07:15AM BLOOD Glucose-124* UreaN-7 Creat-0.7 Na-134 K-3.9 Cl-101 HCO3-28 AnGap-9 Brief Hospital Course: The patient was admitted to the General Surgical Service on ___ for concern of a closed loop bowel obstruction. Given his CT scan findings and his tenderness on exam, he was taken urgently to the OR for an exploratory laparotomy, lysis of adhesions and enteroenterostomy. The procedure went well without complication (Please see full Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor for further care. Neuro: The patient received a dilaudid PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. The wound was evaluated daily. He remained afebrile. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; 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 post-gastrectomy diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 5 mg PO DAILY 2. Lorazepam 1 mg PO Q4H:PRN nausea/vomiting 3. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 5. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 6. Ranitidine 300 mg PO HS 7. Capecitabine 500 mg PO 2 TABLETS BID Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Lorazepam 1 mg PO Q4H:PRN nausea/vomiting 3. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth Q 4 hours Disp #50 Tablet Refills:0 5. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 6. Ranitidine 300 mg PO HS 7. Pantoprazole 40 mg PO Q24H RX pantoprazole 40 mg 1 tablet,delayed release (___) by mouth daily Disp #30 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. History of gastric cancer. 2. Closed loop bowel obstruction. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: 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, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon as advised. 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. You have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. Please call your doctor or nurse practitioner if you experience 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 is 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. Followup Instructions: ___
10313447-DS-21	10,313,447	23,980,316	DS	21	2163-01-31 00:00:00	2163-02-01 14:57:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Penicillins / Macrolide Antibiotics / clindamycin / antiemetic Attending: ___. Chief Complaint: ovarian mass ovarian torsion Major Surgical or Invasive Procedure: right salpingo-oophorectomy via mini-laparotomy History of Present Illness: This is a ___ yo G3P___ with several days of intermittent, colicky RLQ pain. Reports that ___ night she awoke from sleep with well localized RLQ pain, and was able to go back to sleep and go into work. Same thing happened ___ night. ___ morning she awoke from sleep with pain again, was able to drink some tea, do some yoga, and eventually had significant enough resolution to go to work. She has a one episode of diarrhea and a BM that day with worsening of her pain, and noted that it continued to come and go. She was seen at the ___ in ___ where blood tests, urine tests, and a KUB were reassuring, and she was called with these results. ___ mornign the pain came again, but resolved enough for her to go out to dinner ___ night. This morning the pain awoke her from sleep at 3am and did not abate. She felt it ___, intense pain, radiating from her RLQ down her anterior leg. During these pain episodes, she felt she could not sit still, and would instead move all around. Today she has had nausea and ___ episodes of vomitting. She has been NPO since 3am. She has never had any similar episodes prior. In the ED she has required 3 doses of morphine 4mg IV. Past Medical History: GynHx: LMP ___ or ___. No hx of abn Pap or STI. No hx of ovarian cyst. ObHx: - LTCS x3 via Phannensteil, all term, first for NRFHT. Kids ages ___, ___, ___ now. PMH: - autoimmune hepatitis ___, normalization of LFTs per pt - depression PSH: LTCS x3 only Social History: ___ Family History: denies t/e/d Physical Exam: on day of discharge: afebrile, VSS NAD, comfortable RRR, CTAB abd soft, appropriately tender, ND mini-laparotomy intact, no erythema or drainage no edema Pertinent Results: ___ 05:09PM BLOOD WBC-8.8 RBC-3.96* Hgb-12.2 Hct-35.0* MCV-88 MCH-30.9 MCHC-34.9 RDW-12.4 Plt ___ ___ 07:45AM BLOOD WBC-6.8 RBC-4.34 Hgb-13.6 Hct-38.4 MCV-88 MCH-31.3 MCHC-35.4* RDW-12.3 Plt ___ ___ 07:45AM BLOOD Glucose-119* UreaN-13 Creat-0.8 Na-136 K-4.2 Cl-103 HCO3-26 AnGap-11 ___ 07:45AM BLOOD ALT-23 AST-25 AlkPhos-72 TotBili-0.2 Brief Hospital Course: Ms. ___ was taken from the ED to the OR for an exploratory lapartotomy via small Phannensteil incision, evacuation of hemoperitoneum, right salpingoopherectomy of torsed complex right ovary and tube. Please see operative report for full details. From the recovery room, she was transported to ___ ___, where her recovery was uncomplicated. She was discharged home on POD#1 in good condition, ambulating, voiding, tolerating a full diet and with pain well controlled on po pain medications. She will follow up at the ___. Medications on Admission: - unknown antidepression, likely SSRI, 10mg qd - lorazepam prn sleep - MVI, Vitamins C, D, calcium, fish oil, probiotic Discharge Medications: 1. Percocet ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp:30 Tablet(s) Refills:0 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every ___ hours as needed for pain. Disp:30 Tablet(s) Refills:2 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:60 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: ovarian torsion, adnexal mass (pathology pending) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___
10313534-DS-2	10,313,534	27,887,078	DS	2	2150-06-23 00:00:00	2150-06-24 12:19:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Allergy Information Available Attending: ___. Chief Complaint: confusion Major Surgical or Invasive Procedure: none History of Present Illness: Mrs. ___ is a ___ year old female with history of sick sinus syndrome s/p pacemaker, afib not on coumadin, HTN, dementia, presenting with c/o syncope vs AMS. Patient reports yesterday morning she was getting into a cab with her friend to go to ophthalmologist and had episode of 'confusion'. Reports few minutes of loss of awareness, denies passing out or losing conscioussness, says she did not lose vision, fall over, or hit her head. Her friend tried to talk to her but she was apparently unresponsive. Had some associated weakness/dizziness before getting in CAB. Epidose only lasted a few minutes. Patient reports being taken back to her house by her daughter afterwards at which time she had some palpitations and took her metoprolol. She then lay down in bed for the day and felt better within an hour or so. Denies any chest pain or dyspnea. No reported tongue biting, shaking movements, no urinary or bowel incontienence. No headache, no visual changes, numbness/tingling/weakness, no fevers/chills. She reported this episode to her cardiologist today who recommended she go to ___ ED for observation and evaluation of pacemaker. In the ED, initial VS: 97.0 84 145/78 20 100% RA. Labs were notable for unremarkable cbc and ___, u/a with tr protein, normal lactate and CXR. Patient had pacemaker interrogated in ED which revealed no malignant arrythmias. Patient was admitted to medicine for AMS workup. On the floor patient currently feels at baseline, has no complaints. Review of Systems: (+) as above (-) 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: sick sinus syndrome s/p dual chamber pacemaker (___) Parkinsons's disease Afib was on coumadin recently discontinued Postural hypotension - on fludricortisone Syncope Sinus node dysfunction Mitral valve prolapse Hypercholesterolemia Osteoporosis Hypothyroidism Anxiety Low back pain Metacarpal fracture Remote nephritis C section Tonsillectomy Cataract surger Social History: ___ Family History: Mother and sister had arrythmias. Mother died at age ___ of a stroke. Father was a ___ in ___. Sister lives in ___ and also has an arrhythmia. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals- 191/73 hr 66 rr 20 99% RA General- Alert, oriented x3, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, ___, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- ___ intact, strength ___ in UE and ___ b/l, no pronator drift, finger to nose intact DISCHARGE PHYSICAL EXAM: Vitals- 97.6 167/69 (___) 60 20 98%RA General- Alert, NAD HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, ___, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- oriented to name, month and hospital, attentive to ___ and ___ backward, no asterixis or pronator drift, hypoactive lower extremity reflexes bilaterally, strength intact ___ of major muscle groups. Cranial nerves ___ examined and no abnormalities Pertinent Results: Admission Labs: ___ 01:20PM BLOOD ___ ___ Plt ___ ___ 01:20PM BLOOD ___ ___ ___ 01:20PM BLOOD ___ ___ ___ 01:20PM BLOOD ___ ___ ___ 08:00PM BLOOD ___ ___ 02:00AM BLOOD ___ cTropnT-<0.01 ___ 01:20PM BLOOD ___ ___ 01:20PM BLOOD ___ ___ 01:20PM BLOOD ___ Urine: ___ 05:00PM URINE ___ Sp ___ ___ 05:00PM URINE ___ ___ ___ 05:00PM URINE ___ CXR ___: No acute cardiopulmonary abnormality. CT Head noncontrast ___: No acute intracranial process. Brief Hospital Course: BRIEF CLINICAL SUMMARY: ___ year old female hx sick sinus syndrome s/p pacemaker, afib not on coumadin, ___ with postural hypotension on fludricortisone, presenting with a brief period of altered mental status that had resolved well before her presentation. Per her daughter, this has happened in the past and resolved. Primarily reported to hospital for pacemaker interrogation as she had felt palpitations around time. Pacemaker interrogation unremarkable. Episode likely related to brief period of delirium or encephalopathy related to orthostatic hypotension, related to underlying ___ Disease. Patient discharged home and recommended to ___ with PCP. ACTIVE ISSUES: # AMS: Patient with brief period of unawareness and abnormal behavior yesterday. Happened for brief period of time (minutes) and returned to b/l, per patient, family and witnesses. Does not seem consistent with syncope. ___ have been orthostatic as she does have a history of this, but was sitting down when it happened. Arrythmia unlikely as pacemaker normal on interrogation and nothing on telemetry, which was the primary concern of referring physician. ___ have been brief acute encephalopathy in setting of underlying ___. History not consistent with seizure. Although patient does have hx of atrial fibrillation and off of warfarin, does not seem consistent with stroke. Cardiac enzymes have returned negative. TSH normal. # Postural hypotension: Orthostatic signs were positive while here, but she was off of her fludrocortisone yesterday and has this as a known problem. Restarted fludrocortisone. INACTIVE ISSUES: # Afib: coumadin was recently discontinued, presumably from falls. Not on a nodal blocking agent, pacemaker in place. Continued full dose aspirin # HLD: continued simvastatin # Depression: continued citalopram # ___: continued sinemet TRANSITIONAL ISSUES: - F/u w/ PCP - ___ patient and daughter that if she has another episode and doesn't clear promptly that she should seek medical care. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Simvastatin 10 mg PO DAILY 2. Citalopram 10 mg PO DAILY 3. Aspirin 325 mg PO DAILY 4. estradiol 0.01 % (0.1 mg/gram) vaginal daily 5. Alendronate Sodium 70 mg PO QMON 6. Vitamin D 1000 UNIT PO DAILY 7. Metoprolol Tartrate 25 mg PO PRN palpitations 8. Fludrocortisone Acetate 0.1 mg PO DAILY 9. Levothyroxine Sodium 25 mcg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Calcium Carbonate 1250 mg PO DAILY 12. ___ CR (___) 1 TAB PO QID Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Calcium Carbonate 1250 mg PO DAILY 3. ___ CR (___) 1 TAB PO QID 4. Citalopram 10 mg PO DAILY 5. Fludrocortisone Acetate 0.1 mg PO DAILY 6. Levothyroxine Sodium 25 mcg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Simvastatin 10 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Estradiol 0.01 % (0.1 mg/gram) VAGINAL DAILY 11. Metoprolol Tartrate 12.5 mg PO PRN palpitations Do not take if dizzy or lightheaded. 12. Alendronate Sodium 70 mg PO 1X/WEEK (MO) Discharge Disposition: Home Discharge Diagnosis: primary diagnosis: acute encephalopathy secondary diagnoses: sick sinus syndrome, ___ Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ were admitted to the ___ after having a period of unclear thought. The reason for admission was to make sure that ___ did not have any abnormalities with your heart or pacemaker. ___ had a pacemaker interrogation that showed no abnormalities that could explain your problems. I believe your brief period of unclear thought was related to your ___ Disease. Followup Instructions: ___
10313534-DS-6	10,313,534	28,080,910	DS	6	2155-05-05 00:00:00	2155-05-05 20:46:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Allergy Information Available Attending: ___. Chief Complaint: Productive Cough Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman with ___ Disease, Dementia, mitrial valve prolapse, and A-fib (not on anticoagulation) who presents from urgent care with productive cough and fatigue and is admitted for management of lobar pneumonia. The history is taken primarily from the emergency department documentation due to the patient's underlying demented state. The patient presented to ___ Urgent Care with a productive cough and fatigue for approximately 10 days as noted by her care takers in her assisted living home. At urgent care she was afebrile and in no respiratory distress. A CXR was performed and was concerning for left lower lung infiltration with likely trace fluid so she was sent to the ED for further management. In the ED, the patient was afebrile (98.2), HRs ___ (irregular), BPs 150s/80s, RR 18, SpO2 98% on RA. Exam notable for, frail-appearing, normal work of breathing, following commands but intermittently confused. Per patient's daughter at bedside, patient was at baseline alertness. ECG: Afib with intermittent pacing, lateral ST depressions (new from previous EKG in ___ Labs were notable for a normal CBC, Dig 1.0, normal electrolytes with BUN/Cr of ___, troponin less-than assay. Imaging from ___ urgent care was notable for a CXR that showed a "new increased opacity at left lung base. It likely represents left lower lobe infiltrate." Patient received: Levofloxacin PO, olanzapine 5mg IM x1 for agitation and pacing around the ED, and carbidopa-Levodopa (home med). Transfer VS were: 98.5 60 144/89 16 95% RA On arrival to the floor, patient is speaking to herself in her native language. She makes eye contact and promptly falls asleep. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: Tachy-brady syndrome s/p dual chamber pacemaker (___) Parkinsons's disease Dementia - lives in memory unit Afib (not on anticoagulation) Mitral valve prolapse Osteoporosis Hypothyroidism HLD Syncope Social History: ___ Family History: Mother and sister had arrythmias. Mother died at age ___ of a stroke. Father was a cardiol___ in ___. Sister lives in ___ and also has an arrhythmia. Physical Exam: ADMISSION PHYSICAL EXAM: ___ 0031 Temp: 97.4 PO BP: 162/95 L Lying HR: 79 RR: 18 O2 sat: 94% O2 delivery: Ra GENERAL: NAD HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD CV: RRR, S1/S2, holosystolic murmur best at L sternal border PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles GI: abdomen soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ radial pulses bilaterally NEURO: Sleeping, withdrawals all extremities to noxious stimuli, face symmetric DERM: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: VITALS: 97.4 PO 137 / 68 64 20 91 RA GENERAL: NAD, very cachectic, ___ accent HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD CV: RRR, S1/S2, holosystolic murmur best at L sternal border. PPM seated in the L upper chest PULM: CTAB, no wheezes or crackles, breathing comfortably without use of accessory muscles, but coughing actively GI: abdomen soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ radial pulses bilaterally NEURO: Moving all extremities, no focal deficits grossly DERM: warm and well perfused, no excoriations or lesions, no rashes, scattered ecchymoses Pertinent Results: ADMISSION LABS: ================ ___ 04:50PM BLOOD WBC-7.6 RBC-4.45 Hgb-13.1 Hct-42.4 MCV-95 MCH-29.4 MCHC-30.9* RDW-13.8 RDWSD-48.1* Plt ___ ___ 04:50PM BLOOD Neuts-79.7* Lymphs-9.3* Monos-8.0 Eos-2.2 Baso-0.4 Im ___ AbsNeut-6.06 AbsLymp-0.71* AbsMono-0.61 AbsEos-0.17 AbsBaso-0.03 ___ 05:25AM BLOOD ___ PTT-25.4 ___ ___ 04:50PM BLOOD Glucose-98 UreaN-20 Creat-0.9 Na-140 K-5.2 Cl-100 HCO3-26 AnGap-14 ___ 04:50PM BLOOD cTropnT-<0.01 ___ 12:49AM BLOOD cTropnT-<0.01 ___ 04:50PM BLOOD Digoxin-1.0 ___ 08:41AM BLOOD ___ pO2-104 pCO2-54* pH-7.36 calTCO2-32* Base XS-2 Comment-GREEN TOP ___ 12:28AM URINE Color-Straw Appear-Clear Sp ___ ___ 12:28AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG* ___ 12:28AM URINE RBC-4* WBC-95* Bacteri-FEW* Yeast-NONE Epi-<1 INTERIM LABS: ============= ___ 04:50PM BLOOD Digoxin-1.0 DISCHARGE LABS: ================ ___ 07:09AM BLOOD WBC-4.8 RBC-4.00 Hgb-11.7 Hct-39.0 MCV-98 MCH-29.3 MCHC-30.0* RDW-13.8 RDWSD-50.0* Plt ___ ___ 07:09AM BLOOD Glucose-89 UreaN-24* Creat-1.0 Na-144 K-4.3 Cl-105 HCO3-22 AnGap-17 ___ 07:09AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0 MICROBIOLOGY: ============== ___ URINE CULTURE-FINAL- CONTAMINATION ___ Blood Culture, Routine-PENDING ___ Blood Culture, Routine-PENDING IMAGING: ========== ___ CXR Blunting of the left costophrenic angle worrisome for small left pleural effusion with possible left base consolidation. Brief Hospital Course: Ms. ___ is a ___ woman with ___ Disease, Dementia, mitral valve prolapse, and A-fib (not on anticoagulation) who presents from urgent care with productive cough and fatigue and is admitted for management of lobar pneumonia. #Left Lobar Pneumonia CURB65 ___. Started on levofloxacin in the ED. Switched to CTX and azithro while inpatient, received 3d ___, will have 1 day to complete a 5d course (___). Patient was noted by her daughter to be more tired, not walking independently initially. ___ was consulted prior to discharge and patient was back to her baseline, walking independently. She was discharged with ___ per ___ request. #Toxic metabolic encephalopathy #Dementia Was somnolent after receiving 5 mg IM olanzapine, this dose was likely too high for her, cleared without intervention. Also likely some encephalopathy i/s/o infection as she was not moving around as much as baseline, but this improved by discharge. #Poor Urine output #Poor PO intake Has diapers for incontinence at baseline, but reportedly low output. Received IVF. Per patient's daughter, poor urine output has not been noted at her assisted living but she chronically has poor PO intake for years. Would consider nutrition consult outpatient. #Positive UA Ceftriaxone as above. Urine culture was contaminated. ___ Disease Continued Carbidopa-Levodopa/pyridostigmine. #Atrial Fibrillation Not on anticoagulation. Continued home Aspirin. Dig level 1.0 on admission. Held digoxin on discharge in setting of interaction with antibiotics. Rate remained well controlled. Consider discontinuation as it is high risk for toxicity. #Hypothyroidism Continued levothyroxine TRANSITIONAL ISSUES: ====================== [] Please complete 1 day of Levofloxacin ___ to complete a 5d course for pneumonia (___). [] If hospitalized in future and requiring chemical restraint for agitation, would give very small doses and monitor as patient had prolonged period of somnolence after 5 mg IM olanzapine [] Daughter notes poor PO intake chronically, patient cachectic appearing, consider outpatient nutrition consult [] Held digoxin due to drug interaction, would hold until PCP followup and consider restarting if clinically warranted #CODE: DNR/DNI, ok for NIV per MOLST, confirmed with daughter #CONTACT: ___, Relationship: Daughter Phone: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Advanced Eye Relief (propylene glycol-glycerin) ___ % ophthalmic (eye) TID 2. Aspirin 325 mg PO DAILY 3. Digoxin 0.125 mg PO DAILY 4. Levothyroxine Sodium 12.5 mcg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Simvastatin 10 mg PO QPM 7. Vitamin D 1000 UNIT PO DAILY 8. Cyanocobalamin 1000 mcg PO DAILY 9. Pyridostigmine Bromide 30 mg PO NOON 10. Carbidopa-Levodopa CR (___) 1 TAB PO 7AM,11AM,3PM,7PM AND AT BEDTIME 11. Omeprazole 20 mg PO DAILY 12. Calcium Carbonate 500 mg PO DAILY Discharge Medications: 1. GuaiFENesin ER 1200 mg PO Q12H RX guaifenesin 1,200 mg 1 tablet(s) by mouth twice a day Disp #14 Tablet Refills:0 2. Levofloxacin 500 mg PO Q48H Duration: 1 Day RX levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #1 Tablet Refills:0 3. Advanced Eye Relief (propylene glycol-glycerin) ___ % ophthalmic (eye) TID 4. Aspirin 325 mg PO DAILY 5. Calcium Carbonate 500 mg PO DAILY 6. Carbidopa-Levodopa CR (___) 1 TAB PO 7AM,11AM,3PM,7PM AND AT BEDTIME 7. Cyanocobalamin 1000 mcg PO DAILY 8. Levothyroxine Sodium 12.5 mcg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Pyridostigmine Bromide 30 mg PO NOON 12. Simvastatin 10 mg PO QPM 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: cough pneumonia toxic metabolic encephalopathy poor urine output poor PO intake Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You came to the hospital because of cough and pneumonia. While you were here, you got IV antibiotics and IV fluids. You are now safe to go home. When you go home: - Please finish one more day of antibiotics. - Please take the medicine to help thin the mucous in your cough for the next few days until you feel better. - Please do not take digoxin until you see you primary care doctor because it interferes with one of your antibiotics. - Please call your primary care doctor's office to schedule a followup appointment. - Please talk to your doctor about what else you could do to increase your nutrition level. It was a pleasure caring for you and we wish you the best, Your ___ Team Followup Instructions: ___
10313626-DS-13	10,313,626	20,201,482	DS	13	2193-05-04 00:00:00	2193-06-06 12:00:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Productive cough, increasing oxygen requirement Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMHx PulmHTN, obesity hypoventilation syndrome, HFpEF, OSA on BiPAP and DM2 who presents with productive cough and increased oxygen requirement. Patient states he was in his USOH which includes no oxygen during the day and BiPAP at night with ability to walk and climb stairs without difficulty until 2 weeks ago. He started feeling fatigue and a dry cough, sore throat, ear pain, progressing to a cough productive of greenish / whitish sputum. He also developed a bilateral conjunctivitis. He denies fever/chills, N/V/D, dysuria, rash, chest pain, dizziness, LH. He noticed that his O2 sats (on home oximeter) began to go lower than baseline (into the ___ per ED eval) subsequently ordered oxygen from his DME company as they were empty. He began using continuous O2 at rest (around ___ L/min) and reduced his activity. Of note, he endorses intermittently taking his Lisinopril but adhering to his diuretic, but has noticed increased leg edema but no change in his baseline 3 "thin pillow" orthopnea. His ear pain and sore throat have improved but he continues with a cough productive of white sputum and an increased O2 requirement. He does not weigh himself at home and states he began gaining a lot of weight one year ago after he stopped working and his routine became much more sedentary. He is pursuing Bariatric surgery. In the ED, initial VS were 97 83 131/69 20 88%/2LNC Exam notable for diminished breath sounds bilaterally Labs showed: CBC with no leukocytosis, H/H ___, normal Plt Chem10 with CO2 36, BUN/Cr ___ BNP 803 Trop neg x 2 VBG 7.32/45 Lactate 1.6 O2sat 92 Blood cultures drawn EKG - SR, rate 77, NA, NI, TWI V2-V4 new from prior. Imaging included CXR which showed low lung volumes, mild pulm edema, moderate cardiomegaly and a focus that could represent PNA vs atelectasis Received ___ 09:42 PO Aspirin 324 mg ___ ___ 13:20 IV Azithromycin 500 mg ___ ___ 13:50 IV CeftriaXONE 1 gm ___ ___ 13:50 PO/NG Furosemide 20 mg ___ ___ 13:50 PO/NG Lisinopril 5 mg ___ ___ 16:48 PO/NG MetFORMIN (Glucophage) 850 mg ___ ___ 16:48 PO Levofloxacin 750 mg ___ ___ 16:48 IH Albuterol 0.083% Neb Soln 1 NEB ___ ___ 16:48 IH Ipratropium Bromide Neb 1 NEB ___ Transfer VS were 98 78 137/71 20 91%/6L NC On arrival to the floor, patient reports feeling better with albuterol and ipratropium. Complains of productive cough with mild sore throat. Denies fevers, chills, eye pain, vision changes, ear pain, sinus pain, shortness of breath on oxygen, chest pain, palpitations, pleurisy, abdominal pain, N/V/D/C blood in stools, dysuria, hematuria, rashes, weakness, numbness. States his legs feel heavy and notices swelling. Past Medical History: 1. Pulmonary hypertension, WHO group 3. 2. Morbid obesity. 3. Obstructive sleep apnea, on BiPAP. 4. Obesity hypoventilation syndrome. 5. History of right lower extremity cellulitis. 6. Heart failure with preserved ejection fraction. 7. Hypertension 8. Hyperlipidemia 9. Diabetes, type 2 Social History: ___ Family History: No family history of any coronary artery disease, sudden cardiac death, or cardiomyopathy, cancer, or stroke. Physical Exam: ADMISSION PHYSICAL EXAM: VS - 98.5 81 124/61 20 97%/6L -> 95%/3L Weight on admission: 156.5 kg (344.3 lbs) Weight ___ 333 pounds GENERAL: morbidly obese male in NAD HEENT: anicteric sclera, PERRL, EOMI, bilateral injected conjunctiva and with scant purulent exudate, non-crusting, MOM, OP clear NECK: nontender supple neck, no LAD, JVD difficult to determine ___ habitus CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably, speaking in full sentences ABDOMEN: obese, protuberant, soft, +BS, nontender in all quadrants, no rebound/guarding EXTREMITIES: cool but with good cap refill, no cyanosis, clubbing. 1+ pitting edema ___ bilateral ___. PULSES: 2+ DP pulses bilaterally NEURO: A&O, CN II-XII intact, SILT, no weakness SKIN: 10 cm raised erythematous well demarcated rash on lower abdomen. Chronic venous stasis changes BLE without cellulitis DISCHARGE VS - 98.2 HR 84 BP 126/44 RR 20 96%/3L NC WT: 156.6 -> 153.8 -> 150.7kg standing General: well appearing, NAD HEENT: MMM, EOMI, anicteric and no injection of sclera bilaterally with no discharge but hyperemic conjunctiva bilaterally Neck: JVD no appreciable due to adiposity, no LAD CV: RRR, no m/r/g Lungs: NLB, no W/R/R Abdomen: obese, protuberant, non-tender, NABS Ext: warm and well perfused, 2+ distal pulses, 1+ edema ___ anterior shins Neuro: A&O, SILT, MAE Pertinent Results: ADMISSION LABS: ___ 09:30AM BLOOD WBC-7.9 RBC-5.09 Hgb-15.0 Hct-49.4 MCV-97 MCH-29.5 MCHC-30.4* RDW-14.5 RDWSD-50.8* Plt ___ ___ 09:30AM BLOOD Neuts-67.9 ___ Monos-10.1 Eos-0.3* Baso-0.5 Im ___ AbsNeut-5.35 AbsLymp-1.64 AbsMono-0.79 AbsEos-0.02* AbsBaso-0.04 ___ 09:30AM BLOOD Glucose-156* UreaN-18 Creat-0.8 Na-137 K-6.7* Cl-95* HCO3-36* AnGap-13 ___ 09:30AM BLOOD Calcium-8.8 Phos-4.5 Mg-2.3 ___ 09:48AM BLOOD ___ pO2-75* pCO2-75* pH-7.32* calTCO2-40* Base XS-8 ___ 11:18AM BLOOD K-4.6 ___ 09:48AM BLOOD Lactate-1.6 ___ 09:48AM BLOOD O2 Sat-92 ___ 09:30AM BLOOD proBNP-803* DISCHARGE LABS: ___ 07:00AM BLOOD WBC-7.6 RBC-5.37 Hgb-15.7 Hct-51.9* MCV-97 MCH-29.2 MCHC-30.3* RDW-14.4 RDWSD-50.3* Plt ___ ___ 07:00AM BLOOD Glucose-104* UreaN-25* Creat-0.9 Na-143 K-4.2 Cl-93* HCO3-39* AnGap-15 ___ 07:00AM BLOOD Calcium-9.7 Phos-4.4 Mg-2.4 ___ 07:00AM BLOOD proBNP-128 IMAGING: ___ CHEST (PA & LAT) COMPARISON: Chest radiographs ___ through ___. CTA chest ___ IMPRESSION: 1. Focal opacity projecting over the lower thoracic spine could reflect a focus of atalectasis or pneumonia. Recommend follow-up to resolution. 2. Low lung volumes and probable mild pulmonary edema. 3. Moderate cardiomegaly is unchanged. Brief Hospital Course: ___ with history of diastolic heart failure (HFpEF), PulmHTN, obesity hypoventilation syndrome, OSA on BiPAP and DM2 who presented with acute on chronic respiratory failure, likely due to decompensated acute on chronic diastolic heart failure (BNP 803 on admission) and viral bronchitis in the setting of minimal pulmonary reserve. He was diuresed over 24 hrs to weight of 332 lbs (150.7 kg). His home diuretic dose of Lasix 20mg BID was resumed. Of note, troponins were negative x2 and his blood gas showed a stable, compensated hypercarbic respiratory failure, consistent with prior blood gasses. There was no evidence for bacterial pneumonia so antibiotics were not given. He was on ___ oxygen at rest at the time of discharge, above home requirement, but he will wean himself down to room air at home. # Acute on chronic diastolic heart failure: Responded well to IV furosemide diuresis with decreased weight, BNP, O2 requirement. Resume dhome diuresis with furosemide 20mg PO BID on discharge. Discharge weight 150.7 kg, BNP 108. Continued home ASA, lisinopril. # Obesity hypoventilation syndrome/OSA: had desaturation on telemetry at night. Nightime BiPAPon uptitrated to ___. Discussed bariatric surgery as transitional issue. # Viral bronchitis: Cough, mucus production and wheeze improved with duonebs. Consolidation on CXR will require follow-up in 6wks to ensure resolution # Viral conjunctivitis: presented with conjunctival injection and tarsal hyperemia with minimal purulence, came in with erythromycin ointment but held due to irritation and was treated with artificial tears with good response. TRANSITIONAL ISSUES DISCHARGE WEIGHT 150.7 kg [ ] Recommend Chem7 in 1 week [ ] Recommend repeat CXR for follow up of thoracic spine projection on ED CXR in approximately 6 weeks - Started Albuterol with spacer for acute bronchitis - Antibiotic eye drops stopped and replaced with artificial tears for viral conjunctivitis Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Furosemide 20 mg PO BID 3. Lisinopril 5 mg PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO BID 5. Simvastatin 40 mg PO QPM 6. Vitamin D 1000 UNIT PO DAILY 7. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES BID 8. Clotrimazole Cream 1 Appl TP BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Clotrimazole Cream 1 Appl TP BID 3. Furosemide 20 mg PO BID 4. Lisinopril 5 mg PO DAILY 5. Simvastatin 40 mg PO QPM 6. Vitamin D 1000 UNIT PO DAILY 7. Artificial Tears ___ DROP BOTH EYES PRN dryness / irritation RX dextran 70-hypromellose 2 drops each eye twice a day Disp #1 Bottle Refills:0 8. MetFORMIN (Glucophage) 500 mg PO BID 9. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath use a spacer to help the medication go into your lungs better RX albuterol sulfate [ProAir HFA] 90 mcg 2 puffs inhalation every six (6) hours Disp #1 Inhaler Refills:0 10. Space Chamber Plus (inhalational spacing device) miscellaneous DAILY:PRN for use with albuterol RX inhalational spacing device Use with albuterol inhaler every six (6) hours Disp #2 Each Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES #Acute decompensated congestive heart failure with preserved ejection fraction #Obesity hypoventilation syndrome #Obstructive Sleep Apnea #Viral bronchitis #Viral conjunctivitis 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 participating in your care at the ___ ___. You were admitted for a heart failure exacerbation most likely caused by a viral infection. You improved with intravenous Lasix, nebulizers and with adjustment to your nighttime BiPAP. When you go home, we want your oxygen level to be above 88%. If you need to use oxygen during the day for the next several days, that is OK. If you oxygen is above 90%, you can turn it down or not use it until you are back to breathing normally. However, if your oxygen is <88% at rest persistently, call your doctor or go to the emergency room. We are starting a new medication: albuterol which you can use when you feel short of breath. Use a spacer to help the medication go into your lungs better. We encourage you to use your BiPAP every night and follow with your sleep medicine doctors ___. Weigh yourself every morning, call MD if weight goes up more than 3 lbs or 1.5 kg. Your discharge weight was 150.7 kg (332 lbs) Keep taking your lisinopril every day and you should follow closely with your PCP as below to check on your electrolytes and your furosemide dosing. Finally, you have an abnormality on your chest x-ray that should be followed up in 6 weeks with a repeat x-ray. We wish you the best in health. Sincerely, Your ___ team Followup Instructions: ___
10313626-DS-16	10,313,626	22,196,338	DS	16	2197-02-15 00:00:00	2197-02-15 18:58:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: acute respiratory distress Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ year old M, ___, with HTN, DM, HFpEF, OSA, liver cirrhosis, hx PVT/SMVT/PEs on coumadin who presents with weakness, tremors, and chills. According to his wife, patient was reportedly in his normal state of health this morning. Throughout the day, he became tremulous, with shaking chills and generalized weakness. He denies any chest pain, cough, difficulty breathing, abdominal pain, vomiting, diarrhea, worsening ___ swelling, or changes in skin color. In the ED, - Initial Vitals: T 103.1 HR 135 BP 170/78 RR 28 SpO2 91% 4L NC - Exam: Appears unwell, +Cervical LAD, decreased aeration in the right base, slight crackles. Tachycardic. Bilateral lower extremity edema. - Labs: WBC 17.4 Hgb 15 Plt 214 Na 135 K 4.8 Cl 97 HCO3 26 BUN 15 Cr 0.8 Gluc 160 Ca: 8.8 Mg: 1.8 P: 1.5 Lactate: 2.1 pH 7.41 pCO2 47 pO2 42 HCO3 31 Flu negative - Imaging: CXR - Interventions: 1L LR, Vanc 1g, Zosyn 4.5g ROS: Positives as per HPI; otherwise negative. ==== Past Medical History: 1. Pulmonary hypertension, WHO group 3. 2. Morbid obesity. 3. Obstructive sleep apnea, on BiPAP. 4. Obesity hypoventilation syndrome. 5. History of right lower extremity cellulitis. 6. Heart failure with preserved ejection fraction. 7. Hypertension 8. Hyperlipidemia 9. Diabetes, type 2 Social History: ___ Family History: No family history of any coronary artery disease, sudden cardiac death, or cardiomyopathy, cancer, or stroke. Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: T 99.7 HR 102 BP 102/60 RR 25 SpO2 94% BiPAP GENERAL: Lying in bed, obese body habitus, wearing BiPAP, in no acute distress. HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. NECK: Unable to assess JVD. CARDIAC: Regular rhythm, tachycardic. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation in anterior fields, though exam limited by body habitus and patient positioning. No wheezes, rhonchi or rales. Appears to be breathing comfortably on BiPAP. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: R leg with diffuse erythema from ankle extending into inferior thigh, warm to touch, appears mildly enlarged in size compared to L leg. Nontender to palpation, no visible wounds. L leg with mild erythema (less diffuse/prominent compared to R leg) from ankle to inferior knee. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: A&Ox3. No focal neuro deficits, moving all four extremities spontaneous, normal sensation. DISCHARGE PHYSICAL EXAM: ======================== ___ ___ Temp: 98.4 PO BP: 102/62 R Sitting HR: 83 RR: 18 O2 sat: 95% O2 delivery: 2L FSBG: 109 Gen: Seated in char, NAD, on 2L NC CV: NR, RR. Nl S1, S2. PULM: Comfortable, CTAB GI: S, nt, nd. EXT: 2+ bilateral leg edema Pertinent Results: ADMISSION LABS: =============== ___ 11:00PM BLOOD WBC-17.4* RBC-5.07 Hgb-15.0 Hct-47.2 MCV-93 MCH-29.6 MCHC-31.8* RDW-13.6 RDWSD-46.2 Plt ___ ___ 11:00PM BLOOD ___ PTT-38.4* ___ ___ 11:00PM BLOOD Glucose-160* UreaN-15 Creat-0.8 Na-135 K-4.8 Cl-97 HCO3-26 AnGap-12 ___ 11:00PM BLOOD ALT-25 AST-25 AlkPhos-71 TotBili-0.8 ___ 11:00PM BLOOD proBNP-50 ___ 11:00PM BLOOD cTropnT-<0.01 ___ 11:00PM BLOOD Albumin-4.3 Calcium-8.8 Phos-1.5* Mg-1.8 ___ 11:03PM BLOOD ___ pO2-42* pCO2-47* pH-7.41 calTCO2-31* Base XS-3 Intubat-NOT INTUBA Comment-GREEN TOP ___ 11:03PM BLOOD Lactate-2.1* ___ 10:25AM BLOOD Lactate-1.0 IMAGING RESULTS: ================ ___ Imaging CHEST (PORTABLE AP) IMPRESSION: Opacities at the bilateral lung bases could represent atelectasis, however aspiration or pneumonia is not excluded in the appropriate clinical setting. ___ Imaging UNILAT LOWER EXT VEINS IMPRESSION: No evidence of deep venous thrombosis in the visualized right lower extremity veins. Peroneal veins were not visualized. MICRO/OTHER PERTINENT LABS: ========================== ___ 11:00PM BLOOD proBNP-50 ___ 11:20 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): BETA STREPTOCOCCUS GROUP B. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ BETA STREPTOCOCCUS GROUP B \| CEFTRIAXONE-----------<=0.12 S CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.12 S PENICILLIN G----------<=0.06 S VANCOMYCIN------------ 0.5 S Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ (___) @___ ON ___. GRAM POSITIVE COCCI IN PAIRS AND CHAINS. ___ 5:54 am MRSA SCREEN Source: Nasal swab. FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. ___ 1:39 am URINE FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. DISCHARGE LABS: =============== ___ 07:20AM BLOOD WBC-6.7 RBC-4.59* Hgb-13.6* Hct-43.0 MCV-94 MCH-29.6 MCHC-31.6* RDW-13.6 RDWSD-46.6* Plt ___ ___ 11:01AM BLOOD ___ ___ 07:20AM BLOOD Glucose-123* UreaN-11 Creat-0.7 Na-142 K-4.4 Cl-100 HCO3-30 AnGap-12 ___ 07:20AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.2 Brief Hospital Course: TRANSITIONAL ISSUES ==================== Discharge wt: 305.78 lb Discharge Cr: 0.7 [] continue IV CTX for 2 week course (___), will be coming for infusions at ___ [] f/u ___ clinic for INR (will need close follow up while on antibiotics) [] make sure using BIPAP at home, find out if patient not using due to logistical issues [] ensure patient using compression stockings at home to prevent cellulitis infections in the future [] f/u weights and volume status on home diuretic regimen # CODE: Full Code # CONTACT: ___ (Wife) ___ ___ (Daughter) ___ ___ year old male with a h/o HTN, DM, HFpEF, OSA, liver cirrhosis, PVT/SMVT/PEs who initially presented with weakness, tremors, and chills, concerning for sepsis found to have GBS bacteremia likely ___ RLE cellulitis, improving on IV antibiotics. ACUTE/ACTIVE ISSUES: ==================== # Group B strep bacteremia: Patient initially presented with weakness, fever, chills, rigors, and leukocytosis, c/w sepsis likely secondary to cellulitis given his RLE edema and erythema. Last positive blood culture ___ was positive for GPC group B strep. MRSA swab negative so stopped vancomycin ___. Continuing IV CTX for 2 week course (___), midline placed ___. Will need to come to ___ for daily infusions # RLE Cellulitis: Patient presented with erythema, edema, and warmth in RLE. Concerning for cellulitis, given his history of cellulitis infections, obesity, DM Type II, and presentation consistent with sepsis. Given the patient's history of thrombosis, there was concern for possible DVT but right lower extremity venous U/S did not show any e/o DVT. Improving with antibiotics as above RESOLVED ISSUES: ================= # Acute hypoxemic respiratory failure: Presented with a significant O2 requirement and respiratory distress. The initial differential included CAP vs PE vs decompensated HFpEF. However, given the patients rapid improvement in respiratory status with Abx administration, it is more likely that this was due to sepsis. Additionally, patient denied SOB, cough, orthopnea, PND, worsening ___ edema, and there were no ischemic changes on EKG. Weaned off ___. Restarted home diuretics and continued BiPAP overnight (on at home) although patient was intermittently refusing CHRONIC/STABLE ISSUES: ====================== # Cirrhosis: Patient was diagnosed via imaging ___. Likely due to NASH and CHF, well compensated this admission. # Hx of PVT, SMVT, bilateral PEs: Pt was found to have acute SMV thrombosis extending to the main portal vein resulting in mesenteric ischemia in ___ with subsequent subsegmental and segmental bilateral PEs. Evaluated previously by hematology who recommended lifelong anticoagulation. INR subtherapeutic on discharge 1.4. Discharged on 7.5mg coumadin daily, to be followed in ___ clinic closely while on antibiotics (goal INR ___ # HTN: Patient is not on any pharm meds currently # HFpEF: Patient's last TTE was on ___ with LVEF >55%. Patient remained euvolemic this hospital stay. Initially held home lasix due to sepsis but re-started on ___. Discharge weight 305.78 lb # HLD: Continued home simvastatin # T2DM: Patient's last HbA1c was 6.4% (___). Discharged on home metformin # OSA # Obesity hypoventilation syndrome: Patient wears BiPAP at home, he is followed by the Sleep Clinic as an outpatient Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 7.5 mg PO WED/FRI 2. Warfarin 5 mg PO ___ 3. Simvastatin 40 mg PO QPM 4. MetFORMIN XR (Glucophage XR) 500 mg PO BID 5. Furosemide 40 mg PO BID Discharge Medications: 1. CefTRIAXone 2 gm IV Q 24H 2. Furosemide 40 mg PO BID 3. MetFORMIN XR (Glucophage XR) 500 mg PO BID 4. Simvastatin 40 mg PO QPM 5. Warfarin 7.5 mg PO WED/FRI 6. Warfarin 5 mg PO ___ Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES ================== Group B strep bacteremia Right lower extremity cellulitis SECONDARY DIAGNOSES =================== Hypoxia Cirrhosis History of deep venous thrombosis/pulmonary embolism Hypertension Heart failure with preserved ejection fraction Hyperlipidemia Diabetes Obstructive sleep apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, WHY YOU WERE HERE - You were having fevers, chills, and redness of your leg WHAT WE DID FOR YOU - You were found to have cellulitis of your right leg - You were found to have an infection of your bloodstream - You were started on antibiotics to treat the infection, and you had significant improvement - You initially needed oxygen but were weaned off of this WHAT YOU SHOULD DO WHEN YOU LEAVE - Please come to ___ to receive your IV antibiotics every day for the next ___ days - Please follow up with your doctors as below - ___ use your BIPAP every night and take your other medications as directed! It was a pleasure caring for you! Sincerely, Your ___ Care Team Followup Instructions: ___
10313706-DS-15	10,313,706	23,372,643	DS	15	2159-04-18 00:00:00	2159-04-18 18:33:00	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: None History of Present Illness: Patient is a ___ with history of COPD not on home O2, 75-pack years smoking, arterial vascular disease (recent CEA), HTN, and T2DM who presents with subacute SOB. Patient says that her symptoms started acutely on ___ of last week (exertional SOB). No CP or palpitations. Given progressively worsening SOB, patient called EMS ___ and was taken to ___ in ___ ___ where she was found to be tachycardic to the 120-130s (?not sinus), hypoxic to ___ with anemia (Hb 6.2) and ___ (BUN/Cr 55/3.85). Troponin was NEG x1. CXR was notable for bilateral pleural effusions and an increased opacity in the LLL. She was given 1 unit of blood, levofloxacin, methylpred, and metoprolol 5mg IV x 1 prior to transfer to ___ for further work-up/evaluation. At her prior baseline >1wk ago, patient was able to go about her daily tasks without any significant cardiopulmonary symptoms. She states that ever since her CEA ___ at ___ ___ with Dr. ___, she 'hasn't felt good,' endorsing HA and dizziness upon rising out of bed in the AM. She says that the surgery was complicated in that it took ~5hrs instead of the planned ___. She did not require any blood transfusions. Patient says that she saw her PCP after the surgery, but did not have any blood work done until presenting to ___ yesterday. Patient does endorse a chronic cough iso COPD, no major change as of late, no hemoptysis. Though patient always sleeps upright, she denies any orthopnea or PND. Of note, patient does endorse unintentional 14lbs weight loss over the past ___. In the ED, initial VS were: 99.1 122 136/78 95% NC EKG: Regular tachycardia, appreciable Pwaves with short PR interval, normal axis, normal QRS/QTc, TWIs in aVL, biphasic TW in V1, inferolateral submm STDs Labs showed: CBC 5.3>7.4/22.9<358 BMP 137/4.___/3.6/154 Ca 9.8 Mg 2.8 Phos 4.5 ___ 12521 Trop <.01 Lactate 1.3 UA: SG 1.015, pH 6.0, urobilinogen NEG, bili NEG, leuk NEG, blood NEG, nitrite NEG, 30 protein, glucose NEG, ketones NEG, 1 RBC, 2 WBCs, few bacteria Imaging showed: CXR ___ IMPRESSION: 1. Hyperexpanded lungs, compatible with COPD. 2. Mild increased pulmonary congestion with bilateral moderate pleural effusions. 3. Bibasilar opacities may be due to atelectasis, however, superimposed pneumonia cannot be excluded in the appropriate clinical setting. Consults: NONE Patient received: ___ 03:26 IV Furosemide 80 mg ___ 03:26 IV Metoprolol Tartrate 5 mg ___ 03:34 PO Acetaminophen 650 mg ___ 04:00 IV Metoprolol Tartrate 5 mg ___ 04:00 PO/NG Metoprolol Tartrate 25 mg Transfer VS were: 98.3 117 139/73 20 95% 3L NC On arrival to the floor, patient recounts the history as above. She says that she feels somewhat better after having received the blood transfusion and Lasix. No chest pain or palpitations. No lightheadedness or dizziness. No abdominal pain or blood/black stools. No fevers/chills. By report, patient had a normal colonoscopy within the past ___, normal mammogram within the past ___. 10-point ROS is otherwise NEGATIVE. Past Medical History: COPD Dyslipidemia Hypertension Carotid artery stenosis s/p CEA Prior GIB (unknown source, required transfusion ___ ago) T2DM Osteoporosis Depression ? AFib Social History: ___ Family History: Mother passed away in early ___, had a pacemaker Father passed away at ___, alcoholic Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.5 153/85 128 17 94 3L GENERAL: Sitting comfortably in bed, speaking in full sentences. HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: JVP elevated 4cm above the clavicle with head of bed at 45degrees. L CEA scar, well healed. HEART: Tachycardic, mostly regular though with intermittent premature beats, normal S1/S2, ___ systolic murmur heard throughout the precordium, no gallops or rubs. LUNGS: Bibasilar crackles. ABDOMEN: Normoactive BS throughout, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly. EXTREMITIES: WWP, no cyanosis, clubbing, or edema. PULSES: 1+ radial 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: VITALS: ___ 0753 Temp: 98.7 PO BP: 145/71 Lying HR: 66 RR: 18 O2 sat: 96% O2 delivery: 1L FSBG: 113 GENERAL: NAD, sitting in chair EYES: sclera anicteric ENT: OP clear, MMM CV: RRR, no m/r/g, JVP <9cm RESP: mild crackles noted RLL, otherwise CTAB. GI: prominent midline umbilical hernia noted. non-tender, non-distended GU: deferred MSK: no pitting edema SKIN: no rashes noted NEURO: A&Ox3, DOWB intact, EOMI, PERRL, ___ BUE/BLE Pertinent Results: ADMISSION LABS ============== ___ 12:40AM BLOOD WBC-5.3 RBC-2.59* Hgb-7.4* Hct-22.9* MCV-88 MCH-28.6 MCHC-32.3 RDW-17.3* RDWSD-56.3* Plt ___ ___ 12:40AM BLOOD ___ PTT-26.7 ___ ___ 12:40AM BLOOD Ret Aut-3.9* Abs Ret-0.10 ___ 12:40AM BLOOD Glucose-154* UreaN-61* Creat-3.6* Na-137 K-4.7 Cl-96 HCO3-23 AnGap-18 ___ 12:40AM BLOOD ALT-15 AST-15 LD(LDH)-162 AlkPhos-65 TotBili-0.2 ___ 12:40AM BLOOD ___ ___ 12:40AM BLOOD cTropnT-<0.01 ___ 12:40AM BLOOD calTIBC-364 VitB12-1102* Hapto-328* Ferritn-17 TRF-280 ___ 11:25AM BLOOD ___ pO2-174* pCO2-35 pH-7.46* calTCO2-26 Base XS-2 Comment-GREEN TOP IMAGING REPORTS =============== CXR ___. COPD. 2. Cardiac decompensation reflected in moderate cardiomegaly pulmonary vascular congestion and moderate bilateral pleural effusions. 3. Bibasilar opacities probably combination of atelectasis and early edema, but pneumonia is not excluded. Renal US ___. No evidence of hydronephrosis. 2. Small bilateral renal cysts TTE ___: Conclusions The left atrial volume index is severely 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 and regional/global systolic function (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 aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Left atrial enlargement. Mild symmetric left ventricular hypertrophy with preserved biventricular systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. CT CHEST WO CONTRAST ___ IMPRESSION: -Secretions in both lower lobes bronchi associated with bilateral small layering pleural effusions and subsequent relaxation atelectasis/aspiration pneumonia. No evidence of intrathoracic mass or metastasis. -Heavy atherosclerotic calcifications of the coronaries and major thoracic and upper abdominal vessels. PERTINENT LABS ============== ___ 12:40AM BLOOD Ret Aut-3.9* Abs Ret-0.10 ___ 12:40AM BLOOD ___ ___ 12:40AM BLOOD cTropnT-<0.01 ___ 06:15AM BLOOD CK-MB-4 cTropnT-<0.01 ___ 06:15AM BLOOD Folate->20 ___ 12:40AM BLOOD calTIBC-364 VitB12-1102* Hapto-328* Ferritn-17 TRF-280 ___ 12:40AM BLOOD TSH-0.38 ___ 06:15AM BLOOD PEP-PND ___ 08:11AM BLOOD freeCa-1.10* DISCHARGE LABS ============== ___ 06:20AM BLOOD WBC-8.7 RBC-2.51* Hgb-7.2* Hct-22.1* MCV-88 MCH-28.7 MCHC-32.6 RDW-15.9* RDWSD-51.1* Plt ___ ___ 06:20AM BLOOD Glucose-111* UreaN-86* Creat-3.4* Na-135 K-4.3 Cl-95* HCO3-27 AnGap-13 ___ 06:20AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.9* Brief Hospital Course: BRIEF HOSPITAL COURSE ===================== Ms. ___ is a ___ with history of COPD not on home O2, 75-pack years smoking, arterial vascular disease (recent CEA), HTN, and T2DM who presents with subacute SOB after undergoing CEA ___, found to have atrial tachycardia to 120-130s iso severe anemia and ___, CXR with bilateral pleural effusions and BNP>7k with initial concern for heart failure exacerbation. The patient was admitted to the Cardiology service where TTE showed preserved LVEF, mild MR, mild pulmonary hypertension and mild LVH. She was diuresed with Lasix IV to euvolemia, however, she remained hypoxic. Repeat chest xray revealed a right basal pneumonia. She was initiated on azithromycin and ceftriaxone for community acquired pneumonia and her symptoms improved. Her course was complicated by ___ on CKD for which renal was consulted. There is concern that her worsening kidney fuction is a result of ATN that is multifactorial in nature (possible intermittent atrial fibrillation with hemodynamic compromise; anemia; and recent prolonged CEA procedure). Urine sediment bland without evidence of AIN or GN. There was no need for HD and the patient will need to have close renal ___. Discharge Cr 3.4 which may be her new baseline. For her anemia, the patient was given IV iron and will possibly require EPO +/- transfusion as an out-patient as well as consideration for additional work-up of her iron deficiency (colonoscopy, routine cancer screening etc). In regards to her possible atrial tachycardia vs. atrial fibrillation, discussion was held with cardiology and given that the episode was in the setting of acute illness without recurrence while on the medicine service, the plan is to ___ with an out-patient cardiologist for consideration of zio patch for monitoring. Anticoagulation was held at this time pending results of further testing. # Subacute shortness of breath # Bilateral pleural effusions # Leukocytosis # RLL consolidation Patient with subacute worsening of shortness of breath after having undergone CEA on ___, found to be tachycardic and anemic (Hb ___ with bilateral moderate pleural effusions. Initially JVP elevated and BNP increased >12k prompting admission to the cardiology service. She was diuresed with Lasix 80 mg IV but remained hypoxic. TTE showed preserved biventricular systolic function with estimated RA pressure <5 mmHg on TTE, so likely euvolemic. Repeat CXR showed right lower lobe pneumonia and the patient was initiated on ceftriaxone/azithromycin ___ - ___ later transitioned to levaquin for CAP (end ___ for total 7 day course of all abx. The patient will be discharged on torsemide 10mg daily for management of her fluid status with plans to re-check labs within 1 week of discharge. # Atrial Tachycardia/Fibrillation- initially atrial tachycardia in 120s then briefly went into atrial fibrillation on ___ likely in setting of pneumonia vs reduced dose of metoprolol. Increased fractionated metoprolol to equal home dose. Held on warfarin as she was only briefly in atrial fibrillation. Her atrial arrhythmia did not recur following her episode on ___. Plan to discharge home with ___ with Cardiology for consideration of a zio patch. # Normocytic Anemia with inadequate reticulocytosis - Hb ___, Baseline in ___ ~11. Iron deficient on labs. Patient denied any black or bloody stools. No vaginal bleeding. No history of abnormal colonoscopies per patient report. Of note, patient does have a prior hx of GIB requiring transfusion. She was initially managed with IV protonix BID then transitioned to PO PPI once Hb remained stable. It is possible that her anemia is mixed in nature in the setting of worsening CKD and possible blood loss during CEA procedure. She remained stable without signs of bleed during this hospitalization and her PPI was discontinued. She was given iron infusions x2 with plans for renal ___ and consideration of EPO as an out-patient. Will also need close PCP ___ for consideration of colonoscopy. She was offered a blood transfusion on day of discharge given the likelihood that she would take a long time to get hgb to goal as outpatient but declined. # Kidney Injury - Baseline 1.2 in ___ to 1.4 after her CEA in early ___, then 2.4 in late ___. Peaking at 3.8 during this admission. She has no history of renal disease and has not been seen by a renal physician in the past. Of note, she did by report have a recent complicated CEA ___. Renal was consulted who deemed that this is likely ATN that is multifactorial in nature (? afib with hemodynamic compromise, CEA procedure, and anemia) Renal US without hydronephrosis. Urine sediment bland without any signs of GN or AIN. Per renal, Cr ___ represent a new baseline. No indications for HD. Her medications were renally dosed and her anemia, infection, and a-tach/?fib were managed as above with plans to ___ with nephrology as an out-patient. She was discharged on torsemide 10mg daily to manage her fluid status. We discussed monitoring her daily weights and calling her PCP if gains or loses ___ lbs as her torsemide may need to be adjusted. Team spoke with MD covering ___ practice who kindly agreed to have patient get labs a on ___ and be seen on ___. # Recent CEA - By report complicated CEA at ___ with Dr. ___ ___. Continued atorvastatin 40mg qd. Restarted on aspirin 81 mg daily. # COPD Continued home advair 250/50 BID. Managed with tiotropium nebulizers q6h and levalbuterol nebulizers q4h prn while inpatient. # Hypertension Continued home amlodipine 10mg qd and held home lisinopril iso ___. # Type II Diabetes Mellitus Managed with insulin sliding scale while inpatient. Held metformin on discharge given significantly impaired renal function. # Dyslipidemia Continued home atorvastatin 40mg qd # Osteoporosis Continued home alendronate 70mg qweek # Tobacco use Continued home bupropion 150mg qd ======================= TRANSITIONAL ISSUES: ======================= NEW MEDICATIONS: -Levofloxacin 500mg q48h (last ___ -Torsemide 10mg daily CHANGED MEDICATIONS: -ASA 81mg daily STOPPED MEDICATIONS: -Chlorthalidone -Lisinopril -Metformin Other: ======== [ ] Needs renal ___ for CKD and consideration of EPO for anemia [ ] Needs cardiology ___ for ? atach vs. afib and consideration of a zio patch for monitoring [ ] Monitor blood pressures and consider initiation of additional anti-hypertensive agent given need to discontinue Lisinopril/chlorthalidone given renal function [ ] Repeat BMP within 1 week of discharge and adjust torsemide as needed [ ] Needs repeat CXR to ensure PNA and small effusions resolved [ ] Please continue to monitor patient weight and adjust torsemide as needed. Discharge weight:60.3kg [ ] Recommend outpatient work-up of normocytic anemia with inadequate reticulocytosis [ ] Recommend monitoring of weight loss; likely ___ CKD advancing but can consider other age appropriate cancer screening and other workup as well Code Status: FULL Emergency Contact: ___ (husband), ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO DAILY 2. Advair HFA (fluticasone-salmeterol) 45-21 mcg/actuation inhalation BID 3. Alendronate Sodium 70 mg PO 1X/WEEK (___) 4. amLODIPine 10 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. BuPROPion 150 mg PO DAILY 7. Chlorthalidone 25 mg PO DAILY 8. Lisinopril 40 mg PO DAILY 9. MetFORMIN (Glucophage) 500 mg PO BID 10. Metoprolol Succinate XL 200 mg PO DAILY 11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN Discharge Medications: 1. Levofloxacin 500 mg PO Q48H RX levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth On ___ Disp #1 Tablet Refills:0 2. Torsemide 10 mg PO DAILY Please start on ___ RX torsemide 10 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 4. Advair HFA (fluticasone-salmeterol) 45-21 mcg/actuation inhalation BID 5. Alendronate Sodium 70 mg PO 1X/WEEK (___) 6. amLODIPine 10 mg PO DAILY 7. Atorvastatin 40 mg PO QPM 8. BuPROPion 150 mg PO DAILY 9. Metoprolol Succinate XL 200 mg PO DAILY 10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN 11.Outpatient Lab Work N 18.4: Chronic kidney disease Please check basic metabolic panel within 1 week of discharge. Discharge Disposition: Home Discharge Diagnosis: PRIMARY: ========= - Community Acquired Pneumonia - Atrial tachycardia; possible atrial fibrillation - Pulmonary edema - Acute Kidney Injury Secondary: ============ -Chronic kidney disease -Anemia -DMII Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, WHAT BROUGHT YOU INTO THE HOSPITAL? - You were admitted for shortness of breath WHAT WAS DONE FOR YOU IN THE HOSPITAL? - You had a chest x-ray which showed fluid and a possible pneumonia in your lungs. - You received medications to remove excess fluid from your lungs. - You received antibiotics to treat your pneumonia. - You received nebulizers to help you with breathing. - You had an echocardiography to evaluate your heart. It showed normal pumping function - You were seen by the kidney doctors who ___ continue to follow you as an out-patient for management of your kidney disease - You were given iron for your anemia and should ___ with your primary care physician to discuss further management and work-up of your anemia going forward WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL? - It is important that you continue to take your medications as prescribed. - Please weigh yourself daily and call your doctor if you gain more than 3 lbs. - You need to follow up with your PCP ___ ___ days. - Please ___ with the kidney doctor within ___ weeks of discharge - Please ___ with a Cardiologist to discuss your heart rhythm and the possibility of needing a monitor of your heart as an out-patient such as a Zio patch We wish you the best in your recovery! Your ___ Care Team Followup Instructions: ___
10313822-DS-12	10,313,822	20,917,242	DS	12	2179-03-28 00:00:00	2179-03-28 13:23:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: abdominal pain, n/v Major Surgical or Invasive Procedure: EUS with biopsy History of Present Illness: Ms. ___ is a ___ woman with history of HTN, breast cancer s/p mastectomy presenting with nausea, vomiting, and abdominal pain. The patient reports that she was in her usual state of health until ___, when she developed nausea, abdominal pain, and non-bloody, bilious emesis. The abdominal pain was in a band across her upper abdomen without radiation. She also had two loose stools. She attributed her symptoms to ___ food that she had consumed on the day prior. She had multiple episodes of emesis, "too many to count." She denies any fevers or chills at home. She reports she has lost about 20 pounds in the last ___ years. Her symptoms did not abate, so she presented to ___. There, labs notable for: WBC 16 (___), K 2.9, lipase 54, AST 141, ALT 119, Tb 0.8, lactate 1.2. CT A/P with pelvis obtained that demonstrated a 1.7 x 1.3 cm region of soft tissue density in the inferior pancreatic heard at the level of the biliary obstruction suspicious for an underlying mass. She was given ertapenem, morphine 2 mg IV, 1L NS, potassium 40 mEQ IV, Zofran 4 mg IV. Given these findings, the patient was transferred to ___ for ERCP consult. In the ___ ED, initial vitals: 98.8 (Tmax 100.6)119 116/60 20 92% RA Exam notable for: ABD: non-distended, tender in epigastrium Labs notable for: WBC 12.4, Hb 10.8, plt 140, AST 77, LAT 73, Tb 0.8, lip0ase 7, K 3.9; Cl 115, HCO3 19, BUN/Cr 19./0.6; UA bland Imaging notable for: - CXR: No acute process - RUQUS: There is mild-to-moderate intrahepatic biliary dilatation with common bile duct measuring up to 16 mm. A reported pancreatic mass is not well seen on this study. Patient given: ___ 04:48 IV Morphine Sulfate 2 mg ___ 04:48 IV Prochlorperazine 10 mg ___ 05:48 IVF NS 1000 mL ___ 13:40 PO/NG Acetaminophen 650 ___ 13:41 IVF LR 1000 mL ___ 15:34 IV Piperacillin-Tazobactam 4.5 g On arrival to the floor, the patient reports that her abdominal pain was improved with the morphine that she received in the ED but has now recurred. She denies any nausea at present. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: - Breast cancer ___ years ago s/p bilateral mastectomy and with reconstruction; recurrence ___ years after initial cancer s/p surgery; patient denies receiving chemotherapy or radiation - S/p CCY - S/p hysterectomy - Anxiety - Hypertension Social History: ___ Family History: - Daughter with breast cancer Physical Exam: Admission exam VITALS: 98.5 107/63 69 18 94 RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, diffusely mildly tender to palpation, greatest in midepisgastrium and left lower quadrant Bowel sounds present. 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 VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, mildly TTP in RUQ, epigastric area, 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: cantankerous Pertinent Results: Admission labs ___ 05:45AM BLOOD WBC-12.4* RBC-3.78* Hgb-10.8* Hct-32.8* MCV-87 MCH-28.6 MCHC-32.9 RDW-13.6 RDWSD-42.9 Plt ___ ___ 05:45AM BLOOD Glucose-98 UreaN-19 Creat-0.6 Na-144 K-3.9 Cl-115* HCO3-19* AnGap-10 ___ 05:45AM BLOOD ALT-73* AST-77* AlkPhos-49 TotBili-0.8 ___ 07:02AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.9 ___ 05:45AM BLOOD Lactate-1.6 Discharge labs ___ 06:01AM BLOOD WBC-6.1 RBC-3.94 Hgb-11.0* Hct-32.1* MCV-82 MCH-27.9 MCHC-34.3 RDW-13.8 RDWSD-41.1 Plt ___ ___ 06:01AM BLOOD Glucose-111* UreaN-11 Creat-0.5 Na-143 K-3.1* Cl-104 HCO3-26 AnGap-13 ___ 06:01AM BLOOD ALT-52* AST-49* AlkPhos-99 TotBili-0.6 ___ 06:01AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.8 Imaging Imaging: - CXR (___): Hypoinflated lungs without acute cardiopulmonary process. - RUQUS (___): There is mild-to-moderate intrahepatic biliary dilatation with common bile duct measuring up to 16 mm. A reported pancreatic mass is not well seen on this study. - CT A/P with contrast ___ Catholic): Impression: 1. Moderate intrahepatic and extrahepatic biliary ductal dilatation at the level of the pancreatic head. There is an ill-defined region of soft-tissue attenuation arising from the pancreatic head suspicious for malignancy. 2. Nonspecific infiltrative retroperitoneal soft tissue encasing the aorta and left adrenal as well as the confluence of the IVC and left renal vein. Findings may be due to retroperitoneal fibrosis. Possibility of malignancy cannot be excluded particularly given the concomitant abnormality in the pancreatic head. 3. Constipation. Sigmoid diverticulosis with muscularis hypertrophy due to chronic diverticulitis. 4. Nonspecific 5 mm left lower lob pulmonary nodule. MRCP ___ 1. Moderate extrahepatic and intrahepatic biliary dilatation associated with moderate smooth narrowing as the ampulla is approached. There seems to be a smooth thick rind of dense tissue with delayed enhancement along the course of the distal common bile duct, although no definite discrete mass is visualized. Although it is possible that this appearance reflects subtle infiltration by pancreatic adenocarcinoma or cholangiocarcinoma, benign stricture should also be considered, perhaps associated with focal autoimmune or chronic pancreatitis. In addition to suspected stricturing, age and prior cholecystectomy may contribute to biliary dilatation on imaging, and a lack of substantial laboratory abnormalities in this patient is noted, so the degree of visible dilatation may exaggerate the severity of functional obstruction. No choledocholithiasis. Comparison to more remote prior imaging, if available, would be helpful. 2. Extensive retroperitoneal inflammation consistent with retroperitoneal fibrosis/peraortitis with suspected active inflammatory component. No vascular narrowing associated with this aside from perhaps some narrowing of the left renal vein. This type of appearance may be associated with IgG4 disease. 3. Heterogeneous early hepatic enhancement, query possibility of parenchymal abnormality. Brief Hospital Course: Ms. ___ is a ___ woman with history of HTN, breast cancer s/p mastectomy presenting with nausea, vomiting, and abdominal pain, found to have possible pancreatic head mass with biliary ductal dilatation. #Sepsis ___ #possible cholangitis/biliary obstruction #Abdominal pain, nausea, vomiting - Patient with fever and leukocytosis ___ SIRS criteria) with suspected abdominal source of sepsis. She was found to have elevated transaminases and question of pancreatic head mass with biliary ductal dilatation on OSH imaging. She was given zosyn x 1 then maintained on ceftriaxone and flagyl. CT scan reviewed by our radiologist did not show pancreatic mass, rather demonstrated CBD thickening and narrowing. MRCP with findings as above with CBD narrowing and enhancement, also retroperitoneal fibrosis and peraortitis. She underwent EUS with biopsy with ERCP team on ___. No stones or sludge were seen therefore antibiotics were discontinued. Biopsies and brushings of CBD were taken. Her pain improved (but not resolved) and patient tolerating a regular diet. I discussed with patient that because pain was not resolved and I wasn't sure if biliary abnormalities were the source, I would ideally keep her another day for further assessment. Patient was adamant about going home and that she did not want further treatment in the hospital. Because she was hemodynamically stable, tolerating PO, and pain controlled on PO medications, we agreed on discharge and that patient would follow up with her PCP to make sure abdominal pain continued to improve and decide if further work up was warranted. This was also communicated to patient's family. #Retroperitoneal fibrosis #Peraortitis #Possible IgG4 related disease # Left hydronephrosis: MRCP showed RP fibrosis and evidence of peraortitis possibly consistent with IgG4 related disease. IgG subclasses were sent and pending at time of discharge. Path from EUS/bx also pending and would aid in diagnosis. Per ERCP team, if path appears consistent with IgG4 disease, they would refer her to GI/Pancreas team. # Anemia: Unknown baseline, no evidence of active bleeding. She was noted to have low iron on iron studies, could consider screening colonoscopy if within GOC or PO iron supplementation # Thrombocytopenia: Unknown baseline. Normal spleen on outside CT. Counts recovered over admission, may have been related to sepsis # Hypertension: continued on home HCTZ # Anxiety: continued home lorazepam #Constipation: CT scan from OSH with constipation. Discharged on miralax daily Transitional care issues [ ] Anemia - further work up to be determined by PCP, could consider PO iron supplementation [ ] f/u IgG level and biopsy from EUS Greater than 30 minutes were spent providing and coordinating care for this patient on day of discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LORazepam 0.5 mg PO QHS:PRN Insomnia 2. Hydrochlorothiazide 25 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Polyethylene Glycol 17 g PO DAILY constipation Please take to keep stools regular, can hold for loose stools RX polyethylene glycol 3350 [ClearLax] 17 gram 1 powder(s) by mouth daily Disp #30 Packet Refills:0 3. TraMADol 25 mg PO Q6H:PRN Pain - Moderate Duration: 5 Days RX tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6 hours Disp #10 Tablet Refills:0 4. Hydrochlorothiazide 25 mg PO DAILY 5. LORazepam 0.5 mg PO QHS:PRN Insomnia Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Common bile duct narrowing Retroperitoneal fibrosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ were admitted for abdominal pain which may have been related to a narrowing in your bile duct. ___ had an endoscopic procedure which took tissue samples of this area to help in diagnosis. Results will be back in ___ days. No bile stones or infection were seen on endoscopy. ___ had an MRI which showed fibrosis near the kidneys and aorta with some inflammation. This may be related to something called IgG4 disease. The tissue samples from the procedure will help diagnose this as well. The endoscopy team will refer ___ to a gastroenterologist or pancreas specialist if the test comes back positive. Your scan from the other hospital showed chronic constipation so please take stool softener prescribed. Please follow up with your PCP so she can assess your abdominal pain and make sure it is not getting worse. If pain is worse or not improving, your primary doctor may want to do other testing or consider a trial of steroids for IgG4 disease. Followup Instructions: ___
10314068-DS-13	10,314,068	25,342,851	DS	13	2154-02-16 00:00:00	2154-02-16 17:24:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Aphasia Major Surgical or Invasive Procedure: ___ left craniotomy for subdural evacuation History of Present Illness: Mr. ___ is a ___ year old gentleman with a history of CLL who presents as a transfer from ___ with a subdural hematoma. The patient had noted some speech and word finding difficulty prior to presentation but did not seek medical attention. His daughter-in-law notified his Hematologist who recommended he go to the ER. Upon arriving to the ___ ___, imaging revealed a large L SDH with 1.7cm of midline shift. He was subsequently transferred to ___ for further neurosurgical evaluation. Past Medical History: CLL, urinary retention from BPH (?), HLD Social History: ___ Family History: NC Physical Exam: ON ADMISSION: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: word finding difficulty Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch Coordination: normal on finger-nose-finger with mild dysmetria on R Handedness: Right ON DISCHARGE: Awake, alert and oriented. Left craniotomy site CDI, closed with sutures. Occasionally slow to find wording. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Pertinent Results: ___ CXR Mild cardiomegaly is associated with top-normal mediastinal contour. Lungs are clear. There is no appreciable pleural effusion. There is no pneumothorax. Mild vascular congestion cannot be excluded. ___ CT head Status post left frontal craniotomy for evacuation of a left hemispheric subdural hematoma. Since the prior CT, the subdural hematoma has slightly decreased in size with mildly decreased rightward midline shift. No intraparenchymal or intraventricular hemorrhage. ___ CT head 1. Minimally decreased left hemispheric subdural hematoma status-post left frontal craniotomy and drain placement. 2. Minimally decreased rightward midline shift. 3. In the setting of a large subdural hematoma with midline shift, dilated bilateral superior ophthalmic veins are almost certainly the sequela of high intracranial pressure rather than cavernous sinus thrombosis. ___ CXR Comparison to ___. No relevant change is noted. Moderate cardiomegaly. Low lung volumes. Mild pulmonary edema. No pleural effusions. No pneumonia. ___ CT head No relevant changes in this patient status post left craniotomy for left subdural hematoma which demonstrates mixed density blood products, stable in volume and resultant mass effect. ___ BILAT LOWER EXT VEINS No evidence of deep venous thrombosis in the right or left lower extremity veins. There is a small left ___ cyst. ___ CT HEAD W/O CONTRAST IMPRESSION: 1. Status post left craniectomy for evacuation of subdural hematoma, with mild decrease in mass effect, as described above. Otherwise, no significant interval changes compared to the prior study from ___. 2. No new hemorrhage detected. ___ PLT 20 (Baseline ___ Given 1 pack platelets. Brief Hospital Course: Mr. ___ is a pleasant ___ year old gentleman who was admitted to the neurosurgery service for management of left subdural hematoma. # Left subdural hematoma Unop arrival the patient was admitted to the Neuro ICU given size of subdural and history of CLL. Patient started on prophylaxis antiepileptics. Patient went to the OR on ___ for left craniotomy for subdural evacuation with Dr. ___ procedure was uneventful, patient was extubated in the OR and transferred to the Neuro ICU for close monitoring. NCHCT was repeated on ___ for concern for worsened mental status which was stable. Subdural drain was removed on ___ and post pull CT scan was stable. EEG monitoring was placed for concern for worsened mental status and was negative for seizures. The patient remained stable from a neurologic perspective on ___ and was transferred to the floor. His examination remained stable for the remainder of admission. Repeat head CT on ___ showed slight decrease in mass effect. #Thrombocytopenia Known history of thrombocytopenia in the setting of Ibrutinib treatment. The patient's platelet counts were monitored closely during his admission with hematology following. He received platelets prior to the OR and prior to removal of subdural drain. The patient experienced no episodes of bleeding during this admission. At the time of discharge, the patient's platelet count was 20, he was given 1pack of platelets on ___, consistent with home baseline of ___. #Hyponatremia Patient was noted to be hyponatremic to 134 on ___ and was started on a hypertonic saline drip. Sodiums were closely monitored and hypertonic saline drip was titrated to a goal of 135-145. Hypertonic saline was stopped on ___ and his Na was trended and remained stable for the remainder of admission. #Neutropenia Known neutropenia secondary to CLL. Patient was febrile on ___ and was started on empiric Vancomycin and Cefepime. Cultures obtained were without growth. Antibiotics were discontinued on ___ and the patient subsequently remained afebrile for the remainder of admission. Inbrutibib was stopped on admission and after discussion with outpatient oncologist, will remain on hold until outpatient follow up after rehab. #Hypertension The patient was hypertensive preoperatively (average SBP 150). Postoperatively, the patient's systolic blood pressure goal was less than 160 mmHg. The patient intermittently required short-acting anti-hypertensives and was subsequently initiated on amlodipine 5 mg on ___. The patient has been instructed to follow up with his primary care physician following discharge for continued management of hypertension. Medications on Admission: Alfuzosin ER 10mg QD, Finasteride 5mg QD, Atrovastatin 10mg QD, Ibrutinib Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain OTC 2. amLODIPine 5 mg PO DAILY 3. Bisacodyl 10 mg PO DAILY:PRN Constipation 4. Docusate Sodium 100 mg PO BID 5. Famotidine 20 mg PO BID 6. Heparin 5000 UNIT SC BID 7. LevETIRAcetam 1000 mg PO BID 8. Milk of Magnesia 30 mL PO Q6H:PRN Constipation 9. Senna 17.2 mg PO QHS 10. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 11. Tamsulosin 0.4 mg PO DAILY 12. Finasteride 5 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left Subdural Hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Surgery · * You underwent a surgery called a craniotomy to have blood removed from your brain. · Please keep your sutures or staples along your incision dry until they are removed. · It is best to keep your incision open to air but it is ok to cover it when outside. · Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity · We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. · You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. · No driving while taking any narcotic or sedating medication. · If you experienced a seizure while admitted, you are NOT allowed to drive by law. · No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications · Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. · **You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. You should continue this medication until your follow up with Dr. ___. · You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: · You may have difficulty paying attention, concentrating, and remembering new information. · Emotional and/or behavioral difficulties are common. · Feeling more tired, restlessness, irritability, and mood swings are also common. · You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. · You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. · Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: · Headache is one of the most common symptoms after a brain bleed. · Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. · Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. · There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: · Severe pain, swelling, redness or drainage from the incision site. · Fever greater than 101.5 degrees Fahrenheit · Nausea and/or vomiting · Extreme sleepiness and not being able to stay awake · Severe headaches not relieved by pain relievers · Seizures · Any new problems with your vision or ability to speak · Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: · Sudden numbness or weakness in the face, arm, or leg · Sudden confusion or trouble speaking or understanding · Sudden trouble walking, dizziness, or loss of balance or coordination · Sudden severe headaches with no known reason Followup Instructions: ___
10314068-DS-14	10,314,068	24,052,260	DS	14	2154-02-23 00:00:00	2154-02-23 17:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: fever Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ man PMH CLL (previously on ibrutibib) s/p l craniotomy for subdural evacuation (discharged ___ p/w fever to 100.4. He reports associated cough that has improved. He denies any dysuria. Of note, patient has an expressive aphasia (which has been present since ___). In review of medical record, he was admitted ___ after presenting to ___ with a subdural hematoma. The patient had noted some speech and word finding difficulty prior to presentation but did not seek medical attention. His daughter-in-law notified his Hematologist who recommended he go to the ER. Upon arriving to the ___ ___, imaging revealed a large L SDH with 1.7cm of midline shift. He was subsequently transferred to ___ for further neurosurgical evaluation. Patient went to the OR on ___ for left craniotomy for subdural evacuation. His course was complicated by AMS of unclear etiology as well as pancytopenia. He required platelet transfusion in the ___ period. His ibrutibib was during that admission and since admission per recommendations of his outpatient oncologist. In the ED, initial vitals were: 99 77 147/67 18 96% RA - Exam notable for: Neuro at baseline, EOMI intact, pupils 3mm b/l, Strength ___, expressive aphasia without receptive aphasia LLLF crackles Nonproductive cough - Labs notable for: 1.2> 6.9/19.5<24 78% neutrophils (previously pan cytopenic but worse than baseline) lactate 0.8, Na 131, crt 1 - Imaging: Low lung volumes with moderate cardiomegaly and mild interstitial pulmonary edema. - Stable left subdural hematoma with decreased mass-effect compared to ___. No new hemorrhage is identified. - NSGY contacted about patient and felt there was no neurosurgical intervention necessary. - Patient received vanc and cefepime. Upon arrival to the floor, patient reports that he feels fine but would like some water. He is having word finding difficulties. Past Medical History: CLL, recent SDH, urinary retention from BPH (?), HLD Social History: ___ Family History: NC Physical Exam: ADMISSION EXAM ============== ___ - well appearing man, NAD, speaking in full sentences HEENT - stable in place on scull, MM, no lesions NECK - no JVD CARDIAC - RRR, no M/R/G LUNGS - CTAB ABDOMEN - soft, non-tender EXTREMITIES - no edema NEUROLOGIC - aphasia, moving all extremities, PERLA, CN II-XII intact SKIN - no rash DISCHARGE EXAM =============== VS: 98.2PO 133 / 69 78 18 97 RA ___ - well appearing man, NAD, difficult to express words but demonstrates understanding of language HEENT - craniotomy incision c/d/i, mild erythema surrounding lesion but no TTP, warmth, edema NECK - JVP flat CARDIAC - RRR, no M/R/G LUNGS - CTAB ABDOMEN - s/nd/nt EXTREMITIES - no ___ edema. 4 cm ecchymosis on L knee, non-tender to palpation. NEUROLOGIC - aphasic speech but demonstrates verbal understanding of speech. CN II-XII intact. moving all extremities spontaneously. sensation intact. SKIN - no rashes or lesions Pertinent Results: ADMISSION LABS ============== ___ 07:50PM BLOOD WBC-1.2* RBC-2.07* Hgb-6.9* Hct-19.5* MCV-94 MCH-33.3* MCHC-35.4 RDW-12.5 RDWSD-42.4 Plt Ct-24* ___ 07:50PM BLOOD Neuts-78* Bands-0 Lymphs-12* Monos-6 Eos-3 Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-0.94* AbsLymp-0.16* AbsMono-0.07* AbsEos-0.04 AbsBaso-0.00* ___ 07:50PM BLOOD Glucose-115* UreaN-18 Creat-1.0 Na-131* K-4.1 Cl-97 HCO3-23 AnGap-15 ___ 07:50PM BLOOD Hapto-40 ___ 05:37AM BLOOD IgG-984 IgA-51* IgM-100 ___ 08:01PM BLOOD Lactate-0.8 ___ 03:54PM URINE Color-Yellow Appear-Clear Sp ___ ___ 03:54PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 03:54PM URINE RBC-143* WBC-5 Bacteri-NONE Yeast-NONE Epi-0 ___ 05:10AM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE MICRO ===== BLOOD CULTURES x3 without growth. URINE CULTURE ___ NEGATIVE ___ 9:01 pm CATHETER TIP-IV Source: PICC. FINAL REPORT ___ WOUND CULTURE (Final ___: No significant growth. ___ 5:10 am Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. FINAL REPORT ___ Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. IMAGING ======= CT HEAD W/O CONTRAST ___ Stable left subdural hematoma with decreased mass-effect compared to ___. No new hemorrhage is identified. CHEST PA&LAT ___ No radiographic evidence of acute cardiopulmonary disease. RUQ US ___ IMPRESSION: 1. Biliary sludge and cholelithiasis. No specific sonographic evidence for acute cholecystitis. 2. No biliary ductal dilation. 3. Splenomegaly, 18.6 cm, may be related to patient's provided history of CLL. DISCHARGE LABS ============== ___ 05:05AM BLOOD WBC-1.2* RBC-2.45* Hgb-7.9* Hct-23.3* MCV-95 MCH-32.2* MCHC-33.9 RDW-13.7 RDWSD-46.3 Plt Ct-28* ___ 05:05AM BLOOD Neuts-58 Bands-1 ___ Monos-6 Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.71* AbsLymp-0.42* AbsMono-0.07* AbsEos-0.00* AbsBaso-0.00* ___ 05:05AM BLOOD Glucose-93 UreaN-22* Creat-1.1 Na-135 K-4.1 Cl-102 HCO3-22 AnGap-15 ___ 05:05AM BLOOD ALT-8 AST-11 LD(LDH)-262* AlkPhos-202* TotBili-0.7 ___ 05:05AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.2 Brief Hospital Course: Mr. ___ is a ___ yo man with CLL, recent SDH presenting with neutropenic fever. # Febrile Neutopenia: Intermittent fevers up to 101 upon arrival and beginning of admission. Besides a mild cough, patient w/ no focal s/s infection. No sputum production to send for cx. Did arrive w/ a PICC in place, removed and sent for culture, which was negative. Influenza swab negative. ANC 940 on admission and downtrended to a nadir of 630, but rebounded to 710 on discharge. Exam, cultures, CXR and RUQUS without cause of fever. No growth on blood and urine cultures. Treated w/ IV vanc/cefepime, then narrowed to cefepime on ___, and then to PO levofloxacin on ___. Remained afebrile after ___. # CLL # Recent SDH # Pancytopenia: Previously treated w/ ibrutibib, but developed SDH, a rare but known side effect of that medication. S/p recent hospitalization w/ craniotomy, patient stabilized but has persistent expressive aphasia at baseline now. CT head this admission w/ no acute changes. Patient has not been treated for his CLL since that recent admission. Spoke to outpt oncologist, pt has appointment in mid ___ to discuss potential of restarting another systemic chemo, but no need for onc c/s at this time. Per oncologist, patient's worsening pancytopenia most likely ___ CLL not currently being treated. Hemolysis labs negative. Immunoglobulin levels normal. # HTN: continued home amlodipine TRANSITIONAL ISSUES ================== [] Patient will finish 1 week of antibiotic therapy with levofloxacin on ___ [] ANC at discharge = 710. Please repeat CBC/diff on ___ to track neutropenia. [] Alk phos, LDH, and GGT noted to be elevated during admission. RUQ showed gallstones without obstruction. Consider repeating LFTs as outpatient and monitor for signs of cholelithiasis or complications in future. [] L PICC line removed during admission. PICC tip culture negative. # CODE: Full Code (confirmed) # CONTACT: Name of health care proxy: ___ Phone number: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 2. amLODIPine 5 mg PO DAILY 3. Bisacodyl 10 mg PO DAILY:PRN Constipation 4. Docusate Sodium 100 mg PO BID 5. Famotidine 20 mg PO BID 6. Finasteride 5 mg PO DAILY 7. LevETIRAcetam 1000 mg PO BID 8. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 9. Senna 17.2 mg PO QHS 10. Milk of Magnesia 30 mL PO Q6H:PRN Constipation 11. Tamsulosin 0.4 mg PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 2. amLODIPine 5 mg PO DAILY 3. Bisacodyl 10 mg PO DAILY:PRN Constipation 4. Docusate Sodium 100 mg PO BID 5. Famotidine 20 mg PO BID 6. LevETIRAcetam 1000 mg PO BID 7. Levofloxacin 750 mg PO DAILY Duration: 1 Dose until ___. Milk of Magnesia 30 mL PO Q6H:PRN Constipation 9. Senna 17.2 mg PO QHS 10. Tamsulosin 0.4 mg PO DAILY 11. Finasteride 5 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Febrile Neutropenia SECONDARY DIAGNOSIS ==================== Chronic Lymphocytic Leukemia Hypertension Chronic Anemia Chronic 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 for having a fever and low blood counts. Your low blood counts are likely due to your blood cancer. We gave you antibiotics and tested you for infections. None of the tests showed a bacterial infection, and your fever did not come back. You will go back to a rehab facility and finish a course of oral antibiotics. We wish you the best of health, Your ___ Care Team Followup Instructions: ___
10314106-DS-16	10,314,106	22,190,684	DS	16	2119-08-24 00:00:00	2119-08-25 20:27:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___ ___ drain History of Present Illness: This is a ___ year-old male with history of insulin-dependent diabetes mellitus and more recently perforated appendicitis complicated by a pelvic abscess that required percutaneous drainage, now with increasing abdominal pain, nausea and emesis. Patient was discharged from our hospital on ___ with a drain ___ place and on oral antibiotics (2-week course of ciprofloxacin and metronidazole). Since discharge, he admits to having persistent mild lower abdominal pain, nausea, and diarrhea. He was seen ___ clinic on ___ for a scheduled follow-up appointment and found overall to be progressing well, however given symptoms and the amount of output from his drain, he was scheduled to undergo a repeat CT scan next ___. Since yesterday, patient reports worsening nausea, one episode of non-bloody, non-bilious emesis, and slightly worsening abdominal pain. As before, he states that the pain is located mostly on the lower abdomen, is continuous and cramping, improved when lying still and with Motrin, exacerbated by movement and when going from the sitting to the upright position. He states nausea improved after taking some Zofran last night, however this morning it increased ___ intensity once again with a few episodes of dry heaving. Mr ___ denies fevers, but endorses occasional chills as well as anorexia (both from decreased appetite and from the nausea). His drain output has been slowly decreasing, from 25 cc/day three days ago, to 10 cc/day yesterday. He has been flushing his drain on a daily basis. He continues to take his antibiotics, except for yesterday given the nausea. Past Medical History: IDDM w/ diabetic retinopathy Hyperlipidemia Hypertension Nephrolithiasis Social History: ___ Family History: NC Physical Exam: Physical examination: On admission Vital signs - 98.3 88 152/63 16 100% RA Constitutional - Well appearing, ___ no distress Cardiopulmonary - RRR, normal S1 and S2. No murmurs. CTAB Abdominal - Lower abdominal drain ___ place, insertion site appears intact. Drain bag with thin, yet purulent light brown output. Abdomen is somewhat firm, non-distended, with lower abdominal tenderness, worse on the left lower quadrant. No rebound or guarding Extremities - Atraumatic, no clubbing, cyanosis or edema Neurologic - Grossly intact. Alert and oriented x 3 Physical examination upon discharge: ___ vital signs: t=98.5, hr=80, 141/64, rr=18, oxygen sat=97% General: NAD CV: ns1, s2, -s3, -s4, LUNGS: clear ABDOMEN: soft, lower left adominal drain with DSD, post. right drain with DSD, no drain ___ bulbs EXT: no calf tenderenss bil., no pedal edema bil. NEURO: alert and oriented x 3 Pertinent Results: ___: CT abd/pelvis 1. Acute peritonitis with 3 new rim enhancing fluid collections, consistent with abscess. Two of these ___ the right flank inferior to the liver are likely communicating, and one is ___ the pelvis, between the bladder and rectum. 2. No residual collection at the site of the existing pigtail catheter. 3. Small bilateral pleural effusions. 4. Diffuse bowel wall thickening is likely reactive. ___: CT procedure The patient was initially placed ___ prone position on the CT table for drainage of the pelvic fluid collection. Limited preprocedure CTscan was performed to localize the collection. Based on the CT findings an appropriate skin entry site for right trans gluteal approach was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was inserted into the collection. A sample of fluid was aspirated, confirming needle position within the collection. A 0.038 ___ wire was placed through the needle and needle was removed. An ___ pigtail catheter was placed over the wire into the collection. Th metal stiffener and the wire were removed. The pigtail was deployed. The position of the pigtail was confirmed within the collection via CT fluoroscopy. Approximately 15 cc of purulent fluid was aspirated with a sample sent for microbiology evaluation. The catheter was secured by a StatLock. The catheter was attached to bag. Sterile dressing was applied. The patient was then placed ___ supine position on the CT scan table. Contrasted CT images were obtained of the abdomen and pelvis. Two accessible fluid pockets ___ the right lower quadrant were targeted for aspiration, one slightly anterior and one more posterior. An appropriate skin entry site for the posterior collection was chosen first. 1% lidocaine was administered for local anesthesia. Using CT guidance, an 18 gauge ___ needle was inserted into the collection. A syringe was attached to the needle, and a total of 1 clear fluid was aspirated. Further attempt at aspiration did not yield any additional fluid. Next, a skin entry site for the anterior fluid collection was chosen and aspiration was performed using the same procedure as above, yielding a total of 5 cc clear fluid. The aspirated samples were sent for microbiology evaluation. Given the small size of these fluid collections, an additional drain was not placed. The procedure was tolerated well, and there were no immediate post-procedural complications. ___: CT abd/pelvis IMPRESSION: 1. Resolution of pelvic and intra-abdominal abscesses with 2 pigtail drains ___ situ. 2. Decrease ___ size of a perihepatic fluid collection. 3. No new fluid collection. 4. Small right and trace left pleural effusions are unchanged from ___ ___ 09:50AM BLOOD WBC-5.4 RBC-3.96* Hgb-12.2* Hct-35.3* MCV-89 MCH-30.8 MCHC-34.5 RDW-12.9 Plt ___ ___ 07:48AM BLOOD WBC-7.6 RBC-4.20* Hgb-13.0* Hct-38.4* MCV-91 MCH-30.9 MCHC-33.8 RDW-13.1 Plt ___ ___ 10:08AM BLOOD WBC-9.1 RBC-4.31* Hgb-13.3* Hct-39.7* MCV-92 MCH-30.8 MCHC-33.4 RDW-13.1 Plt ___ ___ 10:08AM BLOOD Neuts-84.6* Lymphs-9.0* Monos-5.3 Eos-0.8 Baso-0.2 ___ 09:50AM BLOOD Plt ___ ___ 11:09AM BLOOD ___ ___ 09:50AM BLOOD Glucose-191* UreaN-9 Creat-1.1 Na-136 K-4.6 Cl-93* HCO3-29 AnGap-19 ___ 09:50AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.2 ___ 3:32 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. *FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. ___ 5:15 pm ABSCESS PELVIC ABSCESS. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS, CHAINS, AND CLUSTERS. SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Brief Hospital Course: ___ year old gentleman previously admitted with appendiceal abscess, was discharged home with RLQ drain. He was readmitted to the hospital on ___ for increased abdominal pain. A cat scan was done which showed multiple fluid collections. He underwent ___ placement of a pigtail catheter into the pelvic collection via transgluteal approach. 15cc of pus was aspirated and sent for culture. Also 2 fluid pockets ___ RLQ (5 cc from anterior, 1 cc from posterior) were aspirated. No new drain was placed to RLQ. The patient was started on a course of zosyn for gm + cocci. The patient's white blood cell count was monitored. His appetite and his overall health status gradually improved. His diarrhea which was more pronounced on admission had decreased. Prior to discharge, the patient underwent an abdominal cat scan which showed resolution of the pelvic and intra-abdominal abscesses with 2 pigtail drains ___ situ. No new fluid collections were identified. The ___ drains were converted to bulb catheters. The patient was discharged home on HD #6 ___ stable condition. His zosyn was converted to augmentin for completion of a ___ follow-up appointment was made on ___, for potential removal of the drains. Medications on Admission: Novolin R human recombinant 100 units/mL 0.1 units/kg pump, simvastatin 40 daily, mavik 4 mg daily, ASA 81 mg daily, vitamin D 400 daily Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain/fever 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H last dose ___ RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #20 Tablet Refills:0 3. Insulin Pump SC (Self Administering Medication)Insulin Aspart (Novolog) (non-formulary) Basal rate minimum: 0.4 units/hr Basal rate maximum: 0.8 units/hr Bolus minimum: 1 units Bolus maximum: 12 units Target glucose: ___ Fingersticks: Q6H, if NPO MD acknowledges patient competent MD has completed competency 4. Trandolapril 4 mg PO DAILY 5. Simvastatin 40 mg PO DAILY 6. Aspirin 81 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: abdominal abscesses Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You returned to the hospital with abdominal pain. You underwent a cat scan of the abdomen and you were found to have new abdominal collections. You had an additional drain placed for drainage. The collections have decreased ___ size. You are now preparing for discharge home and will follow-up ___ clinic to have the drains removed. Please call your doctor or return to the emergency room if you have any of the following: * Increased drainage from the drains, drainage from around drain sites * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep ___ fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change ___ your symptoms, or any new symptoms that concern you. You will also need to follow- up with your primary care provider, Dr. ___ to address the left lung nodules. Followup Instructions: ___
10314106-DS-17	10,314,106	21,051,268	DS	17	2119-11-24 00:00:00	2119-11-30 22:16:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Abdominal pain, fever Major Surgical or Invasive Procedure: ___: ___ drainage of right lower quadrant abscess History of Present Illness: Mr. ___ is a ___ year old gentleman with perforated appendicitis complicated by pelvic abscesses treated conservatively with antibiotics and ___ placed drains. After removal of the drains and completion of PO antibiotics (cipro/flagyl, then augmentin due to GI upset), he had another abscess that was treated with antibiotics. He then underwent an interval appendectomy on ___ notably, the case was difficult because of chronic inflammation. He went home that day and was doing well at home. He tolerated a regular diet and pain was well-controlled without pain medications. However, the day prior to presentation, ___, he started having lower abdominal pain, chills, malaise, and fever to 103.4. He called the clinic in the morning of day of presentation, ___, and was asked to come in to the ED for evaluation. He denies any changes in bowel habits. He is passing flatus and having bowel movements. Past Medical History: IDDM w/ diabetic retinopathy Hyperlipidemia Hypertension Nephrolithiasis Social History: ___ Family History: Noncontributory Physical Exam: Vitals: Temp 99.7, HR 89, BP 145/51, RR 18, SpO2 97% on room air Gen: pleasant gentleman in no acute distress, alert and oriented Lungs: clear to auscultation bilaterally, non-labored breathing CV: regular rate and rhythm Abd: soft, non-distended, mildly tender to palpation in area of RLQ drain Ext: warm and well-perfused, peripheral pulses intact Pertinent Results: CT ABDOMEN/PELVIS (___): 1. Complex fluid and gas collections in the right lower quadrant, extending along the inferior peritoneal cavity to the contralateral side. The main collection abuts the severely thickened cecal wall. 2. There is also significant peritoneal enhancement and stranding of the right lower quadrant and inferior peritoneal cavity with significant inflammatory changes of the terminal ileum, loops of the small bowel in the region and the urinary bladder dome, likely reactive to the adjacent severe peritoneal inflammation. INTERVENTIONAL RADIOLOGY PROCEDURE (___): CT-guided placement of an ___ pigtail catheter into the right lower quadrant fluid collection. Samples were sent for microbiology evaluation. Brief Hospital Course: The patient presented to the ___ Emergency Department on ___. Upon arrival to the ED a CT scan was performed and he was found to have a right lower quadrant fluid collection. Given these findings, the patient was admitted to the Acute Care Surgery service for management. On hospital day 2, this right lower quadrant fluid collection was drained by ___ and an ___ pigtail catheter was left in place. He was then discharged home with ___ services and a 10-day course of Augmentin. He will follow up in the ___ clinic on ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Simvastatin 40 mg PO QPM 3. Trandolapril 4 mg PO DAILY 4. Vitamin D 400 UNIT PO DAILY 5. Insulin Pump SC (Self Administering Medication)Insulin Aspart (Novolog) (non-formulary) Target glucose: 80-180 Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth twice a day Disp #19 Tablet Refills:0 2. Aspirin 81 mg PO DAILY 3. Simvastatin 40 mg PO QPM 4. Trandolapril 4 mg PO DAILY 5. Vitamin D 400 UNIT PO DAILY 6. Insulin Pump SC (Self Administering Medication)Insulin Aspart (Novolog) (non-formulary) Target glucose: 80-180 7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain You may not drive while taking Oxycodone pain medication RX oxycodone 5 mg ___ tablet(s) by mouth every four hours Disp #30 Tablet Refills:0 8. Docusate Sodium 100 mg PO BID Hold for loose stools RX docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Post-operative abscess 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 fever and abdominal pain. We performed a CT scan which showed a fluid collection. This collection was drained by the interventional radiologists and a drain was left in place. We will set up ___ services to assist you with drain care when you return home. Additionally, we will send you home with a prescription for an oral antibiotic called Augmentin. Please take this medication as prescribed. 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. General Drain Care: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. Wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Best wishes, Your ___ surgical team Followup Instructions: ___
10314252-DS-3	10,314,252	25,593,676	DS	3	2165-09-13 00:00:00	2165-09-13 16:39:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain, diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ year old female with history significant for HTN, palpitations on digoxin, diverticulitis, IBS, GERD, anxiety and depression who presents with 10 days of abdominal pain and diarrhea. Abdominal pain described as intermittent crampy abdominal pain, worst in RLQ for the past 10 days. Worse with eating and laying down, better when taking her medications at night. Currently ___ pain but was worse in the ED. Has had decreased PO intake because of the pain associated with eating but had scrambled eggs this morning without vomiting. To note she had a G-tube placed about 8 months ago because she was underweight. States she has gained about 50 lbs since then. The G-tube was removed in ___. Also describes ~3 episodes of diarrhea per day which are "black" and watery. No BRBPR. Worries she may be dehydrated with decreased urinary output but no symptoms of lightheadedness, presyncope, SOB, chest pain or palpitations. No recent travel or sick contacts. She is very anxious on interview and is hoping to go home tomorrow. She denies fever/chills, rashes. She had a recent visit to ___ for abdominal pain and urinary symptoms where she was diagnosed with a UTI. Started on Macrobid last ___ with plan to finish 7 day course on ___. No current dysuria, frequency or urgency. In the ED, initial vitals were: T 96.2 BP 156/71 HR 79 RR 18 O2 95% RA Exam was notable for: - Abd: Soft, nondistended; normal bowel sounds; tender to palpation in lower abdomen, particularly near midline, mild umbilical tenderness, no epigastric/RUQ tenderness Labs were notable for: (use specific numbers) - WBC 5.8 - ALT 18, AST 28, AP 20, Tbili 0.2 - Dig < 0.4 Studies were notable for: - ___ CT abdomen/pelvis w/ contrast: 1. Apparent circumferential rectal wall thickening may be due to underdistention, but in the context of the patient's symptoms, is suggestive of proctitis. 2. Cholelithiasis without acute cholecystitis. New mild intrahepatic biliary ductal dilatation with suggestion of stone within the common bile duct. MRCP is recommended for further assessment. 3. Stable 0.6 cm splenic artery aneurysm. EKG - Sinus with probably left atrial enlargement. The patient was given: - Ceftriaxone 1g IV, Flagyl 500mg IV - 1L LR Past Medical History: Past psychiatric history: Reviewed and updated as needed from initial psychiatry consult note by ___ from ___. "Hospitalizations: none patient reports that for over ___ years she had agoraphobia and for the past years only went between her and her mother's house and mother lived next door until her death ___ years ago. Current treaters and treatment: none per patient, per her PCP the patient has a psych treater ___ @ ___ @ ___ ) Former psychiatrist Dr. ___, patient saw him for ___ years until he retired ___ years ago Medication: Venlafaxine, Trazodone, Clonazepam Doxepin, Fluoxetine Mirtazapine Self-injury: denies previous suicide attempts until today Harm to others: denies Access to weapons: denies access to guns" Past medical history: Reviewed and updated as needed from initial psychiatry consult note by ___ from ___. * PCP ___ (___) * GERD * Irregular heart rate-states this had been case since patient was in ___. * IBS * abnormal mammogram * Colonic polyps * urinary frequency Social History: ___ Family History: Family psychiatric history: Reviewed and updated as needed from initial psychiatry consult note by ___ from ___. "* Mother with depression * Father alcoholic * Son with developmental delay * Ex husband alcoholic * Brother used marijuana and cocaine" Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: T98.3, BP 168/78, HR 60, RR 16, O2 95% on RA GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended. Tender to palpation in RUQ, RLQ, and LLQ, worst in RLQ. No rebound or guarding. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. DISCHARGE PHYSICAL EXAM: ======================== ___ Temp: 98.0, BP: 134/72, HR: 90, RR: 18, O2 sat: 93%, O2 delivery: Ra GENERAL: Alert and interactive. NECK: No cervical lymphadenopathy. CARDIAC: RRR. No m/r/g. LUNGS: CTAB, no w/r/r. ABDOMEN: Hyperactive bowels sounds, non distended, nontender to deep palpation. No rebound/guarding. No organomegaly. Negative ___ sign. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. BACK: No CVA tenderness. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. Pertinent Results: ADMISSION LABS: ================ ___ 12:09PM BLOOD WBC-5.8 RBC-4.56 Hgb-13.6 Hct-40.7 MCV-89 MCH-29.8 MCHC-33.4 RDW-12.7 RDWSD-41.6 Plt ___ ___ 12:09PM BLOOD Neuts-73.6* Lymphs-17.9* Monos-7.4 Eos-0.3* Baso-0.5 Im ___ AbsNeut-4.27 AbsLymp-1.04* AbsMono-0.43 AbsEos-0.02* AbsBaso-0.03 ___ 12:09PM BLOOD ___ PTT-26.4 ___ ___ 12:09PM BLOOD Plt ___ ___ 12:09PM BLOOD Glucose-120* UreaN-10 Creat-0.7 Na-140 K-4.4 Cl-99 HCO3-28 AnGap-13 ___ 12:09PM BLOOD ALT-18 AST-28 AlkPhos-20* TotBili-0.2 ___ 12:09PM BLOOD Lipase-35 ___ 12:09PM BLOOD cTropnT-<0.01 ___ 12:09PM BLOOD Albumin-4.0 Calcium-9.3 Phos-3.3 Mg-2.3 ___ 12:09PM BLOOD Digoxin-<0.4* ___ 12:21PM BLOOD Lactate-1.7 RELEVANT LABS: ============= ___ 07:13AM BLOOD WBC-4.7 RBC-4.53 Hgb-13.6 Hct-41.3 MCV-91 MCH-30.0 MCHC-32.9 RDW-12.8 RDWSD-42.0 Plt ___ ___ 07:13AM BLOOD Plt ___ ___ 07:13AM BLOOD Glucose-88 UreaN-6 Creat-0.6 Na-141 K-3.5 Cl-101 HCO3-30 AnGap-10 ___ 07:13AM BLOOD ALT-15 AST-14 AlkPhos-24* TotBili-0.4 ___ 07:13AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.3 ___ 10:19AM STOOL CDIFPCR-NEG RELEVANT MICROBILOGY: ====================== ___ 10:19 am STOOL CONSISTENCY: SOFT Source: Stool. *FINAL REPORT ___ FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. RELEVANT IMAGING: ================= ___BD & PELVIS WITH CO IMPRESSION: 1. Apparent circumferential rectal wall thickening may be due to underdistention, but in the context of the patient's symptoms, is suggestive of proctitis. 2. Cholelithiasis without acute cholecystitis. New mild intrahepatic biliary ductal dilatation with suggestion of stone within the common bile duct. MRCP is recommended for further assessment. 3. Stable 0.6 cm splenic artery aneurysm. ___ Imaging MRCP (MR ABD ___ IMPRESSION: 1. Cholelithiasis with borderline dilated intrahepatic and extrahepatic bile ducts and main pancreatic duct, which are minimally increased compared to prior CT from ___, likely related to chronic changes from prior stone passage or age related changes. No evidence of choledocholithiasis, cholecystitis, cholangitis, or pancreatitis. 2. Lobulated right breast lesion measuring 1.4 cm with benign appearing features and similar to ___ CT. Correlation with mammography/ultrasound is recommended. DISCHARGE LABS: ================= ___ 07:29AM BLOOD WBC-4.1 RBC-4.48 Hgb-13.3 Hct-40.5 MCV-90 MCH-29.7 MCHC-32.8 RDW-12.8 RDWSD-42.1 Plt ___ ___ 07:29AM BLOOD Plt ___ ___ 07:29AM BLOOD Glucose-87 UreaN-9 Creat-0.7 Na-144 K-3.5 Cl-103 HCO3-28 AnGap-13 ___ 07:29AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.2 Brief Hospital Course: Ms. ___ is a ___ year old female with history significant for HTN, palpitations on digoxin, diverticulitis, IBS, GERD, anxiety and depression who presents with 11 days of abdominal pain and diarrhea, now largely resolved. Patient was also concerned of her hyperactive bowel which she notes improvement after starting Simethicone. ACUTE/ACTIVE ISSUES: ==================== # Diarrhea/abdominal pain Patient presents with 11 days of abdominal pain and diarrhea. Work up for this included CT scan of her abdomen which showed possible proctitis but was felt to likely be underdistention of her rectum. She had an MRCP which demonstrated cholethiasis without cholecystitis. Stool studies including C. diff were negative. Digoxin level < 0.4. She was initially treated with antibiotics which were ultimately discontinued due to lack of clear infectious etiology. Etiology of pain and diarrhea was felt to be either IBS or resolving viral infection. Low suspicion for ischemic colitis. Her abdominal pain and diarrhea improved during her hospitalization. She was started on simethicone which helped some of the borborygmi which was most concerning to the patient #Anxiety/Depression: Patient was noted to be very anxious about her borborygmi. Upon evaluation, she reported many symptoms of worsening depression. Psychiatry evaluated the patient and do not think she is actively suicidal. Was started on Seroquel 50mg for depression and increase Sertraline to 100mg. Continued Diazepam 10mg PO QHS, Trazodone 100mg PO QHS. She will follow up with her outpatient psychiatrist and therapist #Insomnia Started on Seroquel per above. #Palpitations Some bradycardia noted ___, asymptomatic. Palpitations may be related to anxiety. Remained on home digoxin. # CT with intrahepatic biliary ductal dilatation MRCP negative for choledocholithiasis, cholecystitis, cholangitis, or pancreatitis CHRONIC/STABLE ISSUES: ====================== #HTN - continue metoprolol tartrate 25mg BID #GERD - Prior EGD ___ years ago with mild gastritis. Stopped Prilosec > ___ year ago. TRANSITIONAL ISSUES: ======================= [] Consider outpatient GI follow up if patient continues to have abdominal pain/discomfort [] MRCP with "Lobulated right breast lesion measuring 1.4 cm with benign appearing features and similar to ___ CT. Correlation with mammography/ultrasound is recommended." [] Will need to follow up with her outpatient psychiatrist for further depression management [] Ensure up to date on colonoscopy # CODE: Full Patient seen and examined on day of discharge. >30 minutes on discharge activities. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Digoxin 0.125 mg PO DAILY 2. Diazepam 10 mg PO DAILY 3. TraZODone 100 mg PO QHS insomnia 4. Metoprolol Tartrate 25 mg PO BID 5. Nitrofurantoin (Macrodantin) 100 mg PO BID UTI 6. Aspirin 81 mg PO DAILY 7. Sertraline 50 mg PO QHS Discharge Medications: 1. QUEtiapine Fumarate 50 mg PO QHS RX quetiapine 50 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:0 2. Simethicone 40 mg PO QID RX simethicone 80 mg 1 mg by mouth four times a day Disp #120 Tablet Refills:0 3. Sertraline 100 mg PO QHS RX sertraline 100 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:1 4. Aspirin 81 mg PO DAILY 5. Diazepam 10 mg PO DAILY 6. Digoxin 0.125 mg PO DAILY 7. Metoprolol Tartrate 25 mg PO BID 8. TraZODone 100 mg PO QHS insomnia Discharge Disposition: Home Discharge Diagnosis: #Abdominal pain #Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Ms. ___, It was a privilege caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You were in the hospital because you had 10 days of abdominal pain and diarrhea. WHAT HAPPENED TO ME IN THE HOSPITAL? - In the hospital, we did blood work and imaging to investigate potential causes for your abdominal pain. The tests were reassuring that there was not any underlying infection or inflammation. It was also reassuring that improvement in pain and diarrhea was noted. - We also noted that your hyperactive bowel sounds were increasing your anxiety so we optimized your medication. - We also started a medication to help with your hyperactive bowel which helped with your symptoms. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Please continue to take all of your medications and follow-up with your appointments as listed below. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
10314252-DS-4	10,314,252	25,055,534	DS	4	2165-10-10 00:00:00	2165-10-11 13:21:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Intubation ___ History of Present Illness: ___ yo F history significant for HTN, palpitations on digoxin, diverticulitis, IBS, GERD, anxiety and depression found lying in bed, breathing but non-responsive. Found with multiple pill bottles this morning, given naloxone with no response. Per EMS was tachycardic, afebrile, with reactive pupils, somnolent on physical exam with no clonus or hyperreflexia. Recently hospitalized ___ for abdominal pain and diarrhea though to be IBS or resolving viral infection. She has hx of anxiety/depression with a suicide attempt about 8 months ago after which G tube was placed (taken out in ___. During the hospitalization, psychiatry evaluated the patient and did not think she is actively suicidal. Was started on Seroquel 50mg for depression and increase Sertraline to 100mg. Continued Diazepam 10mg PO QHS, Trazodone 100mg PO QHS. Per husband (___) patient has had multiple suicide attempts in the past. She has active suicidal ideation and plan but was withholding that information from her doctors. ___ had been attempting to hide her pills in the cabinet but she just got her prescriptions filled yesterday (trazodone and diazepam). Has tried to harm self with carbon monoxide poisoning. Past Medical History: Past psychiatric history: Reviewed and updated as needed from initial psychiatry consult note by ___ from ___. "Hospitalizations: none patient reports that for over ___ years she had agoraphobia and for the past years only went between her and her mother's house and mother lived next door until her death ___ years ago. Current treaters and treatment: none per patient, per her PCP the patient has a psych treater ___ @ ___ Psychiatric @ ___ or ___ ) Former psychiatrist Dr. ___, patient saw him for ___ years until ___ retired ___ years ago Medication: Venlafaxine, Trazodone, Clonazepam Doxepin, Fluoxetine Mirtazapine Self-injury: denies previous suicide attempts until today Harm to others: denies Access to weapons: denies access to guns" Past medical history: Reviewed and updated as needed from initial psychiatry consult note by ___ from ___. * PCP ___ (___) * GERD * Irregular heart rate-states this had been case since patient was in ___. * IBS * abnormal mammogram * Colonic polyps * urinary frequency Social History: ___ Family History: Family psychiatric history: Reviewed and updated as needed from initial psychiatry consult note by ___ from ___. "* Mother with depression * Father alcoholic * Son with developmental delay * Ex husband alcoholic * Brother used marijuana and cocaine" Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98.8 HR 90 121/84 GEN: Intubated, sedated, not rousable to voice HEENT: PERRL CV: RRR regular rhythm RESP: CTABL- anteriorly GI: + BS, soft, NT, ND MSK: No lower extremity edema SKIN: NEURO: 3+ reflexes with spread at L patella, hypoactive reflexes at R. Equal reflexes biceps bilaterally. DISCHARGE PHYSICAL EXAM: ======================== VITALS: reviewed in Metavision GEN: Awake and alert, sitting comfortably in chair listening to music, in no acute distress HEENT: PERRL CV: RRR regular rhythm Lungs: CTAB Abd: normoactive BS, soft, NT, ND Ext: no ___ edema NEURO: A&Ox3 Pertinent Results: ADMISSION LABS ============== ___ 09:08AM BLOOD WBC-5.4 RBC-4.93 Hgb-14.5 Hct-45.7* MCV-93 MCH-29.4 MCHC-31.7* RDW-12.7 RDWSD-43.3 Plt ___ ___ 09:08AM BLOOD Neuts-56.3 ___ Monos-5.9 Eos-0.6* Baso-0.9 Im ___ AbsNeut-3.04 AbsLymp-1.92 AbsMono-0.32 AbsEos-0.03* AbsBaso-0.05 ___ 09:08AM BLOOD Plt ___ ___ 10:26AM BLOOD Glucose-85 UreaN-7 Creat-0.5 Na-90* K-2.4* Cl-65* HCO3-15* AnGap-10 ___ 10:26AM BLOOD ALT-10 AST-10 AlkPhos-18* TotBili-0.2 ___ 10:26AM BLOOD Lipase-9 ___ 09:08AM BLOOD cTropnT-<0.01 ___ 10:26AM BLOOD cTropnT-<0.01 ___ 10:26AM BLOOD Albumin-2.7* Calcium-4.0* Phos-2.7 Mg-GREATER TH ___ 01:58PM BLOOD Osmolal-297 ___ 03:17PM BLOOD Digoxin-<0.4* ___ 10:26AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 09:12AM BLOOD ___ pO2-26* pCO2-59* pH-7.31* calTCO2-31* Base XS-0 ___ 09:12AM BLOOD Lactate-4.0* INTERIM LABS =========== ___ 02:00AM BLOOD WBC-11.2* RBC-4.35 Hgb-12.9 Hct-42.1 MCV-97 MCH-29.7 MCHC-30.6* RDW-13.2 RDWSD-47.3* Plt ___ ___ 03:48AM BLOOD WBC-12.3* RBC-4.19 Hgb-12.3 Hct-38.3 MCV-91 MCH-29.4 MCHC-32.1 RDW-12.7 RDWSD-42.7 Plt ___ ___ 08:37PM BLOOD WBC-7.7 RBC-3.57* Hgb-10.6* Hct-33.6* MCV-94 MCH-29.7 MCHC-31.5* RDW-13.1 RDWSD-45.4 Plt ___ ___ 03:28AM BLOOD Glucose-95 UreaN-9 Creat-0.6 Na-143 K-3.5 Cl-105 HCO3-28 AnGap-10 ___ 03:28AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.2 ___ 02:46PM BLOOD ___ Temp-37.4 pO2-129* pCO2-38 pH-7.46* calTCO2-28 Base XS-3 ___ 02:21PM BLOOD Lactate-5.1* Na-139 K-6.1* ___ 03:24PM BLOOD Lactate-3.2* ___ 02:46PM BLOOD Glucose-113* Lactate-1.9 IMAGES ====== CT HEAD W/O CONTRAST ___ FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. Mild rightward nasal septum deviation with spur. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Status post right lens replacement. IMPRESSION: No acute intracranial findings. CHEST (PORTABLE AP)Study Date of ___ Lung volumes are maintained. Linear atelectasis in the right lung base. Relative increased density in the left base is thought to be secondary to asymmetric overlying soft tissues (breast). No focal areas of consolidation or parenchymal abnormalities. Cardiomediastinal silhouette is normal. No pleural effusion or pneumothorax. IMPRESSION: No acute intrathoracic findings. CHEST (PORTABLE AP)Study Date of ___ IMPRESSION: Compared to chest radiographs most recently ___. Patient is scoliotic, concave to the left, and severely rotated to the left, making it difficult to assess whether there is leftward displacement of the cardiac silhouette. Without clear demonstration of leftward shift to indicate left lower lobe volume loss, new consolidation in the left lower lobe should be considered pneumonia. Smaller region of atelectasis or pneumonia is present at the right lung base. Upper lungs clear. Pleural effusions small if any. Heart size normal. No evidence of cardiac decompensation. MICROBIOLOGY ============ ___ 9:15 am URINE URINE CULTURE (Final ___: NO GROWTH. ___ 9:56 pm BLOOD CULTURE Source: Venipuncture 1 OF 2. Blood Culture, Routine (Pending): No growth to date. ___ 2:30 am BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): No growth to date. ___ 4:36 pm SPUTUM Source: Expectorated. GRAM STAIN (Final ___: >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. ___ 8:37 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): No growth to date. Brief Hospital Course: PATIENT SUMMARY =============== ___ F with hx of depression, anxiety, HTN, diverticulitis p/w found lying in bed unresponsive with surrounding pill bottles, admitted to the ICU with drug overdose, respiratory failure and encephalopathy. This occurred iso of suspected benzodiazepine/trazodone overdose leading to possible serotonin syndrome c/b aspiration PNA requiring intubation and treated with Unasyn and later transitioned to augmentin. She was evaluated by psychiatry and placed on a ___. ACUTE ISSUES =============== # Encephalopathy # Hypercapnic respiratory failure # Intentional drug overdose (suspected Benzodiazepine/Trazodone) # Suicide attempt Intubated on arrival in ED for somnolence and hypercapnia. Encephalopathy thought to be secondary to polypharmacy and urine tox positive for benzodiazepines. Presentation ultimately concerning for serotonin syndrome and benzo overdose. Treated with activated charcoal. Patient was treated with supportive care. Home psych meds restarted including sertraline, diazepam at reduced dose 5mg daily, quetiapine 50qhs and 25tid prn per psychiatry recommendations. Psych and SW consulted. Patient stated to psych that this was a suicide attempt. Placed on ___. # Aspiration PNA # Hypoxemic respiratory failure Presented w/fevers, AGMA, leukocytosis. RLL infiltrate. Sputum Cx was inadequate. BCx NGTD. Extubated ___ and weaned to RA. Was on Unasyn, transitioned to PO Augmentin (___), total 5 day course which she completed prior to discharge. # HTN # Fever # Serotonin syndrome # Benzodiazepine withdrawal During hospital course, patient presented with new fever, tachycardia, hyperreflexia, leukocytosis, anion gap metabolic acidosis. Concerning for bzd withdrawal and serotonergic syndrome vs medication effect (off of home HTN meds). Resolved with continuation of home bzd, supportive care, and restarting home metoprolol. # Lactic acidosis # AGMA Lactate 4.0 on admission which downtrended to 3.2 with fluids but subsequently rose to 5. CK was normal. AGMA was attributed to lactic acidosis ___ sepsis given CXR findings showing RLL infiltrate. Resolved with supportive care. CHRONIC ISSUES =============== # IBS: - Given home simethicone 80 mg TID #Insomnia - Quetiapine as above - Trazodone 100 mg po qhs #Palpitations - Home Metoprolol Tartrate 25 mg PO BID #GERD -Home omeprazole TRANSITIONAL ISSUES =================== [] Will need to follow up with her outpatient psychiatrist for depression and suicidal ideations/attempts Medications held: [] Per family, patient on digoxin for tachycardia. No history of atrial fibrillation. Medication held at presentation and recommend continuing to hold pending further discussions with PCP ___ cardiology. [] Aspirin held at discharge as patient appeared to have no clear indication for aspirin and had only been started for primary prevention. #CODE STATUS: Full (confirmed with HCP) #EMERGENCY CONTACT: ___ (Husband) ___ ___ (Daughter) ___ hcp Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Diazepam 10 mg PO DAILY 3. Digoxin 0.125 mg PO DAILY 4. Metoprolol Tartrate 25 mg PO BID 5. Sertraline 100 mg PO QHS 6. TraZODone 100 mg PO QHS insomnia 7. QUEtiapine Fumarate 50 mg PO QHS 8. Simethicone 40 mg PO QID Discharge Medications: 1. Diazepam 5 mg PO DAILY 2. QUEtiapine Fumarate 100 mg PO QHS 3. QUEtiapine Fumarate 25 mg PO TID:PRN agitation 4. TraZODone 50 mg PO QHS insomnia 5. Metoprolol Tartrate 25 mg PO BID 6. Sertraline 100 mg PO QHS 7. Simethicone 40 mg PO QID 8. HELD- Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until directed to by a doctor. 9. HELD- Digoxin 0.125 mg PO DAILY This medication was held. Do not restart Digoxin until instructed Discharge Disposition: Extended Care Discharge Diagnosis: Primary diagnosis: Encephalopathy Hypercapnic respiratory failure Suicide attempt Intentional drug overdose Secondary diagnosis: Lactic acidosis IBS Anxiety Depression Insomnia Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted because you were unresponsive after you had ingested prescription pills at home. - You were cared for in the intensive care unit because you were intubated to protect your airways. What was done for me while I was in the hospital? - You were intubated and given supportive care which included fluids and close monitoring of your vitals. - You were treated for an infection in your lungs with antibiotics. What should I do when I leave the hospital? - Take all your medications as prescribed - Keep all your doctors' appointments Sincerely, Your ___ Care Team Followup Instructions: ___
10314359-DS-11	10,314,359	22,713,099	DS	11	2128-03-15 00:00:00	2128-05-27 09:07:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Zosyn / vancomycin Attending: ___ Chief Complaint: diarrhea, "seeing black", hypotension Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo male with idiopathic ___ neuropathy, alcohol abuse, history of necrotizing pancreatitis c/b abdominal compartment syndrome s/p multiple abdominal surgeries, right foot osteomyelitis on ertapenem, presenting today as a transfer from ___ with watery diarrhea since ___, hypotension to SBP ___, now s/p volume resuscitation and on levophed. For the past four days, he reports ___ episodes of non-bloody watery diarrhea. He has had intermittent nausea and vomiting but no abdominal pain. He has tried to stay hydrated with water and Gatorade, but has had significant vomiting and inability to tolerate PO. Today, he presented to ___ with a chief complaint of "seeing black." He was found to be hypotensive to SBP ___ with a leukocytosis. His creatinine was 4.12, Mg 1.2, CRP 31.5, Lipase 55, WBC 28.3. He was given 4L IVF, started on levophed, and IV flagyl, and transferred to BID ED (due to family request). BP improved to SBP ___ prior to transfer. He denies fevers, chills, nightsweats. No abdominal pain, no bleeding, no cough, dysuria, or skin changes. Of note, he has a RLE pressure ulcer that developed a few weeks ago ___ wearing his foot orthoses on the wrong feet. He subsequently developed osteomyelitis (group c strep) for which he was admitted and followed by podiatry. He was recently discharged on Ertapenam x6 weeks with a PICC (___) and a wound vac. He was seen by podiatry in the ED who felt his foot was healing well. He has a history of an SMV thrombus for which he has been on warfarin, which is recently being bridged with enoxaparin. His last INR was 1.9 3 days ago, and he has been taking 7 mg warfarin each day for the past 3 days. In the ED, initial vitals: 98.4, HR 109, BP 117/65, O2 99% RA - Exam notable for well healing wound on right foot - Labs were notable for: WBC 24.9, Hgb 12.9, INR 10.9, Lactate 1.6, Cr 2.4, Bicarb 16. Stool cx and cdiff pending from OSH - Imaging: CXR at OSH normal (as per report) - Patient was given: morphine - Consults to podiatry, felt the right foot was healing well and not the cause of his leukocytosis On arrival to the MICU, he is a&ox3. He denies headaches, chest pain, shortness of breath, light headedness, and abdominal pain. He continues to have diarrhea but is not nauseous. Past Medical History: - Chronic inflammatory Demyelinating Polyneuropathy: Dense sensorimotor loss in bilateral lower extremities to midshin. Diagnosed in ___. - Alcohol abuse - Necrotizing pancreatitis complicated by abdominal compartment syndrome s/p decompressive exploratory laparotomy, multiple abdominal washouts, ___ patch placement and multiple surgical adjustments (___) - Anxiety Social History: ___ Family History: No known family history of hepatobiliary disorder. Hypertension, grandmother with diabetes. One cousin with ___. Bell's palsy in cousin, and another cousin with cystinosis (an autosomal recessive lysosomal storage disease). Both on mother's side. Mother with granuloma ___, Physical Exam: ADMISSION PHYSICAL EXAM: ============================= VITALS: afebrile, HR 115, BP 121/76, HR 115, RR 17, O2 96% RA GENERAL: Well appearing, overweight, no acute distress HEENT: EOMI, PERRL, mucous membranes dry NECK: no LAD, no JVD CARDIAC: Tachycardic, regular rhythm, normal s1,s2 LUNG: CTAB, no wheezes ABDOMEN: Large mid-line well-healed surgical scar, nontender, nondistended, soft, BS+ EXTREMITIES: RLE is bandaged (underlying RLE ulcer). R PICC line PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, sensation decreased to light touch in lower extremities (right leg is more sensitive than left leg) DISCHARGE PHYSICAL EXAM: ============================ Vitals: AVSS Gen: NAD, lying in bed, comfortable Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, no edema Resp: normal effort, no accessory muscle use, lungs CTA ___. GI: soft, NT, ND, BS+ MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. PICC site CDI, no erythema or drainage. Neuro: AAOx3. No facial droop. Psych: Full range of affect. Pleasant GU: No foley Pertinent Results: ADMISSION LABS: ==================== ___ 12:46PM BLOOD WBC-24.9# RBC-4.25 Hgb-12.9* Hct-35.9* MCV-85 MCH-30.4 MCHC-35.9 RDW-15.5 RDWSD-47.2* Plt ___ ___ 12:46PM BLOOD Neuts-65.9 ___ Monos-8.7 Eos-0.4* Baso-0.4 Im ___ AbsNeut-16.44* AbsLymp-5.66* AbsMono-2.17* AbsEos-0.10 AbsBaso-0.10* ___ 12:46PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 12:46PM BLOOD ___ PTT-59.9* ___ ___ 12:46PM BLOOD Glucose-97 UreaN-22* Creat-2.4# Na-135 K-3.3 Cl-105 HCO3-16 AnGap-17 ___ 12:46PM BLOOD ALT-14 AST-13 LD(LDH)-223 AlkPhos-51 TotBili-0.5 ___ 12:46PM BLOOD Lipase-13 ___ 12:46PM BLOOD Albumin-2.2* Calcium-6.0* Phos-3.9 Mg-1.0* ___ 12:46PM BLOOD CRP-16.6* ___ 01:10PM BLOOD ___ Comment-GREEN TOP ___ 01:10PM BLOOD Lactate-1.6 ___ 01:21PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 01:21PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 01:21PM URINE RBC-1 WBC-9* Bacteri-FEW Yeast-NONE Epi-0 ___ 01:21PM URINE CastHy-8* OTHER RELEVANT LABS: ======================= ___ 09:41PM STOOL NoroGI-NEGATIVE NoroGII-NEGATIVE ___ 05:22AM STOOL NoroGI-NEGATIVE NoroGII-NEGATIVE URINE CULTURE (Final ___: NO GROWTH. C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay. CXR (___): IMPRESSION: Left basilar atelectasis without evidence for acute cardiopulmonary process. DISCHARGE LABS: ================ ___ 06:08AM BLOOD WBC-9.4 RBC-3.63* Hgb-10.4* Hct-30.5* MCV-84 MCH-28.7 MCHC-34.1 RDW-14.8 RDWSD-45.7 Plt ___ ___ 06:08AM BLOOD ___ PTT-38.0* ___ ___ 06:08AM BLOOD Glucose-90 UreaN-7 Creat-0.7 Na-143 K-3.3 Cl-109* HCO3-24 AnGap-13 ___ 06:08AM BLOOD Albumin-2.8* Calcium-8.8 Phos-2.6* Mg-1.5* Brief Hospital Course: ___ yo male with idiopathic ___ neuropathy, alcohol abuse, history of necrotizing pancreatitis c/b abdominal compartment syndrome s/p multiple abdominal surgeries, right foot osteomyelitis on ertapenem, presenting as a transfer from ___ with watery diarrhea since ___, hypotension to SBP ___, now s/p volume resuscitation and on levophed. # Septic shock: Presented with leukocytosis, tachycardia, and hypotension refractory to fluids consistent with septic shock. Likely source was initially thought to be cdiff given prior history of cdiff, multiple days of watery diarrhea. Norovirus negative x2. Lactate normal, but evidence of ___. Initially required levofed but was aggressively IVF resuscitated with 7L IVF and BPs were stable during ICU stay. Patient was empirically started on flagyl 500 mg IV initially that was discontinued when C diff studies were negative. Home anti-hypertensives were held during his ICU stay. Blood cultures were pending at discharge. # Acute kidney injury: Cr baseline 0.7. BUN/cr ratio < 20. Acute elevation likely prerenal in setting of dehydration. Returned to baseline with IVF rehydration # Right foot osteomyelitis: Diagnosed with neuropathic ulcer with superimposed SSTI in early ___. Cultures grew group c strep and polymicrobia. Discharged previously with wound vac and 6 weeks of ertapenem through ___. Now presents with well-healing ulcer, seen by podiatry in ED. Patient was continued on meropenem during ICU course due to ertapenem shortage. He will be discharged home on ertapenem to complete his 6 week course (___). Podiatry was consulted to place wound vac. Pain was controlled with oxycodone PRN. # Supertherapeutic INR: Likely in setting of poor PO intake and antibiotics, and perhaps an elevated warfarin dose (he was discharged on 3 mg, but is reportedly taking 7 mg daily). No evidence of bleeding. Hgb stable. Patient was given 1 dose of Vitamin K 2.5 mg. Once his INR normalized, his warfarin was restarted at his home dose of 3 mg daily. # History of SMV thrombus: Patient on warfarin for planned 6 months after a SMV thrombus (provoked by abdominal surgeries and compartment syndrome). Home warfarin dose is 7 mg daily (for past three days, for INR of 1.9). P/w supertherapeutic INR, perhaps in setting of poor PO intake and antibiotics. Warfarin was held as above during his ICU course. His INR normalized and he was restarted on his warfarin 3 mg daily at discharge. # Idiopathic demyelinating neuropathy: Followed by Dr. ___ ___ at ___, but now transitioning care to ___ (next appointment early ___. Patient was continued on his home lyrica and duloxetine. # Hypertension: His home amlodipine and lisinopril were initially held in setting of hypotension. His home amlodipine was resumed at discharge. *TRANSITIONAL ISSUES* - Projected end date of ertapenem on ___ - Home lisinopril discontinued pending f/u with PCP ___ on ___: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. DULoxetine 30 mg PO DAILY 3. Lisinopril 10 mg PO DAILY 4. Pregabalin 150 mg PO BID 5. Warfarin 3 mg PO DAILY16 6. Enoxaparin Sodium 90 mg SC Q12H 7. Morphine Sulfate ___ ___ mg PO Q4H:PRN Pain - Moderate 8. Ertapenem Sodium 1 g IV 1X Discharge Medications: 1. Morphine SR (MS ___ 15 mg PO Q12H Do not take while operating machinery or with alcohol. RX morphine 15 mg 1 tablet(s) by mouth every twelve (12) hours Disp #14 Tablet Refills:0 2. amLODIPine 10 mg PO DAILY 3. DULoxetine 30 mg PO DAILY 4. Enoxaparin Sodium 90 mg SC Q12H 5. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose Daily. Projected end date on ___. RX ertapenem [Invanz] 1 gram 1 gm IV daily Disp #30 Vial Refills:0 6. Morphine Sulfate ___ ___ mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 7. Pregabalin 150 mg PO BID 8. Warfarin 3 mg PO DAILY16 9. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do not restart Lisinopril until you see your primary care physician 10.Outpatient Lab Work ICD 9 code ___ Mesenteric thrombosis. Please draw CBC, INR, and Chem 10 on ___ and have results faxed to: Dr. ___: ___ Fax: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: viral gastroenteritis acute renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___ ___. You were admitted to the hospital with diarrhea. You were very will and was initially admitted to the intensive care unit. Your stool cultures showed no evidence of infection thus far, and you have improved significantly just with supportive treatment. You were continued on your home antibiotics for treatment of your foot infection. Please follow-up with your outpatient providers as instructed below. Thank you for allowing us to participate in your care. All best wishes for your recovery, Your ___ medical team Followup Instructions: ___
10314518-DS-5	10,314,518	27,222,462	DS	5	2153-09-07 00:00:00	2153-09-08 16:13:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Ceftin Attending: ___. Chief Complaint: headache Major Surgical or Invasive Procedure: ___ Cerebral Angiogram (negative) History of Present Illness: This is a ___ year old female on aspirin 81 mg reports spontaneous headache of ___ yesterday morning. The patient reports she was falling asleep when she experienced a headache ___ headache in the base of her skull. She concurrently experienced bilateral lower face numbness and lower lip edema. The patient has not been eating and attributes her nausea to having a empty stomach. She has not been eating due to jaw pain. The patient denies weakness, arm, leg pain, bowel or bladder deficit. vision deficit or hearing deficit. The patient denies recent injury accident or fall. the patient denies head strike of any kind. The patient was seen at ___ and a ___ was performed consistent with SAH left frontal. A CTA Head was performed and found to be negative. The patient was transferred here for further Neurosurgical evaluation. Past Medical History: pulmonary disease, asthma, valvular heart diease, MVP, hyperlididemia, gastric bypass, depression, + smoker x ___ years, right foot Achilles repair, begnign mass removed from right breast. Social History: ___ Family History: ___ Physical Exam: General: NAD HEENT: mucous membranes are tacky Neck: Supple w/out meningismus Pulmonary: breathing comfortably on RA Cardiac: RRR Abdomen: soft, nondistended Extremities: RLE in brace post angio Skin: no rashes or lesions noted. NEUROLOGIC EXAMINATION -Mental Status: Alert, oriented. Able to relate history without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of neglect. Labile affect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm bilaterally. VFF to confrontation with finger counting. III, IV, VI: EOMI without nystagmus. V: Facial sensation symmetric. VII: No facial droop with symmetric upper and lower facial musculature bilaterally VIII: Hearing intact to voice IX, X: Palate elevates symmetrically. XI: full strength in trapezii bilaterally. XII: Tongue protrudes in midline with full ROM right and left -Motor: Normal bulk throughout. No pronator drift bilaterally. No tremor noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ ___ 5 5 5 5 5 R ___ ___ 5 UNABLE--> 5 5 5 5 -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 UNABLE 2 - Toes were downgoing bilaterally. -Sensory: Decreased pinprick to 50% in left foot compared to right. Otherwise, no deficits to light touch, pinprick, cold sensation, throughout. -Coordination: No dysmetria on FNF bilaterally. Unable to HSK given activity restrictions and brace post-angio. -Gait: deferred given bedrest Pertinent Results: LABS: ___ 04:21PM BLOOD WBC-11.2* RBC-4.80 Hgb-14.7 Hct-44.8 MCV-93 MCH-30.6 MCHC-32.8 RDW-14.0 RDWSD-47.8* Plt ___ ___ 04:21PM BLOOD Neuts-64.0 ___ Monos-10.1 Eos-2.1 Baso-0.7 Im ___ AbsNeut-7.16* AbsLymp-2.56 AbsMono-1.13* AbsEos-0.24 AbsBaso-0.08 ___ 04:21PM BLOOD ___ PTT-31.2 ___ ___ 04:21PM BLOOD Glucose-102* UreaN-13 Creat-0.9 Na-138 K-5.0 Cl-102 HCO3-26 AnGap-15 ___ 02:24AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.2 ___ 05:45AM BLOOD CRP-24.4* ___ 05:45AM BLOOD SED RATE-33 *********** IMAGING: Cerebral angiogram ___: IMPRESSION: No evidence of aneurysm, arteriovenous malformation, dural AV fistula, vasculitis, vasospasm on 6 vessel cerebral angiogram MRA neck w/wo contrast ___: IMPRESSION: 1. Unremarkable MRA neck, allowing for common anatomic variations described above. No evidence for dissection of the cervical vessels. 2. Incidental note is made of a 1.4 cm nodule in the left lobe of thyroid. Per ACR guidelines, the lesion does not reach size criteria for further evaluation however correlation prior imaging and clinical history is recommended. Brief Hospital Course: Patient was transferred initially to ___ Neurosurgery for acute headache, had been found at OSH to have left frontal convexal SAH. Angiogram found no occult aneurysm or arteriovenous malformation. She was subsequently transferred to Neurology service. Her history and risk factors was felt to be most consistent with reversible cerebral vasoconstriction syndrome. MRA neck with fat sats was ordered to exclude associated arterial dissection. Her SSRI's were discontinued. She was started on verapamil XR 120mg and her blood pressure was monitored and stable. ESR/CRP were also ordered due to her jaw pain to exclude temporal arteritis given her age, although the etiology of her headache was felt strongly to be from her SAH. CRP was elevated at 22 and ESR was mildly elevated at 33, which does not suggest temporal arteritis. Transitional issues: [ ] Verapamil 120mg XR was started; please follow her BPs and if tolerable, uptitrate to the highest dose that patient can tolerate for RCVS [ ] Discuss other options besides SSRI antidepressants for patient; we suggest a trial of tricyclic antidepressants if not contraindicated or started previously as these may also help with her neuropathy Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Budesonide Nasal Inhaler 32 mcg Other DAILY 2. Ciclodan (ciclopirox) 0.77 % topical prn 3. Dulera (mometasone-formoterol) 100-5 mcg/actuation inhalation BID 4. Fluconazole 200 mg PO Q24H 5. FoLIC Acid 1 mg PO DAILY 6. Gabapentin 300 mg PO 6X/DAY 7. Omeprazole 20 mg PO DAILY 8. Pravastatin 40 mg PO QPM 9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation QID:PRN sob, wheeze 10. Aspirin 81 mg PO DAILY 11. Venlafaxine 75 mg PO BID 12. Ferrous Sulfate 325 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Cyanocobalamin 100 mcg PO DAILY 15. Magnesium Oxide 400 mg PO DAILY 16. Loratadine 10 mg PO DAILY 17. Vitamin D Dose is Unknown PO DAILY 18. Phytonadione Dose is Unknown PO DAILY Discharge Medications: 1. Budesonide Nasal Inhaler 32 mcg Other DAILY 2. Dulera (mometasone-formoterol) 100-5 mcg/actuation inhalation BID 3. Fluconazole 200 mg PO Q24H 4. FoLIC Acid 1 mg PO DAILY 5. Gabapentin 300 mg PO 6X/DAY 6. Omeprazole 20 mg PO DAILY 7. Pravastatin 40 mg PO QPM 8. Loratadine 10 mg PO DAILY 9. Magnesium Oxide 400 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Verapamil SR 120 mg PO Q24H RX verapamil 120 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:*5 12. Ciclodan (ciclopirox) 0.77 % topical prn 13. Phytonadione 1.25 mg PO DAILY 14. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation QID:PRN sob, wheeze 15. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Left frontal subarachnoid hemorrhage Reversible cerebral vasoconstriction syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted for headache which was likely caused by a hemorrhage in your brain. We evaluated you extensively for the cause of the hemorrhage, including performing a procedure called a cerebral angiography, which fortunately did not show any abnormalities of your blood vessels. Instructions for post-angiography care are attached below. We felt that the most likely cause of your hemorrhage is a condition called Reversible Cerebral Vasoconstriction Syndrome (or RCVS), which occurs when the blood vessels of your brain squeeze too hard, and can cause them to bleed. This can be precipitated by certain medications such as SSRI antidepressants, which you were taking. Please stop taking these, and talk to your PCP about other options for treating your depression. We also started a medication called verapamil which works to stop the squeezing and prevent further bleeding. For your headache, you may take Tylenol as needed, however we recommend avoiding NSAIDs or aspirin as these may worsen the bleeding. Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted, you are NOT allowed to drive by law. No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: You may have difficulty paying attention, concentrating, and remembering new information. Emotional and/or behavioral difficulties are common. Feeling more tired, restlessness, irritability, and mood swings are also common. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: Headache is one of the most common symptom after a brain bleed. Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit Nausea and/or vomiting Extreme sleepiness and not being able to stay awake Severe headaches not relieved by pain relievers Seizures Any new problems with your vision or ability to speak Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: Sudden numbness or weakness in the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headaches with no known reason Care of the Puncture Site You will have a small bandage over the site. Remove the bandage in 24 hours by soaking it with water and gently peeling it off. Keep the site clean with soap and water and dry it carefully. You may use a band-aid if you wish. What You ___ Experience: Mild tenderness and bruising at the puncture site (groin). Soreness in your arms from the intravenous lines. The medication may make you bleed or bruise easily. Fatigue is very normal. It was a pleasure taking care of you. We wish you the best. Sincerely, Your ___ Care Team Followup Instructions: ___
10314824-DS-8	10,314,824	23,685,639	DS	8	2156-10-03 00:00:00	2156-10-04 21:26:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Erythromycin Base / Benadryl Attending: ___. Chief Complaint: seizure Major Surgical or Invasive Procedure: None History of Present Illness: HPI: ___ with history of metastatic breast cancer including brain lesions who presents with seizure from clinic. She was in her usual state of health until today. She presented to outpatient ___ clinic and received 1 of 2 scheduled chemo doses when she stared to the left, developed teeth chattering, slurred speach, aphasia, left sided facial droop and facial shaking. Per report she was aware and oriented during the event. She had full strength, no LOC, incontinence or tongue biting. The episode resolved in under a few minutes and she immediately returned to her baseline. She endorses fatigue but denies all other symptoms. Of note, she is on a decadron taper and yesterday went from taking 1mg decadron per day to 1mg every other day. Of note, she had poor PO intake today and notes thirst and dark urine. In the ED, initial vitals were: 98.8 70 136/76 18 98% ra. She had a head CT which showed metastatic lesions with vasogenic edema increased in the left occipital lobe and stable lesion in the frontal lobe. No acute hemorrhage or midline shift. Dr. ___ was contacted who recommended decadron 8mg x1 and keppra load. She was admitted to oncology. Currently, she feels fatigued but otherwise is at baseline. ROS: Per above. She denies fevers, chills, nausea, vomiting, diarrhea, constipation, chest pain, shortness of breath, headache, weakness, numbness, prior seizures, bowel or stool incontinence, abdominal pain, problems walking or other symptoms. Past Medical History: asthma hyperlipidemia hypertension impaired fasting glucose left partial mastectomy prior cesarean section laparoscopy for history of endometriosis PAST ONCOLOGIC HISTORY: -mammogram performed on ___ showed predominantly fatty breast parenchyma, an irregular mass of 2.8 cm in the left outer breast. Ultrasound performed on the same day showed a hypovascular hypoechogenic mass of 2 x 2.7 x 2.4 cm. An ultrasound-guided biopsy was performed that revealed an invasive ductal carcinoma of grade 3, measuring at least 1.2 cm. The tumor was estrogen and progesterone receptor negative. -___: Partial mastectomy, Left axillary sentinel node mapping and biopsy by Dr. ___. -___ CT scan followed by an ultrasound-guided biopsy of a liver lesion and this confirmed the presence of metastatic disease. bone scan showed no evidence for metastatic disease. Lab data was significant for a ___ level elevated to 85. -___: rec'd a total of 10 doses of weekly Taxol before restaging scan showed mixed response. -___: started weekly Adriamycin 3wk on/1 off. given 4 doses total ___: started reduced-dose Doxil q4wks -___: started reduced-dose Doxil q4wks. given 3 doses before progression of disease seen on PET scan performed ___. increase in size of pulmonary nodules, liver metastisis and new ___ met on right acromion process. -___: Started Eribulin D1,8 dose reduces for elevated LFTs -___: D8 Eribulin held d/t fever, cough and flu-like symptoms. admitted to ___. likely cytokine storm ___ recent chemo. CXR, UA, abd u/s all wnl. Urine and blood cx negative. -___ C3D1 Eribulin - ___: C3D8 gemzar held d/t fatigue, general malaise. restaging PET showed new brain mets, as well as increased size of pulmonary and liver mets; admitted to hospital for urgent management. ___ started whole brain radiation. completed on ___ started Carboplatin/Gemcitabine ___ sent to ED from ___ clinic for witnessed seizure Social History: ___ Family History: Mother living, age ___ with ductal carcinoma in situ diagnosed at age ___, hypertension, some type of vasculitis that presented as dementia, treated with chemotherapy, alcohol abuse. Father deceased at ___ from primary prostate cancer and primary lung cancer. Brother living at age ___ with prostate cancer diagnosed at ___, sister living at age ___ with migraine headaches. Physical Exam: Vitals: 97.9, 130/78, 63, 20, 96% RA Pain: ___ General: ill appearing female, no apparent distress, mildly somnolent HEENT: EOMI, PERRL, OP without lesions, dry MM Neck: unable to assess JVD CV: rr, nl rate, no r/g/m appreciated Lungs: CTAB Abd: soft, nontender, nondisteded, obese, bowel sounds Ext: wwp, no edema Neuro: CNII-XII intact, strength ___, light touch sensation intact, gait deferred Psych: pleasant Pertinent Results: ___ 05:30PM BLOOD WBC-9.0 RBC-3.99* Hgb-9.7* Hct-32.1* MCV-81* MCH-24.5* MCHC-30.3* RDW-17.9* Plt ___ ___ 05:30PM BLOOD Neuts-87.2* Lymphs-7.5* Monos-4.9 Eos-0.2 Baso-0.2 ___ 05:30PM BLOOD Glucose-120* UreaN-22* Creat-0.5 Na-128* K-4.3 Cl-95* HCO3-20* AnGap-17 ___ 12:10PM BLOOD ALT-179* AST-236* AlkPhos-686* TotBili-1.0 ___ 05:30PM BLOOD Calcium-8.0* Phos-3.0 Mg-1.9 ___ 12:10PM BLOOD CEA-12* ___ CT Head ___ (prelim): Three intracranial mass lesions are easily identifiable with surrounding vasogenic edema including in the left frontal lobe, right frontal lobe as well as the left occipital lobe. The largest of these is in the right frontal lobe again measuring 2.5 x 2.4 cm. While the amount of surrounding vasogenic edema is similar in the frontal lobe lesions, it does appear to have increased around the lesion in the left occipital lobe. No hemorrhagic transformation or other areas of acute intracranial hemorrhage. No shift of normally midline structures. Mild mass effect by the edema on the frontal horn of the right lateral ventricle. Basal cisterns are patent. Mastoid air cells and paranasal sinuses are clear. IMPRESSION: Numerous metastatic lesions, stable in size, with surrounding vasogenic edema; slightly increased edema surround the left occipital lobe lesion. Discharge: ___ 06:15AM BLOOD WBC-7.4 RBC-3.62* Hgb-9.0* Hct-28.6* MCV-79* MCH-24.7* MCHC-31.3 RDW-17.7* Plt ___ ___ 11:00AM BLOOD ___ ___ ___ 06:15AM BLOOD Ret Aut-2.4 ___ 06:15AM BLOOD Glucose-164* UreaN-20 Creat-0.5 Na-134 K-4.5 Cl-99 HCO3-26 AnGap-14 ___ 06:15AM BLOOD ALT-151* AST-182* AlkPhos-678* TotBili-0.9 ___ 06:15AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.1 Iron-16* ___ 06:15AM BLOOD calTIBC-181* Hapto-349* Ferritn-2536* TRF-139* ___ 12:10PM BLOOD CEA-12* ___ Brief Hospital Course: ___ who was diagnosed with breast cancer that now has brain mets. Presents from outpatient clinic after a witnessed seizure HOSPITAL COURSE: Admitted at night on ___ for first witnessed seizure. The patient has known brain metastases and was tapeing her dose of dexamethasone at the time of the episode. On CT head, at least one lesion had increased edema in comparison to ___ imaging, likely the nidus of the seizures. The patient's dexamethasone was increased to 4mg PO daily for the edema and she was Keppra loaded with 2g IV followed by Keppra 1000 mg PO BID. Pt was also hyponatremic, so her trimaterene-HCTZ was stopped. Given that she likely has difficulty taking in PO fluids, we stopped diuretics and replaced with amlodipine for HTN. She will have follow up with her PCP and oncologist within the week. We also established an appointment with ___, since her blood sugar will likely go up with increased steroid dose. ## PCP: ___ ## Onc: ___ ## Contact: ___ ___ ## CODE STATUS: Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 20 mg PO DAILY 2. Dexamethasone 1 mg PO EVERY OTHER DAY Tapered dose - DOWN 3. Glargine 10 Units Breakfast Insulin SC Sliding Scale using aspart Insulin 4. Lorazepam 0.5 mg PO Q6H:PRN nausea 5. Nystatin Oral Suspension 5 mL PO QID:PRN pain 6. Ondansetron 8 mg PO Q8H:PRN nausea stop citalopram while taking zofran 7. Pantoprazole 40 mg PO Q12H 8. Prochlorperazine 10 mg PO BID:PRN nausea 9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY 10. calcium carbonate-vitamin D3 NF 1,000 mg(2,500 mg)-800 unit Oral daily Discharge Medications: 1. Citalopram 20 mg PO DAILY 2. Dexamethasone 4 mg PO DAILY RX dexamethasone 4 mg 1 tablet(s) by mouth once a day Disp #21 Tablet Refills:0 3. Lorazepam 0.5 mg PO Q6H:PRN nausea 4. Nystatin Oral Suspension 5 mL PO QID:PRN pain 5. Pantoprazole 40 mg PO Q12H 6. Prochlorperazine 10 mg PO BID:PRN nausea 7. calcium carbonate-vitamin D3 NF* 1,000 mg(2,500 mg)-800 unit Oral daily 8. Ondansetron 8 mg PO Q8H:PRN nausea 9. Amlodipine 5 mg PO DAILY RX amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 10. LeVETiracetam 1000 mg PO BID RX levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 11. Glargine 10 Units Breakfast Insulin SC Sliding Scale using Novolog Insulin Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Seizure, secondary to brain metastasis from breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You were admitted to ___ after suffering a probable seizure while receiving chemotherapy. Because your seizure was likely due to swelling around the metastases in your brain, you will be restarted on a larger dose of regular dexamethasone to control swelling. You will also start a new medication, Keppra, to prevent seizures. Your blood sugars will likely go up as a result of the larger dose of steroids, so you have an appointment with the ___ ___ to help manage your blood sugars. Your sodium levels were low, so we replaced your blood pressure medication with one that should not affect your sodium. You will have follow-up with your PCP, ___, and neur-oncologist as below. Followup Instructions: ___

Subsets and Splits

No community queries yet

The top public SQL queries from the community will appear here once available.