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10029108-DS-2 | 10,029,108 | 20,360,088 | DS | 2 | 2145-05-30 00:00:00 | 2145-05-31 19:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
lisinopril / banana
Attending: ___
Chief Complaint:
Rectal pain
Major Surgical or Invasive Procedure:
___: Exam under anesthesia and incision and drainage of
posterior perirectal abscess.
History of Present Illness:
___ hx CAD/MI x2, DM presenting with ___ rectal pain described
as burning in nature, exacerbated by sitting and with defection
and notes subjective fever last night. WBC 9.1, CTAP with 2cm
rim-enhancing collection in posterior midline at level of
sphincters. No personal or family history of inflammatory bowel
disease or colorectal cancer. No prior episodes. No change in
bowel habits.
At time of consultation, pt AFVSS with DRE notable for
fluctuance and tenderness in the posterior midline, no blood or
drainage.
Past Medical History:
PMH: DM2, HTN, glaucoma, HL, CAD/MIx2
PSH: Prostate needle-biopsy ___
Social History:
___
Family History:
No family history of IBD, CRC. Father: CAD/PVD
Physical Exam:
Admission Physical Exam:
Weight:
VS: T 99.0, HR 101, BP 110/78, RR 16, SaO2 100%rm air
GEN: NAD, A/Ox3
HEENT: EOMI, MMM
CV: tachycardic
PULM: CTAB
BACK: No CVAT
ABD: soft, NT/ND
PELVIS: perianal exam - unremarkable. DRE: posterior midline
fluctuance and tenderness at level of sphincters, no blood, no
drainage.
EXT: warm, well-perfused
Discharge Physical Exam:
Pertinent Results:
___ 10:20AM GLUCOSE-139* UREA N-15 CREAT-1.3* SODIUM-138
POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15
___ 10:20AM WBC-6.4 RBC-3.53* HGB-11.1* HCT-34.0* MCV-96
MCH-31.4 MCHC-32.6 RDW-13.4 RDWSD-47.7*
___ 10:20AM PLT COUNT-155
___ 04:17AM GLUCOSE-101* UREA N-18 CREAT-1.2 SODIUM-138
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15
___ 04:17AM WBC-7.9 RBC-3.54* HGB-11.1* HCT-34.0* MCV-96
MCH-31.4 MCHC-32.6 RDW-13.2 RDWSD-47.3*
___ 04:17AM PLT COUNT-149*
___ 11:05PM LACTATE-1.8
___ 05:55PM GLUCOSE-81 UREA N-20 CREAT-1.3* SODIUM-140
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-22 ANION GAP-22*
___ 05:55PM WBC-9.1 RBC-4.23* HGB-13.1* HCT-40.2 MCV-95
MCH-31.0 MCHC-32.6 RDW-13.3 RDWSD-46.5*
___ 05:55PM NEUTS-71.6* ___ MONOS-6.6 EOS-1.1
BASOS-0.4 IM ___ AbsNeut-6.49* AbsLymp-1.81 AbsMono-0.60
AbsEos-0.10 AbsBaso-0.04
___ 05:55PM PLT COUNT-175
___ 05:40PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG
___ 05:40PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 05:40PM URINE MUCOUS-RARE
Imaging:
___: CT Pelvis:
1. 2.0 cm rim enhancing midline fluid collection just posterior
concerning forpossible perirectal abscess.
2. Sigmoid colon diverticulosis without evidence of
diverticulitis. Enlarged prostate.
Brief Hospital Course:
Mr. ___ is a ___ year-old male who presented to ___ with
complaints of rectal pain and received a CT pelvis which showed
him to have a perirectal abscess. He was admitted to the Acute
Care Surgery team for further medical evaluation. On ___,
the patient was taken to the Operating Room and underwent
incision and drainage of his perirectal abscess. He tolerated
this procedure well (reader, please see operative note for
further information). Post-operatively, the patient received IV
antibiotics. on post op day 1, patient noticed to have some pain
and induration just anterior to the incision, MRI showed small
residual abscess, we took him back to the OR and another I&D
(please refer to the operative note for more information). He
tolerated this procedure well and transferred to the regular
floor.
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.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient's diet was advanced sequentially to a
Regular diet, which was well tolerated. Patient's intake and
output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, and he received antibiotics post-operatively..
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Polyethylene Glycol 3350:PRN, Gatifloxacin 0.5%'''',
Prednisolone 1% q2h, Metformin 1000, HCTZ 25, Losartan 25,
Toprol XL 50, Atorvastatin 80, Alphagan 0.1%, Cosopt 2% L eye'',
Latanprost ___ 81
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
5. Lorazepam 1 mg PO Q4H:PRN Anxiety
6. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Senna 8.6 mg PO BID:PRN constipation
10. Hydrochlorothiazide 25 mg PO DAILY
11. Losartan Potassium 25 mg PO DAILY
12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. gatifloxacin 0.5 % ophthalmic QID
15. Docusate Sodium 100 mg PO BID
16. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q3 Disp #*30 Tablet
Refills:*0
17. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth q12 Disp #*2
Tablet Refills:*0
18. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth q8 Disp #*3 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perirectal abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You presented to the ___ and
were found to have an abscess. You were admitted to the Acute
Care Surgery team for further medical management. On ___,
you were taken to the Operating Room and underwent an incision
and drainage of your abscess which you tolerated well. You were
started on antibiotics to treat and prevent infection.
Your pain is better controlled and you are tolerating a regular
diet. You are now medically cleared to be discharged 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.
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.
Followup Instructions:
___
|
10029295-DS-5 | 10,029,295 | 27,059,161 | DS | 5 | 2180-10-26 00:00:00 | 2180-10-26 11:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Crush injury with an open fracture dislocation to the right
forearm.
Major Surgical or Invasive Procedure:
___
1. Open reduction, internal fixation of the of the radial
forearm fracture.
2. Carpal tunnel release.
3. Fasciotomy of the forearm x3 compartments.
4. Irrigation and debridement over the crush injury to the
mid forearm area over a 4 x 14 x 6 cm area.
5. Tenotomy of the ECU as well as EPL tendons due to severe
necrosis to the muscle.
6. Open reduction, internal fixation of distal radioulnar
joint dislocation.
7. Neurolysis of the ulnar nerve and median nerve in the
forearm.
8. Exploration of the ulnar artery.
9. Neurolysis of the ___ and ___ digit radial digital
nerves.
___
1. Repeat irrigation and debridement of the right arm, both
volar and extensor surface all the way down to bone.
2. Neurolysis of the median nerve in the forearm.
3. Open reduction, internal fixation of the distal radioulnar
joint.
4. Placement of VAC dressing.
___
1. Cystoscopy with clot removal
___
1. Right forearm wound debridement, volar 21 x 6 cm, dorsal
wound was 19 x 4 cm.
2. VAC dressing exchange.
___
1. Cystoscopy for clot removal
2. Arterial bleed found in false urethral passage
History of Present Illness:
Mr. ___ is a ___ y/o RHD gentleman who was working with a
metal lathe earlier today when his forearm got caught in the
lathe. He was subsequently airlifted to the ___ ED from
___ for further management and care. He
denies other injuries. Last meal was ~12:30 ___. He received
Tetanus, Ancef, and Gentamicin in the ED bay.
Past Medical History:
GERD, Gout
Social History:
___
Family History:
Non-contributory
Physical Exam:
AVSS
AAOx3, NAD
Resp - RR, non-labored breathing
CV - RRR
Abd - Soft, NTND
Ext - WWP
Pertinent Results:
___ 06:05AM BLOOD WBC-9.0 RBC-2.62* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.5 MCHC-33.0 RDW-14.7 Plt ___
Brief Hospital Course:
The patient was admitted to the orthopaedic hand surgery service
on ___ for a crush injury to the right forearm with an open
fracture dislocation. He was taken urgently to the OR. He
underwent open reduction internal fixation of the of the radial
forearm fracture, carpal tunnel release, fasciotomy of the
forearm x3 compartments, irrigation and debridement over the
crush injury to the mid forearm area over a 4 x 14 x 6 cm area,
tenotomy of the ECU as well as EPL tendons due to severe
necrosis to the muscle, open reduction internal fixation of
distal radioulnar joint dislocation, neurolysis of the ulnar
nerve and median nerve in the forearm, exploration of the ulnar
artery, neurolysis of the ___ and ___ digit radial digital
nerves and wound vac placement. He was given a nerve block both
pre and post-surgery, with a pain catheter left in place for
pain control. A foley catheter was placed post-operatively for
urinary retention. This was a traumatic placement with immediate
bleeding. He continued to have pink urine throughout the
following days with clot formation.
He was then taken back to the OR on ___ and underwent a
repeat irrigation and debridement of the right arm, both volar
and extensor surface all the way down to bone, neurolysis of the
median nerve in the forearm, ORIF distal radioulnar joint, and
placement of VAC dressing. Post-operatively on ___ he was
transfused 2 units PRBCs for Hct 20.
Overnight on ___ he developed acute urinary retention, without
successful flushing of the foley. He was then taken urgently by
urology for cystoscopy and clot evacuation on the morning of
___. He was also transfused another 2 units PRBCs for Hct 17.
Post-operatively he was started on continuous bladder
irrigation.
He was then taken back to the OR on ___ and underwent a repeat
irrigation and debridement, with a vac change. IV gentamicin was
discontinued at this time.
Over the following days his Hct stabilized and his CBI was
stopped on ___. Overnight he began to again form clots in his
foley, irrigation was unsuccessful. He was then taken back to
cystoscopy urgently on the morning of ___. At that time he was
found to have an arterial bleed in a false urethral passage
which was cauterized. Clots were evacuated and he then had clear
urine. Upon return to the floor he had no further events of clot
formation and his urine remained clear.
The RUE was kept in strict elevation and dressed with dry
sterile gauze and splinted. The extemity was closely monitored
throughout his hospitalization.
Neuro: A nerve block was placed both pre and post-operatively.
The patient received Dilaudid IV with good effect and adequate
pain control. Pain service was consulted who recommended a PO
and IV course of dilaudid, PO gabapentin and PO tylenol. The
patient was transitioned to oral pain medications with continued
adeqaute pain relief.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: The patient was given IV fluids until tolerating oral
intake. His diet was advanced when appropriate, which was
tolerated well. He was also started on a bowel regimen to
encourage bowel movement. Intake and output were closely
monitored.
ID: The patient's temperature and incision was closely watched
for signs of infection. He recieved a brief course of IV
antibiotics, including Gent and Ancef, during his hospital
course. He remained afebrile. He was transitioned to PO
antibiotics for discharge.
Prophylaxis: The patient was encouraged to get up and ambulate
as early as possible. Physical therapy was consulted for
mobilization.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs, tolerating a regular diet, ambulating,
voiding without assistance, and pain was well controlled.
Medications on Admission:
Omeprazole
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*40 Capsule Refills:*0
2. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 8 hours
Disp #*60 Tablet Refills:*0
3. Omeprazole 20 mg PO DAILY
4. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 3
hours Disp #*80 Tablet Refills:*0
5. Gabapentin 300 mg PO Q8H
RX *gabapentin 300 mg 1 capsule(s) by mouth every 8 hours Disp
#*60 Capsule Refills:*0
6. Cephalexin 250 mg PO Q6H Duration: 10 Days
RX *cephalexin 250 mg 1 tablet(s) by mouth every 6 hours Disp
#*40 Capsule Refills:*0
7. Bacitracin Ointment 1 Appl TP TID
RX *bacitracin zinc [Antibiotic (bacitracin zinc)] 500 unit/gram
Apply to urethral meatus while catheter is in place Once daily
Disp #*1 Tube Refills:*0
8. Oxybutynin 5 mg PO TID
RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth Three times a
___ Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Crush injury with an open fracture dislocation to the right
forearm.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Personal Care:
1. Keep your splint on until follow-up.
2. Non weight bearing right arm.
3. Wound vac should remain to suction at all times until it is
changed at your follow-up appointment on ___.
4. You are going home with a foley catheter and leg bag. Please
perform flushes as needed. Please call urology to schedule an
appointment for next week.
Activity:
1. You may resume your regular diet.
2. DO NOT lift anything with your right arm.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Take Colace, 100 mg by mouth 2 times per ___, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
5. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
6. You have been given a prescription for an antibiotic, Keflex.
Take the entire course of the antibiotic as directed.
7. you have been given a prescription for Oxybutinin to prevent
bladder spasms while your catheter is in place. Take this
medication three times a ___. Stop taking the medication on
___, with a plan for a voiding trial on ___.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness,swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Physical Therapy:
NWB RUE
Treatments Frequency:
Dressing, including the wound vac, should remain on until his
follow-up appointment on ___. The wound vac will be changed
in the clinic during his appointment. Please do not perform any
dressing or vac changes at home.
Foley with leg bag - flush as needed
Followup Instructions:
___
|
10029429-DS-13 | 10,029,429 | 22,981,727 | DS | 13 | 2187-01-14 00:00:00 | 2187-01-14 16:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / Penicillins
Attending: ___.
Chief Complaint:
R distal femur periprosthetic fx
Major Surgical or Invasive Procedure:
Surgical fixation (open reduction, internal fixation), R distal
femur
History of Present Illness:
___ female hx of CHF (EF 65% last TTE ___, A. fib (on
Eliquis) who presents after a mechanical fall after slipping on
a raw vegetable on the ground at the grocery market. She denied
head strike or loss of consciousness. She denied any
presyncopal symptoms. She was brought to ___
where her initial evaluation and workup revealed a right
periprosthetic distal femur fracture. She states that she last
took her Eliquis the morning of her fall. She denies any other
complaints including neck pain, chest pain, shortness of breath,
pain in the left lower or bilateral upper extremities. She
states that she ambulates with a cane and is functionally
independent of ADLs and IADLs.
Past Medical History:
Hypertension
CAD
CHF
Hyperlipidemia
Hypothyroidism
Atrial fibrillation
Social History:
___
Family History:
NC
Physical Exam:
Admission Physical Exam
Vitals: AVSS
General: Well-appearing female in mild distress due to her right
thigh pain
Neck: No C-spine tenderness or palpable step-offs, full passive
range of motion of the neck
Right lower extremity:
- Skin intact
- No deformity evident, moderate ecchymosis and swelling
- Soft, but tender distal thigh and proximal leg
- Full, painless ROM at bilateral hip, left knee, and ankle
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Discharge Physical Exam
VS: 98.2 PO 149/66 HR 63 RR 16 ___ 94 Ra
General: Alert and oriented, NAD
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: JVP 6 cm.
CV: Irregularly irregular, no MRG
Lungs: Scattered crackles at bases, no wheezes, normal
respiratory effort
GI: soft, NT/ND
Extremities: warm, well perfused, trace edema on the L ankle,
1+ edema on the RLE
Neuro: No gross motor/coordination abnormalities
Pertinent Results:
Admission Labs
___ 12:45PM BLOOD Glucose-139* UreaN-33* Creat-1.0 Na-135
K-4.1 Cl-100 HCO3-25 AnGap-10
___ 06:30AM BLOOD
WBC-7.9 RBC-2.70* Hgb-7.9* Hct-24.9* MCV-92 MCH-29.3 MCHC-31.7*
RDW-14.9 RDWSD-50.2* Plt ___
___ 05:14AM URINE Hours-RANDOM
UreaN-712 Creat-89 Na-<20
___ 08:30AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM*
Discharge Labs
___ 06:16AM BLOOD WBC-9.9 RBC-2.89* Hgb-8.7* Hct-25.9*
MCV-90 MCH-30.1 MCHC-33.6 RDW-14.9 RDWSD-48.8* Plt ___
___ 06:16AM BLOOD ___ PTT-28.1 ___
___ 06:16AM BLOOD Glucose-110* UreaN-22* Creat-0.7 Na-139
K-3.8 Cl-99 HCO3-28 AnGap-12
___ 06:16AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.9
___ Imaging VENOUS DUP EXT UNI (MAP
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ Imaging KNEE (2 VIEWS) RIGHT
Distal femur fracture. No definite involvement of the
prosthesis
radiographically.
Brief Hospital Course:
Ms. ___ is a ___ w/ HFpEF, afib on apixiban, CAD (60%
LAD in ___, h/o sinus pauses and Mobitz I AVB, HTN, and
hypothyroidism, admitted with R periprosthetic femur fracture
(now s/p ___ ORIF). Course c/b bradycardia (now improved off
carvedilol), CHF and cardiorenal ___ (both improved with
diuresis), and anemia requiring 1u pRBCs.
ACUTE ISSUES ADDRESSED
========================
#R periprosthetic distal femur fracture: The patient was found
to have a right distal femur periprosthetic fracture and was
admitted to the orthopedic surgery service. Given her elevated
Chads2Vasc score, she was bridged from her home apixaban to a
heparin drip for tight control of her anticoagulation status on
the way to the operating room. The patient was taken to the
operating room on ___ for open reduction with internal
fixation, which the patient tolerated well. 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 her home
anticoagulation was restarted. She received a blood transfusion
for an asymptomatic low hematocrit which she tolerated without
issue.
Activity restrictions: touch down weight bearing in unlocked
___ knee brace on R side. ___ recommended: discharge to
rehab.
#Acute on chronic diastolic HF exacerbation: Likely ___ IV fluid
administration and holding diuretics post-operatively. On Lasix
40mg BID at home. Admission weight 180lbs. Standing weight was
not trended given patient's activity restriction. She was
treated with IV diuresis with improvement which was transitioned
to PO diuretics at discharge.
___: likely cardiorenal as this developed I/s/o volume
overload. Cr improved with IV diuresis.
#Bradycardia: likely ___ to carvedilol as bradycardia improved
with discontinuation of medication. Patient has history of AVB
2nd degree type ___elay, previously with HR ___ and
pauses on telemetry. The patient continued to have episodes of
HR in ___ that were asymptomatic after discontinuation of
beta blocker. Non-urgent cardiology follow up is recommended for
continued surveillance of her asymptomatic bradycardia.
#Oral bleeding: the patient had hemorrhage from the site of a
recent tooth extraction after resuming her home Eliquis. If this
issue recurs, she should see her outpatient oral surgeon
promptly.
CHRONIC ISSUES:
===============
#Atrial fibrillation - continued home apixaban, stopped
carvedilol as
above
#HTN - continued home amlodipine
#HLD - continued home atorvastatin
#GERD - continued home omeprazole
#Depression - continued home citalopram
#Hypothyroidism - continued home levothyroxine
Transitional Issues
=====================
[] R Distal Femur Periprosthetic Fracture: f/u with orthopedics
team in 2 weeks (contact information listed above)
[] TDWB RLE in unlocked ___ brace until ortho follow up.
[] Consider treatment for presumed osteoporosis with Prolia or a
bisphosphonate (unclear to this author from available records if
she has had a bisphosphonate in the past). She is continued on
vitamin D.
[] Bradycardia: Stopped carvedilol. Because she also has
paroxysmal a-fib, watch for any RVR or palpitations off her beta
blocker.
[] HFpEF: If possible to obtain accurate weights with her
weight-bearing restrictions, please trend daily weights. Please
check BMP in one week. Notify the rehab doctor if creatinine is
1.2 or higher, or if weight changes by five pounds or more.
Titrate PO Lasix pending volume status.
[] Tooth bleeding: Follow-up with surgeon who performed recent
dental extraction PRN
#CODE: Full, presumed
#CONTACT: Name of health care proxy: ___
___ number: ___
Medications on Admission:
1. amLODIPine 5 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Carvedilol 6.25 mg PO BID
4. Citalopram 20 mg PO DAILY
5. Apixaban 5 mg PO BID
6. Furosemide 40 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. PreserVision Lutein (vit C-vit E-copper-zinc-lutein) 226
mg-200 unit -5 mg-0.8 mg oral BID
10. Cholecalciferol ___ IU daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
Do not drink or drive on this medication. Please beware sedation
RX *oxycodone 5 mg 0.5 - 1 tablet(s) by mouth q4hrs Disp #*24
Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
4. Furosemide 80 mg PO DAILY
5. amLODIPine 5 mg PO DAILY
6. Apixaban 5 mg PO BID
7. Atorvastatin 20 mg PO QPM
8. Citalopram 20 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. PreserVision Lutein (vit C-vit E-copper-zinc-lutein) 226
mg-200 unit -5 mg-0.8 mg oral BID
13. Cholecalciferol 1000 IU daily (this was omitted in error by
the discharging resident but was called in to the rehab)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
====================
R Distal Femur Periprosthetic Fracture
Acute on chronic diastolic heart failure exacerbation
SECONDARY DIAGNOSES
===================
Anemia
Constipation
___
Bradycardia
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- 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.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a surgery on your R leg.
- You were treated with diuretics for fluid overload
- You were given a blood transfusion for bleeding.
- You had a kidney injury that improved with diuresis.
- You had slow heart rate that improved with stopping
carvedilol.
- You had tooth bleeding that improved.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
- You also slow heart rate and had volume overload which was
treated with diuresis.
We wish you the best!
Sincerely,
Your ___ Team
ACTIVITY AND WEIGHT BEARING:
- Touchdown weight bearing in the right lower extremity in an
unlocked ___ brace.
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please continue to take your apixaban as you were previously.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Followup Instructions:
___
|
10029468-DS-6 | 10,029,468 | 28,440,970 | DS | 6 | 2169-01-16 00:00:00 | 2169-01-16 18:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Amoxicillin / Iodinated Contrast Media - IV Dye / iodine /
Lupron / Lyrica / Migranal / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / Percocet / piroxicam / Salsalate /
Tegretol / Tylenol-Codeine / Ultram / Vicodin / iodoform /
Tegaderm
Attending: ___
Chief Complaint:
motor vehicle accident
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female presenting to ___ after a motor vehicle
accident. She was the restrained driver and was hit on the left
driver's side while traveling at 35 mph. No loss of
consciousness, no airbag deployment. She was seen at an outside
hospital where FAST showed a pericardial effusion. She was
transferred to ___ for further management.
Past Medical History:
PMH
hypothyroidism
PSH
Anterior Fusion cervical spine
Bilateral Salpingoophorectomy
C section
L tendon repair
Occipital nerve stimulator (placed ___- checked ___
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: HR 72, BP 124/72, RR 19, Sat 96% RA
Gen: NAD
Chest/CV: RRR, no tenderness to palpation
Lungs: CTAB
Abdomen: Soft, NT, ND
Spine: Tenderness to palpation at base c-spine, lumbar spine
DISCHARGE PHYSICAL EXAM
Vitals: T97.9 (Tm 97.9), BP: 97/63, HR: 66, RR: 18, O2 sat: 96%,
O2 delivery: Ra
Gen: NAD, AAOx3
HEENT: MMM, tenderness to palpation left neck
CV: RRR
Resp: breaths unlabored, CTAB
Abdomen: soft, nondistended, nontender
Ext: WWP
Pertinent Results:
___ 10:32PM ___ PTT-30.5 ___
___ 10:32PM PLT COUNT-352
___ 10:32PM NEUTS-41.6 ___ MONOS-10.2 EOS-0.9*
BASOS-0.8 IM ___ AbsNeut-3.23 AbsLymp-3.57 AbsMono-0.79
AbsEos-0.07 AbsBaso-0.06
___ 10:32PM WBC-7.8 RBC-3.87* HGB-13.5 HCT-39.8 MCV-103*
MCH-34.9* MCHC-33.9 RDW-12.0 RDWSD-45.2
___ 10:32PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 10:32PM LIPASE-36
___ 10:32PM UREA N-11
___ 10:38PM GLUCOSE-141* LACTATE-0.8 CREAT-0.9 NA+-141
K+-3.6 CL--109* TCO2-23
IMAGING:
Outside Hospital Imaging
1) CT Head
- No acute intracranial abnormality
- Post surgical changes of bilateral mastoid occipital region
noted with what appears to be implantable meshlike material. On
the right, material thickened relative to left. Internal gas
therefore infection cannot be excluded.
- Neurostimulator device is positioned as above
2) CT C spine
- No fracture seen
- S/p anterior fusion at C5-6 with C5-6 disc age
- Disc bulge at C6-7
- Posterior spinal stimulator electrodes
- Bilateral craniotomies with possible infected mesh on right
3) CT Abdomen
- Moderate sized anterior pericardial effusion
-Electronic implanted device possibly a stimulator unit at
posterior right lower thorax
- Mild stranding seen about the paracolic gutters of uncertain
etiology.
___ Imaging
CT Chest:
IMPRESSION: Essentially normal chest CT. No evidence of trauma.
Brief Hospital Course:
Ms ___ was admitted to the Acute Care Surgery service after
being transferred from an outside hospital given concern for
pericardial effusion. She was FAST + in the ED, but
hemodynamically stable. She had no additional injuries on
imaging obtained at the outside hospital.
On the night of admission, she underwent chest CT which showed
an essentially normal chest CT with no evidence of trauma. She
remained hemodynamically stable. She was tolerating a regular
diet and ambulating independently.
She was seen by Neurosurgery given the previous neurosurgical
procedures and concern for possible infection of the right sided
neurostimulator mesh. On their evaluation, there was no evidence
of infection or neurological deficits. She was instructed to
follow up in ___ clinic and to follow up with her PCP.
She was therefore discharged home.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. Topiramate (Topamax) 200 mg PO DAILY
4. BuPROPion XL (Once Daily) 300 mg PO DAILY
5. FLUoxetine 40 mg PO DAILY
6. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
Discharge Medications:
1. BuPROPion XL (Once Daily) 300 mg PO DAILY
2. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
3. FLUoxetine 40 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Topiramate (Topamax) 200 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
motor vehicle accident, no significant pericardial effusion
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 ___ after a motor vehicle accident due to
concern over fluid around your heart. You had a CT of the chest
which was normal. While in the hospital, you were also seen by
Neurosurgery for your peripheral nerve stimulator. There were no
signs of infection. It is recommended that you follow up with
your neurosurgeon Dr ___ and with your primary care doctor
after discharge. Please continue all of your home medications.
Please come to the Emergency Department if you develop:
* Fever > 101 degrees
* Chills
* Chest pain or shortness of breath
* Dizziness, lightheadedness, or feeling faint
* Any symptoms that concern you
Thank you,
Your ___ Surgery Team
Followup Instructions:
___
|
10029484-DS-12 | 10,029,484 | 20,764,029 | DS | 12 | 2160-11-11 00:00:00 | 2161-01-04 21:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year-old man with a histor of CAD, HTN, HLD, NIDDMII who
presented after multiple syncopal episodes at home in the
setting of 10 episodes of diarrhea.
Patient was in usual state of healt until yesterday ___ when he
awoke not feeling well. He ten ad 10 episodes of diarrhea with
associated nausea and chills, after which syncopized x3
including once with + headstrike. Syncopal episodes were
preceeded by dizziness and diaphoresis but witout chest pain
palpitation. He states he did black out each time and does not
know how long he passed out for. Notably, patiet as had similar
episodes of sycnope in the setting of prior GI illness.
Upon arrival to ___, patient with tachycardic to 100s but
otherwise VSS. Labs notable for leukocytosis to 12.7, Chem-7
with anion gap 15 and Glu 427, UA with + glucose and ketones.
Patient was started on insulin gtt and admitted to MICU for
concern of DKA.
In MICU, patient's anion gap quickly closed on insulin gtt, and
he has been transitioned to lantus 10u with gentle ISS. For his
syncope, EKG unchanged from prior and cardiac biomarkers
negative. Diarrhea has been managed supportively with fluids,
and stool C. dif sent and pending.
VS at the time of transfer T97.5 HR 89 BP 144/64 RR 22 O296%RA.
Patient reports feeling better. able to tolerate PO. no n/v. had
4 BM today, watery. denies f/c. abd slightly distended
Past Medical History:
1. CAD status post PCI of the mid LAD for stable angina in ___
after a positive stress test.
2. Type 2 diabetes.
3. Hyperlipidemia.
4. Hypertension.
Social History:
___
Family History:
Significant for cardiac disease
Physical Exam:
Admission physical exam:
Vitals: T97.5 HR 89 BP 144/64 RR 22 O296%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes
NECK: supple
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
BACK: no spinal processes tenderness, tenderness to the left
paraspinal muscles
EXT: no ___ edema
NEURO: cranial nerves III-XII grossly intact, moving all four
extremities
Discharge physical exam:
Vitals: 98.3 84 152/72 18 98%RA
GENERAL: Well appearing man sitting up in chair in NAD
HEENT: Sclera anicteric, moist mucous membranes
LUNGS: CTAB, no wheezing, rales, rhonchi
CV: RRR, normal S1 S2, no M/R/G
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: WWP, no ___ edema
NEURO: AAOx3, motor and sensory exam grossly intact
Pertinent Results:
ADMISSION LABS
==============
___ 08:30PM BLOOD WBC-12.7*# RBC-4.66 Hgb-13.9* Hct-42.5
MCV-91 MCH-29.9 MCHC-32.8 RDW-12.8 Plt ___
___ 11:13AM BLOOD ___ PTT-34.0 ___
___ 08:30PM BLOOD Glucose-427* UreaN-28* Creat-1.5* Na-133
K-4.8 Cl-101 HCO3-17* AnGap-20
___ 04:38PM BLOOD Albumin-3.7 Calcium-7.5* Phos-2.1* Mg-1.6
___ 08:30PM BLOOD %HbA1c-7.7* eAG-174*
___ 11:13AM BLOOD PTH-112*
___ 11:13AM BLOOD 25VitD-33
.
DISCHARGE LABS
==============
___ 06:55AM BLOOD WBC-3.4* RBC-3.95* Hgb-11.8* Hct-33.8*
MCV-85 MCH-29.8 MCHC-34.9 RDW-12.4 Plt ___
___ 06:55AM BLOOD Glucose-107* UreaN-11 Creat-0.7 Na-138
K-3.6 Cl-105 HCO3-23 AnGap-14
___ 11:13AM BLOOD CK-MB-3 cTropnT-<0.01
___ 03:28AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:55AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.7
.
PERTINENT RESULTS
=================
CT abdomen: There is a 9 mm hypodensity in segment 2 of the
liver which is too small to characterize. The liver otherwise
enhances homogeneously without focal lesions or intrahepatic
biliary dilatation. The gallbladder is unremarkable and the
portal vein is patent. The pancreas, spleen and adrenal glands
are unremarkable. The kidneys present symmetric nephrograms and
excretion of contrast with no pelvicaliceal dilation or
perinephric abnormalities.
The small bowel is fluid-filled with some areas which are mildly
dilated;
however, without sharp transition point. Contrast reaches the
mid sigmoid colon. There is no evidence of obstruction. The
appendix is visualized and there is no evidence of appendicitis.
The intraabdominal vasculature is unremarkable. There is no
mesenteric or retroperitoneal lymph node enlargement by CT size
criteria. No ascites, free air or abdominal wall hernia is
noted.
CT pelvis: The urinary bladder is unremarkable. There is no
pelvic free
fluid. There is no inguinal or pelvic wall lymphadenopathy.
Osseous structures: No lytic or sclerotic lesions suspicious
for malignancy is present.
IMPRESSION:
Fluid-filled small bowel with some mildly dilated loops, as can
be seen in the setting of enteritis. No evidence of
obstruction.
.
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.
Brief Hospital Course:
___ y/o M with PMHx significant for CAD, HTN, HLD, NIDDMII who
presented after multiple syncopal episodes at home in the
setting of 10 episodes of diarrhea.
# AG acidosis: On admission, patient found to have anion gap 15
in the setting of BS 400s and UA with ketones suggestive of DKA.
Although patient does have DM, he is not insulin dependent at
baseline making him at lower risk of DKA. His acidosis is
likely explained by his ___ GI illness with loss of HCO3 in the
GI tract, but this would not explain the AG. Alternatively, the
patient could have had an elevated lactate in the setting of
hypovolemia with under perfusion as evidenced by his ___ on
admission which has resolved with intravenous fluids. Patient
was briefly on insulin drips. His Anion gap closed with fluid
resuscitation.
# Diarrhea: Likely a viral gastroenteritis given acute onset.
Patient also no PPI as outpatient, raising the risk of C. diff
which is therefore, also in the ddx. c. diff antigen returned
negative. CT abdomen was also normal as well. Stool culture
were negative as well. Diarrhea resolved prior to discharge.
# Syncope: Patient wit ___ episodes of syncope at home in the
setting of diarrhea so most likely etiology is ___ to
hypovolemic and orthostasis. Without chest pain or palpitations
changes to suggest ACS or arrhythmia as etiology, which is
consistent with EKG unchanged from prior and cardiac biomarkers
negative. No post-ictal symptoms to suggest seizures. Pt had
no more episodes of ___ stay after IV
fluid support. Pt had no pre-syncope symptoms prior to
discharge.
# Acute kidney injury: Unclear recent baseline, although most
recent Cr from ___ in our system 1.1. pateint presented with Cr
1.5, likely ___ to pre-renal etiology. pt's creatinine improved
to 1.0 with IV fluids.
# HTN: pt's home metoprolol 25mg XL and lisinopril was initially
held in the setting of orthostasis. It was resume prior to
dishcarge and pt had no significant episodes of hypotension or
hypertension prior to discharge.
# HLD: continued on home dose simvastatin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE XL 10 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous daily
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. GlipiZIDE XL 10 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous daily
6. Lisinopril 20 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Gastroenteritis
Diabetic Ketoacidosis
Severe Dehydration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It has been our pleasure caring for you at ___. You were
admitted because you had severe diarrhea. In that setting, you
were severely dehydrated, causing you to faint. You briefly
stayed at the intensive care unit because your blood sugar was
too high. Your diarrhea was likely due to an infection. We are
glad to see that your diarrhea has improved and your blood sugar
level has improved as well. You can resume your home regimen
for diabetes control.
Followup Instructions:
___
|
10030549-DS-7 | 10,030,549 | 28,978,916 | DS | 7 | 2141-11-28 00:00:00 | 2141-11-29 08:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
isoniazid
Attending: ___.
Chief Complaint:
Right upper and lower limb weakness
Major Surgical or Invasive Procedure:
Cyber Knife to brain lesion
History of Present Illness:
Mr. ___ is a pleasant ___ HTN, DL, Asthma, T2DM, RA, and
poorly
differentiated penile SCC s/p partial penectomy ___ w/ rapid
met recurrence s/p C3 TIP ___ who p/w RLE weakness x ___ days.
He acutely developed RUE weakness while walking up the stairs at
6PM tonight and fell back and hit his head. He called EMS and
code-stroked by EMS. In the ED he was noted to have RUE and RLE
weakness although subjectively improved. He was seen by
neurology
and found to have preserved strenght in the RUE but RLE weakness
w/ R foot drop and sensory changes. NCHCT revaled a large
hypodensity in the L frontoparietal region w/ c/f mass. He was
seen by ___ who advised dex and no AEDs. He denied any
headache,
changes to vision, no N/V, no other acute complaints.
REVIEW OF SYSTEMS:
12 point ROS reviewed in detail and negative except for what is
mentioned above in HPI
Past Medical History:
Metastatic Penile SCC with sarcomatoid and acantholytic features
Rheumatoid arthritis previously treated with Plaquenil, MTX,
sulfasalaine, leflunomide
Type 2 diabetes mellitus
Asthma
+PPD and +Quantiferon, s/p 3 months of INH but complicated by
LFT
abnormalities, then s/p full course of rifampin
Osteoarthritis
Right bundle branch block
Ventral hernia
Hypertension
Hyperlipidemia
Social History:
___
Family History:
Mother ___ ___
Father ___ ___ blood cancer
NO history of colon, lung or prostate cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITAL SIGNS: 98.2 PO 120/70 7620 99 ra
General: NAD, Resting in bed comfortably
HEENT: MMM, no OP lesions NCAT
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no peritoneal signs
LIMBS: WWP, no ___, no tremors
SKIN: No notable rashes on trunk nor extremities
NEURO: CN III-XII intact, strength ___ LUE, ___ RUE/RLE with
paresthesias RLE, ___ R ___, + R dysmetria , speech intermittent
difficulty to understand due to aphasia, AOx3
PSYCH: Thought process logical, linear, future oriented but
seems
to have intermittent aphasia, off baseline from when i've met
him
before
ACCESS: Chest port site intact w/o overlying erythema, PIV
DISCHARGE PHYSICAL EXAM
=======================
Vitals: ___ 2347 Temp: 97.9 PO BP: 112/59 HR: 59 RR: 18 O2
sat: 100% O2 delivery: Ra
GENERAL: NAD, lying comfortably in bed, sits up independently,
fully cooperative with exam.
HEENT: AT/NC, EOMI, PERLLA, MMM
NECK: Supple, No LAD
CV: RRR, S1/S2, no murmurs
PULM: CTAB, breathing comfortably without use of accessory
muscles, no wheezes, rales or crackles.
ABD: Bowel sounds appreciated, abdomen soft, nondistended
EXT: WWP. Chronic RA changes to BUE, mostly right hand. 2+
pulses
appreciated in four limbs.
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
NEURO: AOx3, Fluent speech, CN II-XII grossly intact. RUE with
4+/5 strength, no difference in sensation to light touch, stable
from previous exam. RLE with ___ strength, mostly decreased in
right foot plantar flexion but improved from baseline (and
stable), reduced sensation to light touch throughout RLE.
ACCESS: Port, no erythema, no skin breakdown, no tenderness.
PIV.
Pertinent Results:
IMAGING
=======
EEG (___) impression:
This was normal continuous EEG recording. There were no
epileptiform discharges or electrographic seizures. Single
channel ecg showed an irregular heart rhythm.
CT Head and Neck (___) impression:
ECG (___) impression:
Sinus rhythm
Ventricular premature complex
Right bundle branch block
repolarization abnormality- nonspecific
MRI Head w&w/o contrast (___) impression:
1. 1 cm ovoid enhancing lesion in the posterior with aspect of
the left superior frontal gyrus with surrounding moderate
vasogenic edema, raises
concern for metastatic disease. Primary brain malignancy is
also differential consideration.
2. No additional intraparenchymal lesions are identified.
3. There is T1 hypointensity in the C4 and C5 vertebral bodies
which is incompletely assessed on this examination but can
reflect osseous metastatic disease. Consider dedicated imaging
of the cervical spine.
4. No acute infarct or hemorrhage.
5. Cerebellar tonsils are pointed and protrude below the foramen
magnum by approximately 1 cm, which can reflect Chiari type
configuration in the appropriate setting.
Chest CT w/contrast (___) impression:
No good evidence for intrathoracic malignancy. 3 mm solid
nodule left lung apex is indeterminate but more likely a scar
than a solitary metastasis. Recommendations for such incidental
findings provided below.
Benign air-filled cyst, right lower lobe.
CT Abdomen and Pelvis w/Contrast (___) impression:
1. Lucent lesion in the T11 vertebral body with associated soft
tissue, better characterized on the same day thoracic spine MRI,
likely a metastasis.
2. Same date chest CT is reported separately.
MRI Spine w&w/o contrast (___) impression:
1. Enhancing lesion involving the T11 vertebral body, raises
concern for
metastatic disease. No additional lesions are identified in the
spine.
2. Severe bilateral neural foraminal narrowing at L3-L4, L4-L5
and L5-S1.
3. Severe spinal canal narrowing at L4-5 due to degenerative
disease.
4. Additional multilevel multifactorial cervical and lumbar
spondylosis as
described above.
CYTOLOGY
========
SPECIMEN(S) SUBMITTED: CEREBROSPINAL FLUID
DIAGNOSIS:
CEREBROSPINAL FLUID:
NEGATIVE FOR MALIGNANT CELLS.
Lymphocytes and monocytes.
MICROBIOLOGY
============
___ 8:35 pm URINE STROKE.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROBACTER CLOACAE COMPLEX. >100,000 CFU/mL.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
LABS
====
___ 04:52AM BLOOD WBC-5.8 RBC-3.71* Hgb-11.6* Hct-34.4*
MCV-93 MCH-31.3 MCHC-33.7 RDW-13.4 RDWSD-46.3 Plt ___
___ 04:29AM BLOOD WBC-5.8 RBC-3.68* Hgb-11.6* Hct-34.1*
MCV-93 MCH-31.5 MCHC-34.0 RDW-13.5 RDWSD-46.4* Plt ___
___ 05:20AM BLOOD WBC-5.9 RBC-3.75* Hgb-11.6* Hct-35.3*
MCV-94 MCH-30.9 MCHC-32.9 RDW-13.7 RDWSD-46.9* Plt ___
___ 05:24AM BLOOD WBC-5.3 RBC-3.85* Hgb-12.0* Hct-36.3*
MCV-94 MCH-31.2 MCHC-33.1 RDW-13.7 RDWSD-47.6* Plt ___
___ 05:55AM BLOOD WBC-3.8* RBC-3.88* Hgb-12.1* Hct-36.4*
MCV-94 MCH-31.2 MCHC-33.2 RDW-13.7 RDWSD-47.5* Plt ___
___ 06:06AM BLOOD WBC-4.3 RBC-3.81* Hgb-11.8* Hct-35.7*
MCV-94 MCH-31.0 MCHC-33.1 RDW-14.0 RDWSD-47.8* Plt ___
___ 04:11AM BLOOD WBC-4.2 RBC-3.67* Hgb-11.6* Hct-34.5*
MCV-94 MCH-31.6 MCHC-33.6 RDW-13.8 RDWSD-47.4* Plt ___
___ 04:15AM BLOOD WBC-4.8 RBC-3.73* Hgb-11.6* Hct-35.1*
MCV-94 MCH-31.1 MCHC-33.0 RDW-13.8 RDWSD-47.1* Plt ___
___ 05:20AM BLOOD WBC-4.7 RBC-3.68* Hgb-11.5* Hct-34.3*
MCV-93 MCH-31.3 MCHC-33.5 RDW-13.8 RDWSD-47.8* Plt ___
___ 05:30AM BLOOD WBC-5.3 RBC-3.78* Hgb-11.8* Hct-35.7*
MCV-94 MCH-31.2 MCHC-33.1 RDW-14.2 RDWSD-49.7* Plt ___
___ 05:00AM BLOOD WBC-4.9 RBC-3.77* Hgb-11.6* Hct-35.1*
MCV-93 MCH-30.8 MCHC-33.0 RDW-14.1 RDWSD-48.1* Plt ___
___ 05:10AM BLOOD WBC-5.1 RBC-3.59* Hgb-11.2* Hct-33.8*
MCV-94 MCH-31.2 MCHC-33.1 RDW-14.4 RDWSD-49.9* Plt ___
___ 06:04AM BLOOD WBC-6.5 RBC-3.42* Hgb-10.5* Hct-32.1*
MCV-94 MCH-30.7 MCHC-32.7 RDW-14.6 RDWSD-50.7* Plt ___
___ 04:52AM BLOOD WBC-6.3 RBC-3.39* Hgb-10.6* Hct-32.1*
MCV-95 MCH-31.3 MCHC-33.0 RDW-14.9 RDWSD-52.1* Plt ___
___ 05:04AM BLOOD WBC-4.2 RBC-3.62* Hgb-11.2* Hct-34.3*
MCV-95 MCH-30.9 MCHC-32.7 RDW-14.6 RDWSD-51.3* Plt ___
___ 07:25PM BLOOD WBC-6.4 RBC-3.45* Hgb-10.8* Hct-33.5*
MCV-97 MCH-31.3 MCHC-32.2 RDW-15.4 RDWSD-55.3* Plt ___
___ 04:29AM BLOOD Neuts-72.9* ___ Monos-4.1*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-4.25 AbsLymp-1.32
AbsMono-0.24 AbsEos-0.00* AbsBaso-0.01
___ 07:25PM BLOOD Neuts-51.4 ___ Monos-7.4 Eos-5.2
Baso-1.1* Im ___ AbsNeut-3.26 AbsLymp-2.20 AbsMono-0.47
AbsEos-0.33 AbsBaso-0.07
___ 04:52AM BLOOD ___ PTT-27.3 ___
___ 04:29AM BLOOD ___ PTT-52.9* ___
___ 05:20AM BLOOD ___ PTT-25.5 ___
___ 05:00AM BLOOD ___ PTT-25.6 ___
___ 07:25PM BLOOD ___ PTT-29.1 ___
___ 04:52AM BLOOD Glucose-180* UreaN-17 Creat-0.9 Na-133*
K-4.7 Cl-94* HCO3-27 AnGap-12
___ 04:29AM BLOOD Glucose-146* UreaN-14 Creat-0.9 Na-132*
K-4.7 Cl-94* HCO3-26 AnGap-12
___ 05:20AM BLOOD Glucose-215* UreaN-15 Creat-0.8 Na-134*
K-5.0 Cl-96 HCO3-25 AnGap-13
___ 05:24AM BLOOD Glucose-175* UreaN-18 Creat-0.8 Na-135
K-4.8 Cl-98 HCO3-25 AnGap-12
___ 05:55AM BLOOD Glucose-164* UreaN-22* Creat-1.0 Na-133*
K-4.6 Cl-96 HCO3-24 AnGap-13
___ 06:06AM BLOOD Glucose-112* UreaN-19 Creat-0.8 Na-133*
K-4.8 Cl-96 HCO3-24 AnGap-13
___ 04:11AM BLOOD Glucose-149* UreaN-22* Creat-1.1 Na-132*
K-5.0 Cl-93* HCO3-24 AnGap-15
___ 05:45PM BLOOD Glucose-258* UreaN-23* Creat-1.1 Na-133*
K-4.6 Cl-95* HCO3-25 AnGap-13
___ 04:15AM BLOOD Glucose-173* UreaN-22* Creat-1.1 Na-131*
K-5.0 Cl-95* HCO3-24 AnGap-12
___ 05:29PM BLOOD Glucose-225* UreaN-27* Creat-1.2 Na-129*
K-5.5* Cl-92* HCO3-25 AnGap-12
___ 05:20AM BLOOD Glucose-213* UreaN-20 Creat-1.0 Na-131*
K-5.1 Cl-94* HCO3-25 AnGap-12
___ 03:44PM BLOOD Glucose-158* UreaN-22* Creat-1.2 Na-131*
K-5.7* Cl-92* HCO3-22 AnGap-17
___ 05:30AM BLOOD Glucose-158* UreaN-22* Creat-1.1 Na-131*
K-5.4 Cl-94* HCO3-26 AnGap-11
___ 05:00AM BLOOD Glucose-227* UreaN-18 Creat-1.0 Na-133*
K-5.1 Cl-97 HCO3-25 AnGap-11
___ 05:10AM BLOOD Glucose-290* UreaN-18 Creat-1.0 Na-134*
K-5.1 Cl-97 HCO3-26 AnGap-11
___ 06:04AM BLOOD Glucose-239* UreaN-18 Creat-0.9 Na-138
K-4.8 Cl-101 HCO3-24 AnGap-13
___ 04:52AM BLOOD Glucose-201* UreaN-18 Creat-0.9 Na-137
K-4.5 Cl-98 HCO3-25 AnGap-14
___ 07:25PM BLOOD UreaN-10
___ 04:29AM BLOOD ALT-32 AST-19 AlkPhos-95 TotBili-0.4
___ 05:00AM BLOOD ALT-25 AST-24 LD(LDH)-167 AlkPhos-99
TotBili-0.3
___ 07:25PM BLOOD ALT-12 AST-25 AlkPhos-123 TotBili-0.3
___ 07:25PM BLOOD cTropnT-<0.01
___ 04:52AM BLOOD Calcium-9.7 Phos-3.5 Mg-1.9
___ 04:29AM BLOOD Calcium-9.7 Phos-3.5 Mg-1.8
___ 05:20AM BLOOD Calcium-9.5 Phos-3.2 Mg-1.8
___ 05:24AM BLOOD Calcium-9.6 Phos-3.3 Mg-1.8
___ 05:55AM BLOOD Calcium-9.9 Phos-3.9 Mg-1.9
___ 06:06AM BLOOD Calcium-9.6 Phos-4.2 Mg-1.9
___ 04:11AM BLOOD Calcium-9.9 Phos-4.0 Mg-1.9
___ 05:45PM BLOOD Calcium-9.6 Phos-4.0 Mg-1.9
___ 04:15AM BLOOD Calcium-9.6 Phos-4.2 Mg-1.9
___ 05:29PM BLOOD Calcium-9.9 Phos-4.1 Mg-2.1
___ 05:20AM BLOOD Calcium-9.5 Phos-4.1 Mg-2.0
___ 05:30AM BLOOD Calcium-9.6 Phos-3.9 Mg-2.1
___ 05:00AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.8 Mg-2.1
Iron-93
___ 05:10AM BLOOD Calcium-9.8 Phos-3.5 Mg-2.1
___ 06:04AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.0
___ 04:52AM BLOOD Calcium-9.9 Phos-4.9* Mg-2.0
___ 07:25PM BLOOD Albumin-4.5
___ 05:00AM BLOOD calTIBC-321 Ferritn-59 TRF-247
___ 05:00AM BLOOD %HbA1c-8.4* eAG-194*
___ 05:45PM BLOOD Osmolal-286
___ 03:44PM BLOOD Osmolal-285
___ 05:20AM BLOOD TSH-1.8
___ 05:00AM BLOOD 25VitD-37
___ 07:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 08:02PM BLOOD Glucose-150* Creat-0.9 Na-139 K-4.0 Cl-99
calHCO3-29
___ 08:35PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 08:35PM URINE Blood-NEG Nitrite-POS* Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 08:35PM URINE RBC-1 WBC-172* Bacteri-FEW* Yeast-NONE
Epi-0
___ 08:35PM URINE Mucous-RARE*
___ 06:07AM URINE Hours-RANDOM UreaN-736 Creat-78 Na-86
K-61 Cl-84 HCO3-2
___ 07:09PM URINE Hours-RANDOM Na-91
___ 03:44PM URINE Hours-RANDOM UreaN-563 Creat-47 Na-65
K-34 Cl-55 HCO3-2
___ 06:07AM URINE Osmolal-557
___ 07:09PM URINE Osmolal-654
___ 03:44PM URINE Osmolal-441
___ 08:35PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG
___ 12:50PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-29* Polys-7
___ ___ 12:50PM CEREBROSPINAL FLUID (CSF) TNC-2 RBC-12* Polys-0
___ ___ 12:50PM CEREBROSPINAL FLUID (CSF) TotProt-34
Glucose-156 LD(LDH)-40
___ 06:10AM BLOOD WBC-4.8 RBC-3.79* Hgb-12.1* Hct-35.2*
MCV-93 MCH-31.9 MCHC-34.4 RDW-13.6 RDWSD-46.2 Plt ___
___ 06:10AM BLOOD ___ PTT-25.1 ___
___ 06:10AM BLOOD Glucose-194* UreaN-18 Creat-0.9 Na-134*
K-4.7 Cl-94* HCO3-28 AnGap-12
___ 06:10AM BLOOD Calcium-10.0 Phos-3.6 Mg-1.8
Brief Hospital Course:
Mr. ___ is a ___ HTN, DL, Asthma, T2DM, RA, and poorly
differentiated penile SCC s/p partial penectomy ___ w/ rapid
met recurrence s/p C3 TIP ___ who p/w RLE/RUE weakness and a
fall, found to have new brain lesion, concerning for metastatic
disease or second primary tumor.
TRANSITIONAL ISSUES
===================
[ ] Continue dexamethasone 4 mg BID until follow up with
neuro-oncology. This was tapered from TID as of ___
evening. His insulin needs will fluctuate with this taper. His
insulin is being decreased by 30% to accommodate this change,
but will likely need further adjustment in insulin based on his
sliding scale needs.
[ ] Discharge diabetes regimen:
- Continue Lantus 25 units QHS
- Continue Humalog 12 units AC breakfast, Humalog 10 units AC
lunch and Humalog 8 units AC supper
- Continue sliding scale to start at 200 mg/dL 2 units+2
units/50mg/dl
- Metformin 1000 mg daily
[ ] Continue PPI and Bactrim for prophylaxis while on steroids.
[ ] Recommend slow dexamethasone taper when indicated given
prolonged course. Would recommend transition to hydrocortisone
to complete taper before stopping completely.
[ ] Continue Keppra for seizure prophylaxis.
[ ] Recommend rechecking electrolytes in 1 week to assess
hyponatremia.
[ ] Continue outpatient follow up with primary oncologist, neuro
oncologist and radiation oncology.
#New left frontoparietal brain lesion
His R hemiplegia is most likely from the new brain lesion. MRI
demonstrated a 1 cm lesion with vasogenic edema. There is a
question of whether this is a metastatic lesion vs new primary.
Total spine MRI without additional lesions. S/p LP with CSF
Cytology, CEA, immunofixation and Beta2 macroglobulin negative.
More likely metastasis from penile Ca > new primary (e.g. GBM).
Was seen by Neurosurgery, but patient denied surgery or biopsy.
With the caveat that a GBM would do poorly with radiation,
patient elected to start Cyber Knife treatments to lesion.
Started Stereotactic XRT for brain lesion, and completed three
fractions (___). Received dexamethasone before and
during radiation for reduction of vasogenic edema with good
response and significant return of strength to RUE and RLE. His
dexamethasone was tapered from 4 mg QID to TID, then to BID on
discharge.
#T2DM
#Increasing insulin requirements
T2DM background, on home metformin, held as inpatient. Required
large amounts of short acting insulin with metformin held and
Dexamethasone treatment. Had been started on Glargine nightly
and
humolog with meals. The ___ has been
consulted and followed along, insulin scales adjusted as needed,
insulin teaching was provided prior to discharge. While on
dexamethasone 4 mg TID he was stabilized on insulin regimen of
glargine 35 U QHS, Humalog 17 U breakfast/14 U lunch/12 U dinner
with sliding scale.
His insulin was decreased by 30% on day of discharge given the
plan to taper his dexamethasone. His metformin was held during
the admission and restarted on discharge.
#Hypointensity in the C4 and C5 vertebral bodies
Dedicated C-spine MRI negative for spinal mets per Neuro Onc.
T11 lesion identified by CT Torso and T-Spine MRI has been
stable since ___ and unlikely represented new progression of
disease.
#RUE, RLE weakness
Secondary to new brain lesion as above. As per neuro oncology,
less likely that RLE will recover. Radiation planned. ___
consulted and are following, able to walk for short distances
daily. Will be discharged to ___ rehab.
#UTI / Asymptomatic Bacteuria
ED UA reflexed to ___ and found to have bacteria in urine. Was
started on Ceftriaxone for empiric care, final culture grew
ENTEROBACTER CLOACAE COMPLEX, and so therapy was escalated to IV
Cefepime and then changed to PO Bactrim. Assymptomatic and may
be colonized, however chose to complete a course of seven days.
#Hyponatremia
Sodium trending low with nadir of 131 (baseline 141 on
admission). Clinically euvolemic. Normal blood osmolality, urine
Na=65 and urine osmolality=441 raise concern for SIADH in the
presence of known brain lesion, which was communicated to care
team. Hyponatremia asymptomatic. Stable at 131 with water
restriction, but seems dry by kidney function. Sodium up to 133
after 500ml NS, but urine more concentrated (sodium 90, Osm
~600). Sodium stable at 133 with further hydration and
resolution of renal function to baseline, supporting
hypovolemia. TSH wnl. Sodium stable after gentle hydration.
Electrolytes were trended as needed.
#Met Penile Squamous Cell Ca
Unfortunately his high risk localized disease has rapidly
progressed to at least soft tissue and RP nodes. He is being
treated with TIP with palliative intent ___ ___ ___
w/near CR. He completed TIP therapy ___ and has close f/u
with oncology. Given negative LP and scans, planned for
surveillance as outpatient with follow up imaging at 8 weeks
with therapy reserved in case of progression of disease.
#Asthma: quiescent
- Continued advair/flonase, albuterol prn
#HTN:
- Held ACEI and remained normotensive so was not continued on
discharge. Held aspirin indefinitely given brain lesion.
#Dyslipidemia:
- Continued statin
#RA:
- Continued prn oxy
#CODE STATUS: FULL CODE (Confirmed ___ with patient)
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH TID:PRN shortness of
breath/wheezing
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Lisinopril 10 mg PO DAILY
6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
7. Vitamin D 1000 UNIT PO DAILY
8. Dexamethasone 4 mg PO ASDIR
9. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN nasal
congestion
10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
11. Atorvastatin 40 mg PO QPM
12. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
13. diclofenac sodium ___ grams topical BID
Discharge Medications:
1. Glargine 25 Units Bedtime
Humalog 12 Units Breakfast
Humalog 10 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. LevETIRAcetam 1000 mg PO Q12H
3. Omeprazole 20 mg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 8.6 mg PO DAILY:PRN Constipation - Second Line
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. Dexamethasone 4 mg PO BID
Continue BID dosing until follow up with his neuro-oncologist
8. Albuterol Inhaler 2 PUFF IH TID:PRN shortness of
breath/wheezing
9. Atorvastatin 40 mg PO QPM
10. Docusate Sodium 100 mg PO BID:PRN constipation
11. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN nasal
congestion
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
13. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
Do Not Crush
14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
15. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
16. Vitamin D 1000 UNIT PO DAILY
17. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until you follow you with the ___
___ clinic
18. HELD- diclofenac sodium ___ grams topical BID This
medication was held. Do not restart diclofenac sodium until you
follow up with the ___ clinic
19. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until You follow up with your PCP and
your blood pressure is evaluated.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic Penile Squamous Cell Carcinoma
New Brain Lesion, most likely ___ metastasis
Hyperglycemia
Type II Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at ___
___!
Why was I here?
- You came to the hospital because you noticed weakness in your
right leg and right arm.
What was done while I was here?
- You had a scan of your head which showed a mass.
- This mass was thought to be causing your symptoms and looked
consistent with a cancer.
- You had a spinal tap which did not show any cancer cells.
- You were started on steroids which helped with your weakness.
- You had radiation therapy to your brain.
- You were seen by physical therapy who recommended discharge to
an acute rehab facility to help you gain your strength back.
What should I do when I get home?
- Please take all of your medications as prescribed and go to
all of your follow up appointments as listed below.
We wish you the best!
- Your ___ Team
Followup Instructions:
___
|
10030579-DS-11 | 10,030,579 | 26,743,162 | DS | 11 | 2189-07-07 00:00:00 | 2189-07-07 14:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Hayfever / adhesive tape / Latex / Effexor XR
Attending: ___.
Chief Complaint:
Right hip pain
Major Surgical or Invasive Procedure:
R hip TFN - ___
History of Present Illness:
HPI: ___ male with history of hepatic steatosis presents
s/p fall with R hip pain and deformity. States he was watching
television this morning when he dozed off, rolled off the cough
landing on his right side on a concrete floor with immediate
onset of severe R hip pain. Also reports mild L anterior chest
wall pain. Called EMS and was transported to ___ ED where he
was noted to have shortening and external rotation of the R leg
with intact neurovascular exam. No other complaints at this
time.
Imaging showed an intertrochanteric fracture of the R hip, for
which we are consulted.
Past Medical History:
PMH/PSH:
-Hepatic steatosis
-Perforated duodenal ulcer, s/p repair
-L shoulder labral repair
-Bilateral meniscal repair
-Ruptured appendix s/p appendectomy
Social History:
___
Family History:
N/C
Physical Exam:
Exam on Discharge
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right intertrochanteric fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for right hip TFN which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the right lower extremity, and will be discharged on
Lovenox for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram ___ mg PO DAILY
2. Gabapentin 600 mg PO TID
3. Hydrocortisone ___. Cream 0.2% 1 Appl TP BID:PRN psoriasis
4. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
5. QUEtiapine Fumarate 50-100 mg PO QHS
6. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Citalopram ___ mg PO DAILY
2. Gabapentin 600 mg PO TID
3. Multivitamins 1 TAB PO DAILY
4. QUEtiapine Fumarate 50-100 mg PO QHS
5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
6. Calcium Carbonate 1250 mg PO TID
7. Docusate Sodium 100 mg PO BID
8. Enoxaparin Sodium 40 mg SC QPM Duration: 2 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
9. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
Do not drink alcohol, drive, or operate heavy machinery while
taking.
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 3
hours Disp #*50 Tablet Refills:*0
10. Senna 8.6 mg PO DAILY
11. Vitamin D 800 UNIT PO DAILY
12. Hydrocortisone ___. Cream 0.2% 1 Appl TP BID:PRN psoriasis
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right intertrochanteric femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Discharge Instructions:
Instructions After Orthopedic Surgery
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week. - Resume your
regular activities as tolerated, but please follow your weight
bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated right lower extremity with upper
extremity assist as needed
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:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
___ - WBAT RLE with upper extrmeity assist as needed
Treatments Frequency:
Dry sterile dressing changes daily, as needed PRN staining.
Followup Instructions:
___
|
10030682-DS-13 | 10,030,682 | 25,960,647 | DS | 13 | 2118-01-31 00:00:00 | 2118-01-31 14:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Cervical stenosis with spinal cord compression
Major Surgical or Invasive Procedure:
___ - C3-C7 laminectomies and posterior fusion
History of Present Illness:
___ is a ___ year old female who presented to the
Emergency Department on ___ as a transfer from an outside
facility status post motor vehicle collision with complaints of
generalized numbness and weakness. The patient was transferred
to ___ for further evaluation
and management. MRI of the cervical spine in the Emergency
Department was concerning for cervical stenosis with spinal cord
compression. The Neurosurgery Service was consulted for question
of acute neurosurgical intervention.
Past Medical History:
- hyperlipidemia
- hypertension
Social History:
___
Family History:
Noncontributory
Physical Exam:
On Admission:
-------------
Vital Signs: T 98.1F, HR 66, BP 126/59, RR 17, O2Sat 96% on room
air
General: Well nourished. In cervical collar.
Extremities: Warm and well perfused.
Neurologic:
Mental Status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
Deltoid Biceps Triceps Wrist Extension Wrist Flexion
Grip
Right4- 4- 4- 0 0
0
Left4- 4- 3 0 0
0
IP Quadriceps Hamstring AT ___ Gastrocnemius
Right2 3 2 2 3 2
Left2 3 2 2 3 2
Sensation: Intact to light touch and pinprick, but complaining
of diffuse numbness.
Reflexes: Right biceps reflex 2+. Unable to elicit left biceps
reflex. Patellar reflexes 2+ bilaterally.
Toes mute. Proprioception intact. Rectal tone intact. No
___ sign bilaterally. No clonus bilaterally.
On Discharge:
-------------
Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious
Orientation: [x]Person [x]Place [x]Time
Follows Commands: [ ]Simple [x]Complex
Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [x]Yes [ ]No
Motor:
Trapezius Deltoid Biceps Triceps Grip WF WE
Right5 4+ 5 5 5 4+ 5
Left5 4+ 4+ 4- 3 4+ 5
IP Quadriceps Hamstring AT ___ Gastrocnemius
Right5 5 4+ 5 5 5
Left5 5 4+ 5 5 5
[x]Sensation intact to light touch
Pertinent Results:
Please see ___ Record for relevant laboratory and
imaging results.
Left Shoulder Xray Study Date of ___ 9:45 AM
IMPRESSION:
1. Calcific tendinosis of the supraspinatus/infraspinatus.
2. Minimal degenerative changes in the left shoulder
3. No acute fracture or dislocation.
Radiology Report ___ NON-TRAUMA ___ VIEWS Study Date of
___ 2:26 ___
IMPRESSION:
There is posterior fusion hardware from C3 to C7. No hardware
related
complications are seen. There are degenerative changes with
loss of
intervertebral disc height at several levels and worse at C3-C4
and C4-C5.
Lung apices are grossly clear.
Radiology Report BILAT LOWER EXT VEINS Study Date of ___
10:52 AM
IMPRESSION:
No evidence of venous thrombosis.
UNILAT UP EXT VEINS US RIGHT Study Date of ___ 3:10 ___
IMPRESSION:
No evidence of deep vein thrombosis in the right upper
extremity.
Radiology Report MR CERVICAL SPINE W/O CONTRAST Study Date of
___ 5:21 AM
IMPRESSION:
1. Status post bilateral laminectomy and posterior fusion at
C3-C7 with
expected postsurgical changes.
2. New focal expansion and increased T2 signal within the cord
at the C3-4
level. Some degree of underlying myelomalacia is suspected at
the C4-5 level.
3. Overall improvement in the degree of spinal canal narrowing
from C2-C7,
with the worst level, at C2-3, displaying mild to moderate
spinal canal
narrowing.
MR ___ W/O CONTRAST Study Date of ___ 3:12 ___
IMPRESSION:
1. Motion limited exam.
2. Prevertebral edema from the craniocervical junction through
C5-C6. No
clear evidence for anterior longitudinal ligament edema or
disruption, but
evaluation is limited by motion. No other evidence for
ligamentous edema or bone marrow edema.
3. From C3-C4 through C5-C6, there are disc protrusions and
endplate
osteophytes severely narrowing the spinal canal and compressing
the spinal
cord. At C6-C7, right paracentral disc protrusion endplate
osteophytes cause moderate spinal canal narrowing with ventral
spinal cord remodeling. There is patchy T2 hyperintensity in the
cord from C2-C3 through C6-C7 levels, which may represent
contusion in the setting of trauma, versus chronic myelomalacia
in the setting of spinal canal stenosis.
4. No evidence for acute traumatic injuries in the thoracic or
lumbar spine.
5. Multilevel lumbar degenerative disease. Spinal canal
stenosis is moderate to severe at L4-L5, and moderate at L3-L4
and L5-S1, with crowding of the intrathecal nerve roots. There
is also mass effect on multiple traversing and exiting nerve
roots, as detailed above.
6. Trace left pleural effusion and mild bilateral dependent
atelectasis.
7. Highly distended bladder. Please correlate clinically
whether the patient is able to void.
Brief Hospital Course:
___ year old female with cervical stenosis s/p motor vehicle
collision with central cord syndrome.
#Cervical Stenosis With Spinal Cord Compression
#Central cord syndrome
The patient was taken emergently to the operating room for a
C3-C7 laminectomy and posterior fusion. The procedure was
uncomplicated. Please see separately dictated operative report
by Dr. ___ further details. A surgical drain was left
in place, which was subsequently removed on POD#5. The patient
was extubated in the operating room and recovered in the PACU.
She was transferred to the step down unit for close neurologic
monitoring. Her neurologic exam slowly improved postoperatively.
Postoperative x-rays of the cervical spine showed no evidence of
retained surgical drain or hardware complications. On ___
overnight, the patient was noted to have worsened weakness on
exam. A CT of the cervical spine was obtained, which was grossly
negative, but there was significant artifact from the hardware.
An MRI of the cervical spine was also obtained, which showed
increased T2 signal in cord at C3-C4, but overall improvement in
the degree of spinal canal narrowing from C2-C7. Her weakness
subsequently improved and continued to improve with continued
physical and occupational therapy.
#Rib Fracture
Acute Care Surgery was consulted for fracture of the first rib
on the left. There was no surgical intervention or follow-up
needed.
#Hypoxia
The patient required supplemental oxygen on ___. She was
subsequently weaned off the supplemental oxygen, and her oxygen
saturations remained stable on room air for the remainder of her
hospitalization.
#Right Shoulder and wrist Pain
The patient complained of significant right shoulder pain. An
x-ray of the right shoulder was obtained, which showed no
definite fracture or dislocation, however there was a well
corticated rounded density, which was thought to reflect sequela
of remote injury or calcific tendinitis. She also c/o
significant right wrist pain. An ultrasound of the right wrist
was negative. Pain medications were adjusted.
#Urinary Retention
The patient experienced urinary retention postoperatively. Her
Foley catheter was discontinued. She failed a voiding trial on
___, and catheter was replaced. Her Foley catheter was
discontinued again on ___, and she was able to void but
still required intermittent straight cath for retention. On
discharge patient was voiding without difficulty.
#Constipation / Ileus
She was started on an aggressive bowel regimen for constipation.
On ___, the patient was noted to have abdominal distension.
KUB showed postop ileus. No nausea/vomiting. She was made NPO,
limited narcotics, and continued on aggressive bowel regimen.
Repeat abdominal XR ___ showed interval improvement. On ___,
the patient was passing her bowels and her diet was advanced to
regular. A repeat KUB showed interval improvement of the ileus.
On discharge patient was moving her bowels without difficulty.
#Fever
#UTI
The patient became febrile postoperatively. Urinalysis was
positive. Urine culture showed PROTEUS MIRABILIS UTI. She was
started on Ceftriaxone ___.
Blood cultures were negative. Chest x-ray was negative. On
discharged there is no evidence of UTI or ongoing infection,
patient is afebrile.
#Hyponatremia
The patient was hyponatremic and was started on sodium chloride
tablets on ___ with improvement. On ___, the patient's
serum Na level remained low and the salt tablets were increased.
The serum Na level normalized on ___ and the sodium was
monitored closely. On ___, the salt tablets were titrated down
to 1g three times daily. The serum sodium continued to be
monitored, and was stable on ___. Her sodium tablets were
weaned off and her serum sodium levels remained stable.
#Elevated BUN
The patient's BUN was elevated. She received a 500mL normal
saline bolus on ___ with improvement. The BUN returned to
normal range on ___. Her BUN was elevated on ___ and
returned to normal limits the next day.
#Left shoulder pain
Patient developed severe left shoulder pain ___. Ibuprofen was
started with some relief. XR on ___ showed no fracture or
dislocation, but did show mild calcific tendinitis. Ibuprofen
was increased and continued ___ was recommended.
#Disposition
Physical Therapy and Occupational Therapy were consulted and
recommended discharge to rehabilitation. However, the patient's
health insurance does not provide any rehabilitation benefits.
Family training was done inpatient to work towards a safe
discharge. Social Work was consulted given her limited health
insurance. A family meeting was organized that resulted in the
patient's family working to get the patient insurance so
benefits can be obtained. The goal was to obtain benefits for
acute rehab at the recommendation of physical therapy, either
through the ___ or ___. A second family meeting was held
___ where her son, ___, was given power of attorney and
health care proxy status as the family worked on insurance.
Patient was approved for health insurance on ___. She was
discharged on ___ to ___ for further care.
Medications on Admission:
- hydrochlorothiazide 12.5mg by mouth once daily
- lisinopril 40mg by mouth once daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line
3. Docusate Sodium 100 mg PO BID
4. Fleet Enema (Mineral Oil) ___AILY:PRN constipation
5. Gabapentin 300 mg PO TID
6. Heparin 5000 UNIT SC BID
7. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
8. Lidocaine 5% Patch 2 PTCH TD QAM
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
10. Polyethylene Glycol 17 g PO DAILY
11. Senna 8.6 mg PO BID
12. Simethicone 40-80 mg PO QID:PRN gas pain
13. Hydrochlorothiazide 12.5 mg PO DAILY
14. Lisinopril 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cervical stenosis with spinal cord compression
Urinary tract infection
ileus
post operative pain
electrolyte abnormalities
Rib fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Discharge Instructions
Cervical Spinal Fusion
Surgery
Do not apply any lotions or creams to the site.
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. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
Please do NOT take any blood thinning medication (Plavix,
Coumadin) until cleared by the neurosurgeon. You are cleared to
take Aspirin and Ibuprofen if indicated.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
10030746-DS-19 | 10,030,746 | 22,297,761 | DS | 19 | 2169-07-12 00:00:00 | 2169-07-12 13:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
___ Cardiac catheterization
___: Coronary artery bypass grafts x3 (LIMA-LAD,
SVG-AntRV, SVG-OM1); Endovascular saphenous vein harvest
History of Present Illness:
Mr. ___ is a ___ year old male with a past medical history of
diabetes mellitus type 2, hyperlipidemia, and hypertension. He
initially presented to his PCP with epigastric pain and nausea.
An EKG reportedly showed accelerated junctional rhythm with HR
___. He was then sent to ___ and EKG showed sinus
bradycardia. He ruled in NSTEMI and was then transferred to
___ for coronary angiogram which revealed three-vessel
disease. Cardiac surgery consulted for revascularization.
Past Medical History:
Diabetes mellitus type 2
Gastritis c/b duodenal stricture
Hyperlipidemia
Hypertension
Social History:
___
Family History:
Father w/ MI and passed in his ___
Mother CVA and passed at ___
Physical Exam:
BP: 120/72 HR: 56 RR: 18 O2 sat: 97% RA
Height: 68 in Weight: 74.9 kg
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
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
___ Right: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit: none
Discharge examination
24 HR Data (last updated ___ @ 727)
Temp: 98.1 (Tm 99.1), BP: 114/65 (112-133/65-79), HR: 64
(60-71), RR: 16 (___), O2 sat: 96% (95-98), O2 delivery: Ra,
Wt: 167.33 lb/75.9 kg
Fluid Balance (last updated ___ @ 859)
Last 8 hours Total cumulative -230ml
IN: Total 420ml, PO Amt 420ml
OUT: Total 650ml, Urine Amt 650ml
Last 24 hours Total cumulative -1270ml
IN: Total 880ml, PO Amt 880ml
OUT: Total 2150ml, Urine Amt 2150ml
Physical Examination:
General: NAD
Neurological: A/O x3 non focal
Cardiovascular: RRR no murmur or rub
Respiratory: CTA No resp distress
GI/Abdomen: Bowel sounds present Soft ND NT multipleBM
andpassing flatus
Extremities:
Right Upper extremity Warm Edema tr
Left Upper extremity Warm Edema tr
Right Lower extremity Warm Edema tr
Left Lower extremity Warm Edema tr
Pulses:
DP Right:p Left:p
___ Right:p Left:p
Radial Right:p Left:p
Sternal: CDI no erythema or drainage Sternum stable
Lower extremity: Left CDI
Pertinent Results:
Cardiac Catheterization ___ at ___
LM: 70% stenosis in the distal segments, eccentric, calcified
LAD: medium caliber vessel.
Cx: large caliber vessel; 70-80% stenosis in the ostium that
extends into the ___ Obtuse Marginal
RCA: 80% stenosis in the ostium; 100% stenosis in the mid and
distal segments. Collaterals from the mid segment of the AM
connect to the distal segment.
Transthoracic Echocardiogram ___
There is no evidence for an atrial septal defect by 2D/color
Doppler. The estimated right atrial pressure is ___ mmHg.
Overall left ventricular systolic function is mildly depressed
secondary to hypokinesis of the inferior and posterior walls.
The visually estimated left ventricular ejection fraction is
45%. Tricuspid annular plane systolic excursion (TAPSE) is
normal. There is no evidence for an aortic arch coarctation.
There is mild [1+] mitral regurgitation. There is mild [1+]
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is borderline elevated.
IMPRESSION: inferior posterior hypokinesis; mild mitral
regurgitation
Transesophageal Echocardiogram ___
PRE-OPERATIVE STATE: Pre-bypass assessment. Sinus rhythm.
Left Atrium ___ Veins: Dilated ___. No spontaneous
echo contrast or thrombus in the ___.
Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC):
Dilated RA. No spontaneous echo contrast or thrombus is seen in
the RA/RA appendage. Normal interatrial septum. No atrial septal
defect by 2D/color flow Doppler.
Left Ventricle (LV): Mild symmetric hypertrophy. Normal cavity
size. Mild-moderate global hypokinesis. Mildly depressed
ejection fraction.
Right Ventricle (RV): Mild global hypokinesis.
Aorta: Normal ascending diameter. No dissection. Simple atheroma
of ascending aorta. Simple arch atheroma. Simple descending
atheroma.
Aortic Valve: Moderately thickened (3) leaflets. Moderate
leaflet calcification. Minimal stenosis. No regurgitation.
Mitral Valve: Moderately thickened leaflets. Moderate leaflet
calcification. No systolic prolapse. No stenosis.
Mild annular calcification. Mild [1+] regurgitation. Central
jet.
Pulmonic Valve: Thickened leaflets. Trivial regurgitation.
Tricuspid Valve: Mildly thickened leaflets. Mild annular
calcification. Mild [1+] regurgitation.
Pericardium: No effusion.
POST-OP STATE: The post-bypass TEE was performed at 14:16:00.
Atrial paced rhythm.
Support: Vasopressor(s): none.
Left Ventricle: Systolic function is improved. Global ejection
fraction is normal.
Right Ventricle: Improved systolic function.
Aorta: Intact. No dissection.
Aortic Valve: No change in aortic valve morphology from
preoperative state. No change in aortic regurgitation.
Mitral Valve: No change in mitral valve morphology from
preoperative state. No change in valvular regurgitation from
preoperative state.
Tricuspid Valve: No change in tricuspid valve morphology vs.
preoperative state.
Pericardium: No effusion.
___ 06:10AM BLOOD WBC-7.5 RBC-3.67* Hgb-11.2* Hct-34.2*
MCV-93 MCH-30.5 MCHC-32.7 RDW-11.9 RDWSD-40.5 Plt ___
___ 06:10AM BLOOD Glucose-137* UreaN-14 Creat-0.9 Na-140
K-3.6 Cl-99 HCO3-31 AnGap-10
___ 11:34PM BLOOD WBC-8.2 RBC-4.46* Hgb-13.8 Hct-41.0
MCV-92 MCH-30.9 MCHC-33.7 RDW-12.0 RDWSD-40.6 Plt ___
___ 06:51AM BLOOD ___ PTT-41.3* ___
___ 11:34PM BLOOD Glucose-270* UreaN-13 Creat-1.2 Na-141
K-3.9 Cl-102 HCO3-27 AnGap-12
___ 07:06PM BLOOD ALT-23 AST-36 LD(LDH)-312* AlkPhos-46
Amylase-30 TotBili-0.4
___ 05:35PM BLOOD CK(CPK)-719*
___ 06:51AM BLOOD CK-MB-30* cTropnT-1.26*
___ 07:06PM BLOOD Lipase-22
___ 05:35PM BLOOD CK-MB-70* MB Indx-9.7*
___ 05:35PM BLOOD cTropnT-0.53*
___ 06:10AM BLOOD Mg-2.0
___ 02:40AM BLOOD Calcium-8.0* Phos-3.4 Mg-2.5
___ 06:10AM BLOOD ALT-9 AST-11 LD(LDH)-203 AlkPhos-41
Amylase-13 TotBili-0.4
Brief Hospital Course:
Presented to OSH with epigastric pain and ruled in for NSTEMI
and was transferred for cardiac workup including cardiac
catheterization that revealed significant coronary artery
disease. He was managed under cardiology and cardiac surgery
was consulted for surgical evaluation. He underwent routine
preoperative testing and evaluation. He remained hemodynamically
stable and was taken to the operating room on ___. He
underwent coronary artery bypass grafting x 3. Please see
operative note for full details. Post operatively he was taken
to the intensive care unit for management on Propofol and
nitroglycerin. Within a few hours he was weaned of sedation,
awoke neurologically intact and was extubated without
complications. He was transitioned to nicardipine for blood
pressure control. He continued to progress and was
transitioned to betablocker and diuretic on post operative day
one allowing nicardipine to be weaned off. He continued to
progress and was transitioned to the floor. Chest tubes and
epicardial wires were removed per protocol. He developed nausea
and medications were adjusted including pain medications and
bowel medications. It resolved after bowel movement and
scopolamine patch. He was then able to tolerate oral intake.
He worked with physical therapy on strength and mobility with
recommendation for home with services. He was clinically
stable, tolerating diet and pain controlled with acetaminophen
at time of discharge home on post operative day four. Plan to
have labs checked in few days due to recent addition of Ace
inhibitor due to recent NSTEMI.
Medications on Admission:
1. Rosuvastatin Calcium 20 mg PO QPM
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. GlipiZIDE 5 mg PO BID
4. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin EC 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Furosemide 40 mg PO DAILY Duration: 7 Days
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
5. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
6. Metoprolol Tartrate 50 mg PO BID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
8. Scopolamine Patch 1 PTCH TD ONCE nausea Duration: 72 Hours
remove ___. Senna 17.2 mg PO DAILY
change to as needed if loose stool
RX *sennosides 8.6 mg 2 tablets by mouth once a day Disp #*60
Tablet Refills:*0
10. Omeprazole 40 mg PO DAILY
40 mg for 1 month daily then decrease back to 20 mg daily as
prior to admission
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
11. Rosuvastatin Calcium 40 mg PO QPM
RX *rosuvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
12. GlipiZIDE 5 mg PO BID
13. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary Artery Disease s/p coronary revascularization
Non-ST Elevation Myocardial Infarction
Secondary Diagnosis:
Diabetes Mellitus Type II
Gastritis
Hyperlipidemia
Hypertension
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with acetaminophen
Sternal Incision - healing well, no erythema or drainage
Left Leg EVH - healing well, no erythema or drainage
Edema trace
Discharge Instructions:
Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10030753-DS-28 | 10,030,753 | 27,035,421 | DS | 28 | 2194-04-25 00:00:00 | 2194-04-26 10:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Chest pain, presyncopal episode, hyperglycemia.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo woman with extensive PMH including poorly controlled DM1,
CAD (s/p MI, s/p PTCA w/ angioplasty to OM1 no stent ___,
CREST syndrome, APLA, PE in ___ on coumadin, GERD, and
hypothyroidism who is admitted for chest pain, hyperglycemia and
presuncopal event.
.
Last night she felt lousy as if her blood pressure was dropping.
She stood up to answer the door and felt unsteady. She denied
lightheadedness or dizziness. She hit her head when she fell but
denies headache, neck pain, or LOC.
.
She reports right arm and chest pain starting at approximately
8:00 last night. She feels as if her right arm pain is her
anginal equivalent, and was relieved by nitro when given in the
ED. She felt ___ right sided chest pressure is around her
breast and is worse when moving around and with deep breathing.
.
She reports an increasing blood sugar over the past 24 hours. It
was 200 then 400 after not eating. She gave herself 20U of
humalog at home.
.
She reports a UTI which has been treated "since ___".
She could not remember the antibiotic she was using, but
nitrofurantoin was listed in OMR. It appears that she has been
switching antibiotics since then. She was instructed to straight
cath daily but has been only spot cathing when she feels as if
she needs to since ___.
.
She called EMS after her presyncopal event and complained of
right arm pain. EMS reported no deformity of the right arm and a
critically high BS.
.
In the ED, initial vitals were Pain ___ 99/46 14 98% on RA.
Labs revealed trop neg X1 (2AM), WBC 10.6 w/ 90% PMN, Cr:BUN 1.3
(recent baseline Cr 0.9-1.1), Glu = 522, Lactate = 3.8, INR =
2.1, UA: Glu +++, Ketone +. EKG: (ED read) sinus tachycardia
100, indeterminate axis (isoelectric in all limb leads), small Q
wave at III, IRBBB, NI, ? minimal < 0.5mm STE II, III, V2-V6
(STE and axis are changed from prior tracing of ___. CXR:
(ED read) AP film, no infiltrate, edema, effusions; unchanged
from prior. Her arm/chest pain resolved with NTGX2. She got
Aspirin 81mg and got 14u humalog per patient's home sliding
scale for a FSBS of ___ NS given. and she had an #18 RFA
#20 LFA from the field. Most Recent Vitals prior to transfer
were afeb 94 116/57 19 97% RA.
.
Currently, she reports her right arm pain has completely
resolved. She reports persistent right sided chest pain.
.
ROS:
+per HPI, fever, night sweats, nausea, constipation, food
getting stuck/not going down as easily
-chills, headache, vision changes, rhinorrhea, congestion, sore
throat, cough, shortness of breath, chest pain, abdominal pain,
vomiting, diarrhea, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder treated
- ESRD ___ diabetes s/p L side living kidney transplant in ___
- Scleroderma w/ CREST syndrome
- Antiphospholipid antibody syndrome and remote PE history on
Coumadin ___
- CAD s/p MI in ___, s/p PTCA ___: one vessel disease with LAD
60% apical lesion and 90% ___ diagonal lesion. ___ diagonal
branch was treated with ballon angioplasty w/o stenting. Final
angiography demonstrated ___ residual stenosis and improved
flow down the diagonal branch
- LVH
- Gastroparesis
- GERD/Hiatal hernia
- Hypothyroidism
- Gout
- Herniated disk
- OSA not on CPAP
- Multiple UTI's
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Physical Exam:
VS - 98.2 124/76 59 18 100% on RA
GENERAL - NAD, uncomfortable with movement, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
HEART - PMI non-displaced, RRR, ___ systolic murmur heard best
over USB, nl S1-S2, markedly tender at right parasternal border
and around right breast
ABDOMEN - +BS, soft/NT/ND, no masses or HSM, no
rebound/guarding, no graft tenderness
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, decreased sensation in lower extremities
bilaterally, cerebellar exam intact
Pertinent Results:
Labs:
___ 02:00AM BLOOD WBC-10.6 RBC-3.84* Hgb-12.3 Hct-35.8*
MCV-93 MCH-32.0 MCHC-34.3 RDW-13.0 Plt ___
___ 02:00AM BLOOD Neuts-91.2* Lymphs-5.4* Monos-3.3 Eos-0.1
Baso-0.1
___ 02:14AM BLOOD ___ PTT-43.6* ___
___ 02:00AM BLOOD Plt ___
___ 11:15AM BLOOD Glucose-148* UreaN-22* Creat-1.0 Na-139
K-3.6 Cl-107 HCO3-25 AnGap-11
___ 06:55PM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:15AM BLOOD tacroFK-8.8
___ 02:14PM BLOOD D-Dimer-<150
___ 02:22AM BLOOD Glucose-478* Lactate-3.8* Na-135 K-3.9
Cl-98 calHCO3-24
___ 02:22AM BLOOD Hgb-12.8 calcHCT-38
___ 04:50AM BLOOD Hct-32.8*
___ 04:50AM BLOOD UreaN-19 Creat-1.1
Micro:
___ URINE CULTURE-PENDING
___ Blood Culture, Routine-PENDING
Imaging:
___ EKG: ST at 100, NA, NI, RSR' in V2, no ST-T wave changes
compared to prior of ___
___ EKG: NSR at 90, NA, NI, no ST-T wave changes
___ CXR: Lung volumes are low. No focal opacity to suggest
pneumonia is seen. No pleural effusion, pulmonary edema or
pneumothorax is present. The heart size is top normal.
IMPRESSION: No evidence of acute cardiopulmonary process.
___ rib films: No displaced fracture is present. No
sclerotic or lytic lesions are Preliminary Reportidentified. On
the frontal chest radiograph, the heart size is normal, and
Preliminary Reportthe hilar and mediastinal contours are within
normal limits. There is no Preliminary Reportfocal
consolidation, pleural effusion, or pneumothorax. The patient is
Preliminary Reportpost-cholecystectomy. Preliminary
ReportIMPRESSION: No rib fractures detected.
Brief Hospital Course:
___ yo female with extensive PMH including poorly controlled DM1,
CAD (s/p MI, s/p PTCA w/angioplasty to OM1 no stent ___,
CREST syndrome, APLA, PE in ___ on coumadin, GERD, and
hypothyroidism who is admitted for right arm and chest pain,
hyperglycemia and presyncopal event.
# Right arm and chest pain: The patient reported her right arm
pain was similar to her anginal equivalent and resolved quickly
with nitro in the ED. Her right sided chest pain persisted and
given concern for a cardiac cause, we obtained an EKG,
troponins, telemetry, and a cardiology consult. Multiple EKGs,
troponins x3 and the telemetry were negative for ischemic
changes. Cardiology agreed that this was not cardiac in origin.
Her chest pain was felt to be musculoskeletal given its
reproducibility on exam and its improvement with Tylenol. Rib
fractures were ruled out with xrays. She was placed on standing
Tylenol for one week and will follow up with her primary care
physician ___ ___.
# Presyncopal episode: Likely related to hypovolemia given
elevated urine specific gravity and prerenal ___ in the setting
of marked glucouria. She was given IVF during her stay, ate
regularly and was not orthostatic prior to discharge.
# Uncontrolled Type 1 Diabetes with Complications: Elevated BS
at baseline, with hyperglycemia to 400 on a weekly basis. She
was treated with her home dose insulin lantus twice daily and a
sliding scale. Nutrition was consulted to review consistent
carbohydrate, diabetic diets with her.
# ESRD s/p left kidney transplant: She was followed by the
nephrology team in house and will follow up as an outpatient.
Tacro doses were within normal limits during her stay.
TRANSITIONAL ISSUES:
# Code: Full
# Contact: Sister ___
___ on Admission:
ALLOPURINOL ___ mg Tablet - 2 Tablet(s) by mouth once a day
ATORVASTATIN 80 mg Tablet by mouth qpm
CALCITRIOL 0.25 mcg Capsule by mouth once a day
CILOSTAZOL 100 mg Tablet- ___ Tabletby mouth bid 1 qam and ___
qpm
DESIPRAMINE 50 mg Tablet by mouth once a day
DULOXETINE 30 mg Capsule - 3 Capsule(s) by mouth once a day
ESOMEPRAZOLE MAGNESIUM - 40 mg Capsule EC bid
GABAPENTIN 600 mg Tablet by mouth twice a day
INSULIN GLARGINE 100 unit/mL Solution - 40 units qam, 30 units
QPM
INSULIN LISPRO 100 unit/mL Cartridge - sliding scale
LEVOTHYROXINE 137 mcg Tablet by mouth once a day
METOPROLOL SUCCINATE 25 mg Tablet ER 24 hr 0.5 qhs
MYCOPHENOLATE MOFETIL 500 mg Tablet by mouth bid
NIFEDIPINE 30 mg Tablet ER 24 hr daily
NITROGLYCERIN [NITROSTAT] 0.4 mg Tablet, Sublingual - ___ prn CP
PREDNISONE 5 mg Tablet ___ Tablet(s) by mouth once a day
PROMETHAZINE 25 mg Suppository rectally twice a day prn vomiting
PROMETHAZINE 25 mg Tablet by mouth twice a day prn nausea
TACROLIMUS 1 mg Capsule by mouth twice a day
TRAZODONE 50 mg Tablet by mouth once a day
VALSARTAN 40 mg Tablet by mouth once a day
WARFARIN 4mg MWF, 3mg STTS
ZOLPIDEM 10 mg Tablet by mouth once a day
ASPIRIN 81 mg Tablet EC daily
CALCIUM CARBONATE-VITAMIN D3 600 mg calcium (1,500 mg)-400 unit
bid
LOPERAMIDE 2 mg Tablet - ___ Tablet(s) by mouth bid prn
OMEGA 3-DHA-EPA-FISH OIL 900 mg (253 mg-647 mg)-1,400 mg Capsule
bid
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. cilostazol 100 mg Tablet Sig: One (1) Tablet PO qAM ().
4. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
6. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
7. prednisone 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO HS (at bedtime).
10. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
12. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. insulin glargine 100 unit/mL Solution Sig: One (1) 40
Subcutaneous qam.
14. insulin glargine 100 unit/mL Solution Sig: One (1) 30
Subcutaneous qpm.
15. insulin lispro 100 unit/mL Cartridge Sig: One (1) Sliding
Scale Subcutaneous every six (6) hours as needed for
Hyperglycemia.
16. allopurinol ___ mg Tablet Sig: Two (2) Tablet PO once a day.
17. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual once a day as needed for pain: Use one to three tabs
as needed for right arm or chest pain. Please call your doctor
when this occurs.
18. promethazine 25 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for nausea.
19. promethazine 25 mg Suppository Sig: One (1) Rectal twice a
day as needed for nausea.
20. valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day.
21. loperamide 2 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
22. calcium carbonate 600 mg (1,500 mg) Tablet Sig: One (1)
Tablet PO twice a day.
23. cilostazol 100 mg Tablet Sig: 0.5 Tablet PO at bedtime.
24. desipramine 50 mg Tablet Sig: One (1) Tablet PO once a day.
25. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day.
26. gabapentin 600 mg Tablet Sig: One (1) Tablet PO twice a day.
27. warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day:
___.
28. warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day:
___.
29. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
30. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO twice a
day.
31. omega-3 fatty acids Oral
32. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 1 weeks.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Chest Pain, Presyncope, Uncontrolled Type 1
Diabetes with complications, Prerenal acute renal failure
Secondary Diagnosis: ESRD s/p left kidney transplant, CREST
syndrome with scleroderma, GERD
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 ___ during your
hospitalization.
You were seen here in the hospital when you developed chest pain
and fell. You were given nitroglycerin in the emergency
department which temporarily relieved your right arm pain.
However, your right sided chest pain was persistent. We ruled
out all potentially serious etiologies of your chest pain,
including heart involvement. You were seen by the cardiologists
who do not feel this episode of chest pain is related to your
heart. In addition, xrays did not show any evidence of rib
fracture.
This is most likely musculoskeletal chest pain. Please continue
to take up to three grams of Tylenol throughout the day for this
discomfort.
The following changes were made to your medication regimen:
START tylenol ___ three times daily for one week
Followup Instructions:
___
|
10030753-DS-29 | 10,030,753 | 26,285,510 | DS | 29 | 2194-10-23 00:00:00 | 2194-10-24 11:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Nausea/vomiting, lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ F with a complicated past medical history,
including Type I DM c/b ESRD s/p renal transplant ___, CAD s/p
MI ___, antiphospholipid Ab syndrome with remote h/o PE on
coumadin, and scleroderma, who presents with two days of nausea,
vomiting, confusion, and lethargy.
The patient developed nausea during a scheduled dobutamine
stress test on the evening of ___. Her nausea worsened
and she began vomiting on ___, unable to take any POs. She
had many episodes of NBNB emesis. She did not check her blood
glucose during this time but continued to take her standing
insulin (glargine 30U QAM, 40U QHS). On ___, the patient's
nausea and vomiting continued and she became weak and lethargic,
unable to even 'lift her head up'. She had some moderate
substernal burning pain associated with vomiting, which has
since resolved. She urinated normally on ___ but did not
urinate at all on ___ (she catheterizes herself
occasionally for neurogenic bladder. She states her urine looked
dark but denies dysuria or hematuria. She also described some
mild night sweats and subjective fever. She denies any cough,
rhinorrhea, congestion, abdominal pain, diarrhea, or shortness
of breath.
She presented to ___, where labs were notable for
Glucose >600, AG 30, WBC 17.6, Cr 2.0 (baseline 1.0), troponin
0.02. She was started on an insulin gtt, given 3L of NS, and
transferred to ___ for further treatment.
In the ___ ED her anion gap had decreased to 14. She was
quickly converted to SQ insulin with one hour of gtt overlap. By
that time her WBC had decreased to 13.5, BUN/Cr 38/1.8. A UA
revealed 5 WBC, few bacteria and trace leukocyte esterase, also
glucose 1000 and ketones 40. Renal transplant was consulted and
recommended treating bacteriuria with Vancomycin and
ciprofloxacin. She was also restarted on her home tacrolimus and
Cellcept
On the floor, the patient feels much better, denies nausea,
vomiting, confusion, or abdominal pain.
Past Medical History:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catherization) - most recent HgbA1c 12.4 in ___
- End-stage renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
- Scleroderma w/ CREST syndrome
- Antiphospholipid antibody syndrome and remote PE history on
Coumadin ___
- CAD s/p MI in ___ c/ LAD PTCA; s/p PTCA ___: one vessel
disease with LAD 60% apical lesion and 90% ___ diagonal lesion.
___ diagonal branch was treated with ballon angioplasty w/o
stenting. Final angiography demonstrated ___ residual
stenosis and improved flow down the diagonal branch.
- LVH
- Gastroparesis/GERD/Hiatal hernia
- Hypothyroidism
- Gout diagnosed ___ years ago
- Herniated disk
- OSA
- Carpal tunnel s/p release
- H/o multiple UTIs (Enterococcus vanc & amp sensitive,
Klebsiella, E. Coli)
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Physical Exam:
Physical exam on admission:
VITALS: T 98.3 BP 127/63 HR 97 RR 18 SpO2 97% RA
GENERAL: NAD, appears comfortable
HEENT: dry mucous membranes
NECK: JVP flat
LUNGS: CTAB, no wheezes, rales or rhonchi, transmitted upper
airway sounds
HEART: RRR, normal S1 S2, II/VI systolic murmur at ___
ABDOMEN: quiet bowel sounds, soft, non-distended, no TTP in LLQ
(over donor kidney)
EXTREMITIES: warm and well-perfused, no c/c/e
NEUROLOGIC: A+OX3
Physical exam on discharge:
VS T 97.8 Tm 98.3 145/65 (138-188/65-97) HR ___ RR16 100% RA
I/O: ___ 24hrs ___/4900
FSBG: 9:30am 221->40L 14H -> 12pm 55 - 6pm 221 ->6H->8:30pm 255
->16H->163
Gen: NAD, asleep, comfortable
Cardio: RRR, nl S1 S2, II/VI murmur at ___, unchanged from
previous exam
Pulm: CTAB
Abd: +BS, soft, NT, ND
Ext: wwp, no edema, 2+ DP pulses
Pertinent Results:
Labs on admission:
___ 10:15PM BLOOD Neuts-88.7* Lymphs-5.8* Monos-5.1 Eos-0.2
Baso-0.2
___ 10:15PM BLOOD Glucose-297* UreaN-38* Creat-1.8* Na-137
K-4.5 Cl-104 HCO3-19* AnGap-19
___ 10:15PM BLOOD Calcium-9.0 Phos-3.0 Mg-2.2
___ 10:53PM BLOOD tacroFK-5.3
___ 11:02PM BLOOD Lactate-1.8
___ 10:15PM URINE Color-Straw Appear-Clear Sp ___
___ 10:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
___ 10:15PM URINE RBC-0 WBC-5 Bacteri-FEW Yeast-NONE Epi-<1
___ 10:15PM URINE CastHy-4*
___ 08:39AM URINE Hours-RANDOM Creat-56 Na-75 K-23 Cl-81
___ 08:39AM URINE Osmolal-537
Pertinent results:
___ 07:05AM BLOOD ___ PTT-65.5* ___
___ 07:05AM BLOOD ___ PTT-55.6* ___
___ 05:20AM BLOOD ___ PTT-38.8* ___
___ 07:30AM BLOOD ___ PTT-31.8 ___
___ 10:15PM BLOOD cTropnT-0.02*
___ 07:05AM BLOOD CK-MB-5 cTropnT-0.07*
___ 04:10PM BLOOD cTropnT-0.05*
___ 10:53PM BLOOD tacroFK-5.3
___ 07:05AM BLOOD tacroFK-4.1*
___ 07:05AM BLOOD tacroFK-7.8
___ 05:20AM BLOOD tacroFK-5.8
___ 07:30AM BLOOD tacroFK-7.1
___ 11:18PM BLOOD Vanco-25.6*
Labs on discharge:
___ 07:30AM BLOOD WBC-4.4 RBC-3.83* Hgb-11.6* Hct-34.7*
MCV-91 MCH-30.4 MCHC-33.5 RDW-13.5 Plt ___
___ 07:30AM BLOOD ___ PTT-31.8 ___
___ 07:30AM BLOOD Glucose-188* UreaN-19 Creat-1.1 Na-144
K-3.9 Cl-107 HCO3-34* AnGap-7*
___ 07:30AM BLOOD Calcium-9.5 Phos-3.1 Mg-1.8
___ 07:30AM BLOOD tacroFK-7.1
Microbiology:
___ 10:33 pm URINE Site: NOT SPECIFIED ADDED TO
___.
URINE CULTURE (Final ___: ENTEROCOCCUS SP..
>100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
___ 10:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date
___ 11:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date
Imaging:
-CXR ___ - No evidence of acute cardiopulmonary process.
-Renal Transplant Ultrasound ___ - The transplant kidney is
imaged in the left hemipelvis and measures 12.7 cm in length.
Echogenicity and renal architecture is normal, and there are no
signs of ___ fluid collection or hydronephrosis.
Color flow and pulsed Doppler assessment demonstrate normal
arterial waveforms in the main renal artery with no delay in
acceleration time and normal peak velocities of 72 cm/sec.
Venous outflow is also normal. Arterial flow is symmetrically
seen throughout the transplant, but the resistive indices are
elevated ranging from 0.79-0.85. The bladder is not evaluated
due to drainage by Foley catheter.
Brief Hospital Course:
This is a ___ F with complex past medical history, most notable
for poorly controlled Type I DM c/b ESRD s/p renal transplant
___, CAD s/p MI ___, antiphospholipid Ab syndrome with remote
h/o PE on coumadin, and scleroderma, who presented with DKA,
___, and enterococcal UTI.
Active issues:
#DIABETIC KETOACIDOSIS: The patient initially presented to ___
___ with glucose >600, Anion gap 30. This rapidly improved
with administration of IV fluids and insulin gtt. On transfer to
___ ED, her glucose was 297, and anion gap had almost closed
at 14. She was transition to subcutaneous insulin with one hour
overlap with gtt and maintained on IV fluids until ___, at
which point her creatinine returned to baseline and she was
taking adequate PO fluids. Her nausea and vomiting had resolved
prior to admission to the floor. She was restarted on her home
insulin regimen and her FSBGs remained mostly stable in the
___. The trigger for this episode of DKA was most likely
the patient's UTI, treatment for this was begun immediately upon
admission as below.
#ENTEROCOCCAL URINARY TRACT INFECTION: UA on admission showed
trace leukocytes, 5WBC, few bacteria. The patient has a history
of frequent UTI (likely ___ self-catheterization), although the
patient denied dysuria. She was begun immediately on antibiotic
treatment with vancomycin and ciprofloxacin. Urine culture grew
out >100,000 Enterococcus sensitive to vancomycin, after which
the ciprofloxacin was discontinued and the patient was
maintained on vancomycin until blood cultures from ___ showed
no growth by ___. Prior to discharge, the patient was
transitioned from vancomycin to PO nitrofurantoin, on which she
is discharged and will finish the remainder of a 10-day course
at home. The patient remained afebrile and asymptomatic
throughout her admission.
#ACUTE RENAL INSUFFICIENCY: The patient presented with Crt 2.0
(baseline 1.0), most likely secondary to dehydration, with
possible contribution from post-renal obstruction (patient had
no urine output the day prior to admission). Acute rejection in
the setting of missing 3 doses of immunosuppressants is
possible, but unlikely in this case with rapid response to
intravenous fluid repletion. The patient was maintained on
intravenous fluids until her creatinine returned to near
baseline (1.2) and remained stable, and she was taking adequate
PO fluids. Her creatinine remained at baseline throughout the
remainder of her admission.
#ESRD S/P RENAL TRANSPLANT: The patient missed 3 doses of her
home tacrolimus and Cellcept due to nausea and vomiting. She was
restarted on her immunosuppresant medications upon admission to
the hospital and her tacrolimus levels were trended and followed
by the renal transplant team. Her renal function quickly
returned to baseline with IV fluid repletion. Acute rejection in
the setting of missed immunosuppressants was thought unlikely. A
renal transplant ultrasound on ___ showed no evidence of
obstruction in the graft kidney. The patient's home vitamin D
and calcitriol were continued throughout her admission. She
will need to have her tacrolimus level checked one week after
discharge (___).
#SUPRATHERAPEUTIC INR: On coumadin for antiphospholipid
syndrome. She had an elevated INR of 6.5 (goal 2.5-3.5) on
admission likely due to drug-drug interaction between warfarin
and ciprofloxacin. Her warfarin was held and INR was trended
until it returned to her goal range. It was restarted at 3mg
daily on ___ following an INR of 3.5 the previous day. Her INR
was 1.1 on discharge, and she was instructed to measure her INR
at home daily for the next several days and to communicate the
results to her ___ clinic for further titration of
coumadin. Lovenox bridge was considered, but the patient
reports having been subtherapeutic in the past without any need
for bridge.
#TYPE I DIABETES MELLITUS: The patient was maintained on her
home dose of insulin Glargine (40U QAM and 30U QHS) as well as
her home Humalog sliding scale, with stable daytime FSBGs.
Chronic issues:
#ANTIPHOSPHOLIPID AB SYNDROME with H/O PE: The patient's
warfarin was held due to a supratherapeutic INR as above and
restarted on ___. She will check her INR at home and
communicate results with her ___ clinic as she has
been doing.
#CAD s/p MI: Due to an episode of chest pain during vomiting
before admission, she was ruled out for MI, with EKG only
significant for right axis deviation that was resolving on
follow-up EKG. Her troponin was mildly elevated, peaking at 0.07
in the setting of demand ischemia due to tachycardia on
admission. She remained asymptomatic and was continued on her
home regimen of atorvastatin, metoprolol, and aspirin.
#SCLERODERMA: The patient was maintained on her home dose of
7.5mg prednisone daily with good symptom control.
#HYPERTENSION: The patient remained normotensive to slightly
hypertensive during admission, with systolic blood pressures
ranging 120s - 160, with a one-time asymptomatic SBP of 188,.
She was continued on her home regimen of amlodidpine and
metoprolol. Her home valsartan was held until her Creatinine
returned near baseline and was restarted on ___.
# GOUT: The patient was continued on her home allopurinol.
# PAD: The patient was continued on her home cilostazol 100 mg
every other day.
# DEPRESSION/ANXIETY: The patient was continued on her home
duloxetine and despiramine for depression and Ativan for
anxiety. She was continued on her home trazodone and zolpidem
QHS for sleep.
# HYPOTHYROIDISM: The patient was continued on her home
levothyroxine dose.
# GERD: The patient was continued on her home ranitidine and
Nexium.
Transitional issues:
# FOLLOW-UP:
-Primary care: the patient will be contacted by Dr. ___
office to schedule a follow-up appointment
-Nephrology: the patient will be contacted by Dr. ___
office to schedule a follow-up renal appointment within the next
two weeks
-Endocrinology/diabetes: the patient will follow up with Dr.
___ at the ___ on ___ at 3:30pm
-___: the patient was scheduled to have an appointment
with Dr. ___ the ___ on ___ to plan for a breast biopsy. The patient's admission was
communicated to Dr. ___ the ___ will contact
the patient within a few days of discharge to schedule a new
appointment.
-Blood cultures from admission were pending on discharge
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Tacrolimus 1.5 mg PO QAM
2. Tacrolimus 1 mg PO QPM
3. PredniSONE 7.5 mg PO DAILY
4. Mycophenolate Mofetil 500 mg PO BID
5. Atorvastatin 40 mg PO HS
6. Amlodipine 2.5 mg PO DAILY
please hold for sbp<100
7. Allopurinol ___ mg PO DAILY
8. Calcitriol 0.25 mcg PO DAILY
9. cilostazol *NF* 100 mg Oral qod
10. Duloxetine 90 mg PO DAILY
11. Glargine 40 Units Breakfast
Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. Levothyroxine Sodium 137 mcg PO DAILY
13. Metoprolol Succinate XL 12.5 mg PO DAILY
please hold for sbp<100
please hold for hr<60
14. Lorazepam 0.5 mg PO Q8H:PRN anxiety
15. Nitroglycerin SL 0.3 mg SL PRN chest pain
16. Promethazine 25 mg PR Q6H:PRN nausea
17. Promethazine 25 mg PO BID:PRN nausea
18. Ranitidine 150 mg PO HS
19. esomeprazole magnesium *NF* 40 mg Oral bid
20. Gabapentin 800 mg PO BID
21. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q4H:PRN pain
please hold for rr<12 or increased somnolence
22. Desipramine 50 mg PO DAILY
23. traZODONE 50 mg PO HS:PRN insomnia
24. Valsartan 20 mg PO DAILY
25. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
26. Acetaminophen 1000 mg PO BID:PRN pain
27. Aspirin 81 mg PO DAILY
28. Calcium Carbonate 500 mg PO BID
29. Vitamin D 800 UNIT PO DAILY
30. Warfarin 2.5 mg PO DAILY16
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 2.5 mg PO DAILY
please hold for sbp<100
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO HS
5. Calcitriol 0.25 mcg PO DAILY
6. Calcium Carbonate 500 mg PO BID
7. cilostazol *NF* 100 mg Oral qod
8. Desipramine 50 mg PO DAILY
9. Duloxetine 90 mg PO DAILY
10. Gabapentin 800 mg PO BID
11. Levothyroxine Sodium 137 mcg PO DAILY
12. Lorazepam 0.5 mg PO Q8H:PRN anxiety
13. Metoprolol Succinate XL 12.5 mg PO DAILY
please hold for sbp<100
please hold for hr<60
14. Mycophenolate Mofetil 500 mg PO BID
15. PredniSONE 7.5 mg PO DAILY
16. Promethazine 25 mg PR Q6H:PRN nausea
17. Promethazine 25 mg PO BID:PRN nausea
18. Ranitidine 150 mg PO HS
19. Tacrolimus 1.5 mg PO QAM
20. Tacrolimus 1 mg PO QPM
21. traZODONE 50 mg PO HS:PRN insomnia
22. Valsartan 20 mg PO DAILY
23. Vitamin D 800 UNIT PO DAILY
24. Warfarin 3 mg PO DAILY16
25. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
26. esomeprazole magnesium *NF* 40 mg ORAL BID
27. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q4H:PRN pain
please hold for rr<12 or increased somnolence
28. Acetaminophen 1000 mg PO BID:PRN pain
29. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
RX *Macrobid ___ mg 1 capsule(s) by mouth every 12 hours Disp
#*12 Tablet Refills:*0
30. Nystatin Oral Suspension 5 mL PO QID:PRN thrush, throat pain
RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day Disp
#*200 Milliliter Refills:*1
31. Outpatient Lab Work
You should have your tacrolimus level checked one week after
discharge from the hospital; on ___.
32. Nitroglycerin SL 0.3 mg SL PRN chest pain
33. Glargine 40 Units Breakfast
Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
-Diabetic ketoacidosis
-Urinary tract infection
-Acute renal insufficiency
Secondary diagnoses:
-Type I diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on
___ for nausea, vomiting, and weakness.
You were found to have a very high blood sugar and acidic blood
due to a condition called 'diabetic ketoacidosis'. Your kidney
function was also temporarily decreased, most likely due to
dehydration. Your blood sugars and your kidney function improved
with continuous insulin and intravenous fluids. This episode of
'diabetic ketoacidosis' was likely triggered by a urinary tract
infection, for which you were treated with the antibiotic
medicine Vancomycin, and were switched to the oral medicine
nitrofurantoin (Macrobid) before discharge, which you will take
every 12 hours until the evening of ___. Finally, your INR
was found to be higher than normal, so several doses of your
home warfarin were held until the INR came back down to a normal
level, at which time your warfarin was restarted. Please note
that your INR subsequently decreased to 1.1 which is below the
desired level, so please continue checking your INR at home and
call your ___ clinic with the results so that they
can adjust your dose.
You should also have your tacrolimus level checked at the
outpatient laboratory in one week, on ___.
You should continue to administer your long-acting insulin every
morning and every evening. You should also administer
short-acting insulin before each meal based on your blood sugar
levels and carbohydrate counting, as you have been in the past.
When it is necessary to catheterize yourself for urination, you
should make sure to use good sterile technique.
Please not the following change in your medication:
-ADDITION of nitrofurantion (to treat urinary tract infection)
Followup Instructions:
___
|
10030753-DS-35 | 10,030,753 | 23,960,805 | DS | 35 | 2198-07-12 00:00:00 | 2198-07-13 21:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan
Attending: ___
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a medically complex ___ with PMH significant
for poorly controlled T1DM c/b retinopathy, ESRD s/p living
kidney xplant in ___, neuropathy with neurogenic bladder and
gastroparesis, CAD s/p MI in ___ and with 3 DES placed in
___, hypothyroidism and h/o multiple MDR UTIs
(Klebsiella, E.coli, Enterococcus), sclerodermda/CREST and
antiphospholipid antibody syndrome with h/o PE in ___ who
presents to the ED with intractable N/V and mechanical fall with
head strike.
Patient was in her usual state of health until one week prior
to admission when she developed nausea and vomiting. This nausea
and vomiting seemed to occur after she took an oral antibiotic
while on vacation in ___ (unclear why this was
prescribed - clinic paperwork said for inguinal ___. She became
concerned that she was not able to tolerate PO intake and
specifically that she was not keeping down her anti-rejection
meds so she went to ___ urgent care. Vitals at urgent
care were: 97.3, 127/65, 122, 97%RA. She was given 500cc NS and
IV Zofran 4mg x1. Labs were checked which showed an INR of 4.9.
Urgent care recommended that she be seen at the ___ ED for
further evaluation. Patient decided to drive herself to ___
but unfortunately fell while exiting a restaurant (she felt
better after the Zofran and stopped for food on the way to
___. She fell down some stairs and struck her head but did
not lose conciousness. At this point in time, EMS was called and
brought her to ___.
Initial vitals in the ED were: 97.2, 135, 168/69, 18, 100% RA
Exam was notable for: laceration to right forehead and right
wrist swelling.
Labs were notable for: H/H 8.4/25.1 (recent baseline 9.5/28.8
but decline is recent in last 4 months), INR 4.8, plts 292, BNP
1547, Cr 1.4 (baseline 1.2-1.4), lactate 1.4, UA grossly
positive. Blood and urine cultures were sent.
Imaging showed: No acute fractures or intracranial pathology
but with right supraorbital soft tissue hematoma. C-spine
intact. No fracture of the right wrist.
Patient was given: IV ciprofloxacin 400mg x1
Consults: transplant nephrology who recommended medicine
admission.
Vitals prior to transfer were: 98.9, 115, 153/60, 18, 95% RA
On the floor, patient reports that she feels better and only
complains of right wrist pain. She denies nausea since she
received Zofran at the urgent care clinic.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catherization) - most recent HgbA1c 12.4 in ___
- End-stage renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
- Scleroderma w/ CREST syndrome
- Antiphospholipid antibody syndrome and remote PE history on
Coumadin ___
- CAD s/p MI in ___ c/ LAD PTCA; s/p PTCA ___: one vessel
disease with LAD 60% apical lesion and 90% ___ diagonal lesion.
___ diagonal branch was treated with ballon angioplasty w/o
stenting. Final angiography demonstrated ___ residual
stenosis and improved flow down the diagonal branch.
- LVH
- Gastroparesis/GERD/Hiatal hernia
- Hypothyroidism
- Gout diagnosed ___ years ago
- Herniated disk
- OSA
- Carpal tunnel s/p release
- H/o multiple UTIs (Enterococcus vanc & amp sensitive,
Klebsiella, E. Coli)
- Hx of TIA?
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Physical Exam:
ADMISSION EXAM
VS: 98.3, 152/67, 117, 19, 97% RA wt 76.2kg.
General: well appearing Caucasian female in NAD
HEENT: NC, sclerae anicteric. Significant bruising and soft
tissue swelling of the right periorbital area. PERRL, EOMI. OP
clear without lesion or exudate.
Neck: Supple, no ___, no thyromegaly
CV: Tachycardic but regular. Normal s1/s2, no m/r/g
Lungs: CTAB posteriorly, no w/r/r
Abdomen: Distended but soft and nontender. Normal bowel sounds,
no rebound or guarding. Unable to appreciate organomegaly.
GU: no foley
Ext: WWP, DP pulses 1+ bilaterally. No cyanosis, clubbing or
edema
Neuro: CN ___ grossly intact, moving all 4 extremities with
purpose. Gait deferred.
Skin: Ecchymoses around right eye, right wrist, above right
breast and scattered throughout lower extremities.
DISCHARGE EXAM
Vitals 98.3 ___ 18 100RA
General: obese, NAD
HEENT: swollen erythematous R eye that has overall improved but
has some crusting; now L eye has some ecchymoses
Heart: borderline tachycardic, normal rhythm, no murmurs
Lungs: CTAB
Abdomen: Obese, NT, NABS, several well-healed scars
Extremities: 1+ pitting edema bilaterally
Skin: bruising on stomach, R breast, R eye
Pertinent Results:
ADMISSION LABS
___ 04:10PM BLOOD WBC-10.0 RBC-2.70* Hgb-8.4* Hct-25.1*
MCV-93 MCH-31.1 MCHC-33.5 RDW-13.8 RDWSD-45.7 Plt ___
___ 04:10PM BLOOD ___ PTT-60.1* ___
___ 04:10PM BLOOD Glucose-114* UreaN-21* Creat-1.4* Na-136
K-3.7 Cl-101 HCO3-24 AnGap-15
___ 04:10PM BLOOD ALT-16 AST-14 CK(CPK)-99 AlkPhos-85
TotBili-0.2
___ 06:41AM BLOOD Calcium-9.6 Phos-2.5* Mg-1.6
___ 06:41AM BLOOD tacroFK-7.4
DISCHARGE LABS
___ 04:42AM BLOOD WBC-5.5 RBC-2.72* Hgb-8.1* Hct-26.1*
MCV-96 MCH-29.8 MCHC-31.0* RDW-15.3 RDWSD-53.1* Plt ___
___ 04:42AM BLOOD ___ PTT-35.9 ___
___ 04:42AM BLOOD Glucose-304* UreaN-24* Creat-1.5* Na-140
K-4.0 Cl-105 HCO3-27 AnGap-12
___ 04:42AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.8
___ 04:42AM BLOOD tacroFK-5.6
MICRO
___ 4:57 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 ORGANISMS/ML..
___ 8:02 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 7:37 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
WRIST XRAY ___
Dorsal soft tissue swelling along the wrist without underlying
fracture.
Extensive vascular calcification.
CT HEAD ___. No acute intracranial hemorrhage.
2. Right frontal supraorbital superficial soft tissue hematoma.
No underlying fracture seen.
CT C-SPINE ___
No fracture or malalignment in the C-spine.
RENAL TRANSPLANT US ___
Mildly elevated intrarenal resistive indices which are slightly
higher than ___.
CT ABD/PELVIS ___. No intra or retroperitoneal or intramuscular hematoma noted
in the abdomen or pelvis.
2. Transplant kidney in the left lower quadrant demonstrates no
hydronephrosis.
3. Moderate amount of stool throughout the colon without bowel
obstruction.
CT HEAD ___. No acute intracranial hemorrhage.
2. Small, residual, supraorbital, right frontal scalp hematoma.
CXR ___
IN COMPARISON WITH THE STUDY OF ___, THERE IS LITTLE
CHANGE AND NO
ACUTE CARDIOPULMONARY DISEASE. THE CARDIAC SILHOUETTE IS
ENLARGED AND THERE IS NO EVIDENCE OF VASCULAR CONGESTION,
PLEURAL EFFUSION, OR ACUTE FOCAL PNEUMONIA.
CT HEAD ___. No evidence of fracture, infarction or intracranial
hemorrhage.
2. Minimal residual right frontal/supraorbital scalp swelling.
Brief Hospital Course:
___ yo F with history of T1DM and ESRD s/p living kidney
transplant ___ on MMF, tacro, prednisone, also with history of
CAD s/p multiple MI's and recent ___ 3 ___, and h/o
multiple UTI's (mostly enterococcus, Klebsiella, coag neg staph)
who presents for elevated INR and a mechanical fall down some
stairs at ___. Suffered trauma but no head bleed.
Nausea/vomiting resolved on admission. Experienced labile blood
pressures and orthostatic hypotension a/w anemia, improved after
transfusion of 1 unit of blood. INR drifted to <2 with improved
nutrition and warfarin resumed prior to d/c.
Investigations/Interventions
1. Elevated INR: patient is on coumadin for history of PE, and
she presented with INR 4.8 in setting of 1 week of nausea and
vomiting. Elevated INR likely due to poor nutrition. INR was
trended and coumadin restarted ___ when INR was 1.8. INR 1.5 on
day of discharge.
2. Fall: patient fell down some stairs at restaurant and had no
preceding symptoms. EKG on admission was at baseline. We felt
fall to be mechanical in nature due to poor vision related to
diabetic nephropathy.
3. Hypotension: patient initially presented with hypertension
sbp in 190s, then became hypotensive when working with ___ sbp in
___. She was orthostatic. Home anti-hypertensives discontinued.
In setting of fall with elevated INR there was concern for
internal bleeding so CT abd/pelvis, CT head, and CXR (PA &
lateral) were obtained which were negative for evidence of
bleeding. She refused IVF so we encouraged po intake which
resulted in stabilization of blood pressures. Discharging home
on blood pressure medication regimen of metoprolol succinate
12.5 mg daily and losartan 50 mg daily. Amlodipine discontinued
in favor of increasing losartan.
4. Anemia: pt has baseline anemia but Hgb downtrended to 6's in
house. As this was associated with hypotension, bleeding was
ruled out with imaging described above. She was transfused 1
unit PRBC's with return of her hgb to baseline. No evidence of
GI bleeding during hospitalization.
5. Vitreous, retinal hemorrhage: patient reported blurry vision
during hospitalization. Ophthalmology consulted who diagnosed
vitreous and retinal hemorrhage. Recommended to keep HOB
elevated, avoid bending over or straining. Instructed to follow
up with ___ clinic.
6. Diabetes mellitus: patient followed at ___. Home regimen
continued in house initially but patient experienced
hypoglycemia into the 70's in the morning. ___ consulted and
patient agreed to change pm Lantus from 20 units to 16 units.
She will also change her correction factor to 14.
7. History of UTI's: patient has history of many UTI's. UA on
admission c/w UTI so patient placed on ciprofloxacin. UCx grew
yeast which we did not treat. Due to her history of infection we
decided to discharge her on ciprofloxacin for 14 days, last day
being ___.
8. CKD, ESRD s/p kidney transplant: patient is s/p living donor
kidney transplant in ___. Maintained on tacro, MMF, prednisone
as outpt. Her graft has CKD, likely related to diabetic
nephropathy. Serial tacro levels were within goal range and she
was maintained on her home regimen of 1mg q12h. Home prednisone
dose changed from 6mg qd to 5mg qd. Patient also is on Bactrim
DS tab qd which was changed to SS tab qd for PCP ___.
9. CAD: patient with recent ___ 3 placed. Continued on Asa,
Plavix, statin in house.
Transitional Issues:
[]Medication changes: Prednisone to 5mg qd, Bactrim to SS tab
qd, losartan to 50 mg daily, qhs Glargine to 16 units daily.
Amlodipine discontinued.
[]Patient should take ciprofloxacin through ___
[]Patient instructed by ___ attending to change her
carbohydrate correction factor to 14
[]Patient is on several drugs which may not be needed, please
consider decreasing number of medications on an outpatient basis
[]Patient instructed to keep HOB elevated, avoid bending over or
straining due to retinal hemorrhage
[]Please follow up pending BCx
[]Patient has follow up with PCP ___ patient also
instructed to call Dr. ___ for nephrology and
diabetes appointments
#CODE: Full
#CONTACT: Patient, HCP sister ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 2.5 mg PO DAILY
3. Aspirin EC 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Calcitriol 0.25 mcg PO DAILY
6. Cilostazol 50 mg PO TID
7. DULoxetine 60 mg PO DAILY
8. Gabapentin 100 mg PO QHS
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Losartan Potassium 25 mg PO DAILY
11. Metoprolol Succinate XL 12.5 mg PO DAILY
12. Mycophenolate Mofetil 500 mg PO BID
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Pramipexole 0.5 mg PO QHS
15. PredniSONE 6 mg PO DAILY
16. Promethazine 25 mg PO Q6H:PRN nausea or vomiting
17. Ranitidine 300 mg PO QHS
18. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
19. Tacrolimus 1 mg PO Q12H
20. TraZODone 50 mg PO QHS
21. Vitamin D 400 UNIT PO DAILY
22. Warfarin 3 mg PO DAILY16
23. Clopidogrel 75 mg PO DAILY
24. alpha lipoic acid ___ mg oral DAILY
25. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic DAILY:PRN
26. Esomeprazole Magnesium 40 mg ORAL BID
27. Lidocaine 5% Patch 1 PTCH TD QPM
28. Promethazine 25 mg PR Q6H:PRN nausea or vomiting
29. HYDROcodone-acetaminophen ___ mg ORAL Q4H:PRN pain
30. Glargine 36 Units Breakfast
Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
31. melatonin 5 mg po Q24H
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Calcitriol 0.25 mcg PO DAILY
5. Cilostazol 50 mg PO TID
6. Clopidogrel 75 mg PO DAILY
7. DULoxetine 60 mg PO DAILY
8. Gabapentin 100 mg PO QHS
9. HYDROcodone-acetaminophen ___ mg ORAL Q4H:PRN pain
10. Levothyroxine Sodium 125 mcg PO DAILY
11. Lidocaine 5% Patch 1 PTCH TD QPM
12. Mycophenolate Mofetil 500 mg PO BID
13. Pramipexole 0.5 mg PO QHS
14. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
15. Promethazine 25 mg PO Q6H:PRN nausea or vomiting
16. Promethazine 25 mg PR Q6H:PRN nausea or vomiting
17. Ranitidine 300 mg PO QHS
18. Tacrolimus 1 mg PO Q12H
19. TraZODone 50 mg PO QHS
20. Vitamin D 400 UNIT PO DAILY
21. Warfarin 3 mg PO DAILY16
22. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth once a day Disp #*30 Tablet Refills:*0
23. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
24. Esomeprazole Magnesium 40 mg ORAL BID
25. melatonin 5 mg po Q24H
26. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic DAILY:PRN
27. alpha lipoic acid ___ mg oral DAILY
28. Ciprofloxacin HCl 500 mg PO Q12H Duration: 19 Doses
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*19 Tablet Refills:*0
29. Glargine 26 Units Breakfast
Glargine 16 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
30. Losartan Potassium 50 mg PO DAILY
RX *losartan 25 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
31. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Elevated INR
Mechanical fall
Anemia
Secondary:
CAD
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were hospitalized after a fall. You experienced extensive
bruising since you are on blood thinners. You required 1 unit
of blood to be transfused since your blood levels were low,
likely related to all of the bruising. We obtained extensive
imaging of your body to ensure no internal bleeding, and this
was all negative.
You also developed some right eye floaters and blurry vision.
You were evaluated by Ophthalmology who felt that you had a mild
vitreous hemorrhage. You should make sure to sleep with the
head of the bed elevated and to avoid any activities requiring
bending over or straining.
We continued your immunosuppressive drugs and insulin. Please
make sure to follow up with your PCP and kidney doctor, ___.
___. in addition, the diabetes doctors talked with ___ and
we changed your nightly insulin to 16 units of Glargine instead
of 20. You should also change your correction factor to 14.
It was a pleasure taking care of you!
Your ___ team
Followup Instructions:
___
|
10030753-DS-40 | 10,030,753 | 25,629,024 | DS | 40 | 2199-05-16 00:00:00 | 2199-05-22 16:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan
Attending: ___
Chief Complaint:
Dizziness and Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMhx of ___ s/p living kidney transplant ___ on
cyclosporine, cellcept, prednisone, CREST, PE previously on
warfarin, CAD (s/p ___ and OM ___ who presents for
hypotension and prescyncope in the setting of recent
up-titration of her home blood pressure medications.
Of note, she was recently discharged from the ET service for an
admission related to a new ___ for which she underwent renal bx.
Initial concern was for possible acute rejection of her
transplant, but bx was reassuring in this regard, showing
advanced changes associated with diabetic nephropathy.
Additionally during her stay, she was noted to have volume
overload in the setting of her ___, and she was started on a
number of different medications for hypertension management,
volume control and diuretics, as well as an aggressive insulin
regimen recommended by the ___.
Since her discharge, she has felt overall well until in the
middle of the night she awoke and felt dizzy. She notes this was
prior to taking her AM medications. She went back to bed
following this incident, and when she awoke she was notably
lightheaded and dizzy. She went to her PCP office for routine
follow-up, and was noted to have blood pressures ranging from
60-80 systolic, and thus was sent to the ED for further
evaluation. She denies any fevers, chills, CP, SOB, cough,
diarrhea, abd pain, or dysuria.
In the ED, initial vitals were:
97.1 71 110/56 19 93% RA
- Labs notable for: SCr 2.0, stable from recent admission
- Imaging was notable for:
Absent diastolic flow in transplanted kidney
The patient was given 1L NS and her home nifedipine and Lasix
were held. SBPs improved to 150s overnight and patient is
hypertensive to 180s this morning.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___,
DES to LAD and Cx/OM ___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
- End-stage renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
- Scleroderma w/ CREST syndrome
- Gastroparesis/GERD/Hiatal hernia
- Gout diagnosed ___ years ago
- OSA
NOT ACCURATE: - Antiphospholipid antibody syndrome and remote PE
history on Coumadin ___ - this diagnosis viewed unlikely per
___ hematology/oncology note
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITAL SIGNS: Afeb, 120-180/60, 80-90, ___, 94% RA
GENERAL: Comfortable, NAD
HEENT: PERRL, OP clear without lesions or thrush
NECK: supple, no JVD
CARDIAC: RRR, no MRG
LUNGS: CTAB without wheezing or rhonchi
ABDOMEN: soft, nt, nd
EXTREMITIES: wwp, no peripheral edema or cyanosis
SKIN: no suspicious rashes or lesions
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.1, 158/71, 80, 18, 99% RA
GENERAL: Comfortable, NAD
HEENT: PERRL, OP clear without lesions or thrush
NECK: supple, no JVD
CARDIAC: RRR, no MRG
LUNGS: CTAB without wheezing or rhonchi
ABDOMEN: soft, nt, nd
EXTREMITIES: wwp, no peripheral edema or cyanosis
SKIN: no suspicious rashes or lesions
Pertinent Results:
ADMISSION LABS:
===============
___ 06:10AM PLT COUNT-323
___ 06:10AM WBC-7.3 RBC-2.76* HGB-8.3* HCT-25.9* MCV-94
MCH-30.1 MCHC-32.0 RDW-13.5 RDWSD-46.5*
___ 06:10AM CYCLSPRN-168
___ 06:10AM CALCIUM-9.0 PHOSPHATE-4.3 MAGNESIUM-1.9
___ 06:10AM GLUCOSE-85 UREA N-49* CREAT-2.0* SODIUM-138
POTASSIUM-3.9 CHLORIDE-94* TOTAL CO2-31 ANION GAP-17
___ 05:45PM PLT COUNT-272
___ 05:45PM NEUTS-92.0* LYMPHS-3.0* MONOS-4.2* EOS-0.2*
BASOS-0.1 IM ___ AbsNeut-7.47* AbsLymp-0.24* AbsMono-0.34
AbsEos-0.02* AbsBaso-0.01
___ 05:45PM WBC-8.1 RBC-2.74* HGB-8.2* HCT-26.1* MCV-95
MCH-29.9 MCHC-31.4* RDW-13.8 RDWSD-48.3*
___ 05:45PM ALBUMIN-3.2* CALCIUM-8.9 PHOSPHATE-3.9
MAGNESIUM-2.0
___ 05:45PM ALT(SGPT)-22 AST(SGOT)-20 ALK PHOS-81 TOT
BILI-0.3
___ 05:45PM GLUCOSE-231* UREA N-48* CREAT-2.0* SODIUM-134
POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-26 ANION GAP-18
___ 05:52PM LACTATE-1.3
DISCHARGE LABS:
===============
___ 05:24AM BLOOD WBC-6.1 RBC-2.43* Hgb-7.5* Hct-23.2*
MCV-96 MCH-30.9 MCHC-32.3 RDW-13.4 RDWSD-46.5* Plt ___
___ 05:24AM BLOOD Glucose-166* UreaN-42* Creat-1.8* Na-140
K-4.2 Cl-104 HCO3-26 AnGap-14
___ 07:44AM BLOOD ALT-17 AST-12 LD(LDH)-257* AlkPhos-75
TotBili-0.2
___ 05:24AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.9
___ 05:24AM BLOOD Cyclspr-204
MICROBIOLOGY:
=============
None
IMAGING:
========
___ (PA & LAT)
Stable mild cardiomegaly, decreased right pleural effusion, now
tiny.
___ TRANSPLANT U.S.
The left lower quadrant transplant renal morphology is normal
measuring 13.2 cm in length. Specifically, the cortex is of
normal thickness and echogenicity, pyramids are normal, there is
no urothelial thickening, and
renal sinus fat is normal. There is no hydronephrosis and no
perinephric fluid collection.
Doppler: There is absent diastolic flow main renal artery as
well as the intralobar branches, which is more convincing on
todays exam compared with prior. The main renal vein is patent.
Brief Hospital Course:
Ms. ___ is a ___ with PMhx of ___ s/p living kidney
transplant ___ on cyclosporine, cellcept, prednisone, CREST,
PE previously on warfarin, CAD (s/p ___ and OM ___ who
presents for hypotension and prescyncope in the setting of
up-titrating her anti-hypertensives. On admission, the patient
was given 1L NS and her nifedipine and Lasix were held. Her
symptoms resolved. She remained significantly orthostatic,
likely ___ longstanding diabetes and autonomic dysfunction.
Patient was discharged home on Carvedilol 12.5mg PO QAM, 25mg PO
QPM and Lasix 20mg PO daily with plans to continue to adjust her
blood pressure medications as an out-patient and possible
outpatient ABPM.
#Presyncope/hypotension:
Patient presented with hypotension i/s/o starting multiple
antihypertensives and a new diuretic regimen. Held
antihypertensives and diuretics for ___ and gave IVF with
improvement of blood pressure. Likely d/t medication effect, as
no evidence of infection. See "Hypertension" for discharge
regimen.
#Hypertension/Orthostasis:
Essential hypertension in the setting of tacrolimus therapy with
very poorly controlled blood pressures and difficult medication
titration given orthostasis and hypotension. Patient initially
hypotensive on admission but quickly became hypertensive to SBPs
of 200s with IVF and holding antihypertensives. However patient
was very orthostatic with drop to SBPS of 120s from 200s with
standing, despite being asymptomatic. Concern for diabetes
induced dysautonomia. Patient was maintained on carvedilol
12.5mg qAM, 25mg qPM and lasix 20mg PO daily on discharge with
SBPs in the 160s-170s. Plan is forcontinued titration of BP meds
and monitoring of orthostatics as an out-patient with ABPM.
# CKD
# S/p living unrelated donor kidney transplant ___:
Recent admission with renal bx showing diabetic changes without
signs of rejection. Her immunosuppressive regimen was increased
and she was discharged with a more aggressive antidiabetic
regimen and antihypertensive regimen.
- Decreased cyclosporine to 50mg BID given levels
- Continued home prednisone 5mg PO daily
- Continued home MMF 500mg BID
- Continued home diabetes regimen as below
# DM1, hyperglycemia: A1C 7.5% (___), had issues with
hypoglycemia d/t poor intake.
- Continued prior discharge regimen:
* Lantus 22 units qAM and 17 units qhs
* Humalog 8 units TID with meals
* Humalog sliding scale TID with meals
* ___ c/s
CHRONIC ISSUES
===============
# Hypothyroidism: recent TSH 0.69
- Continued home levothyroxine 125 mcg QD
# PE. Hx of provoked PE in 1990s, on warfarin until last
admission ___ at ___. Warfarin was stopped given hx of
GIB on warfarin and negative anti-cardiolipin AB on repeat
check.
# CAD. S/p ___ and OM ___. Completed 6 months on Plavix
- Continued home ASA 81 mg QD
- Continued home Ranexa ER 500 mg BID
# Nausea
- Continued home Zofran 8 mg QD:PRN, reglan 10 mg TID
# Gout
- Continued home allopurinol ___ mg QD
# HLD
- Continued home atorvastatin 20 mg QD
# CREST:
- Held home esomeprazole 40 mg capsule BID
- Pantoprazole 40 mg BID while inpatient
# PVD
- Continued home cilostazol 100 mg QAM, 50 mg QPM
TRANSITIONAL ISSUES:
====================
NEW MEDICATIONS:
- None
ADJUSTED MEDICATIONS:
- Cyclosporin 50mg PO Q12H
- Lasix 20mg daily
- Carvedilol 12.5mg PO QAM, 25mg PO QPM
STOPPED MEDICATIONS:
- Nifedipine CR 30mg daily
TO-DOs:
[ ] Monitor blood pressure and adjust anti-hypertensives
accordingly
[ ] Monitor weight and adjust Lasix accordingly - Dry weight
61.5 Kg
[ ] Set-up patient for ABPM within ___ weeks of discharge with
Dr. ___ appointment above)
[ ] Recheck CMP and CsA levels on ___
[ ] Recheck CMP and CsA levels on ___
# CODE: Full
# Contact: ___ (sister/HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Calcitriol 0.25 mcg PO DAILY
5. Cilostazol 100 mg PO QAM
6. Cilostazol 50 mg PO QHS
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Mycophenolate Mofetil 500 mg PO BID
9. PredniSONE 5 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
11. Carvedilol 25 mg PO BID
12. NIFEdipine CR 30 mg PO DAILY
13. Ascorbic Acid ___ mg PO DAILY
14. Calcium Carbonate 500 mg PO BID
15. Esomeprazole Magnesium 40 mg oral BID
16. Ferrous Sulfate 325 mg PO DAILY
17. Ranolazine ER 500 mg PO BID
18. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
19. Furosemide 20 mg PO BID
20. Glargine 22 Units Breakfast
Glargine 15 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Carvedilol 25 mg PO QHS
RX *carvedilol 25 mg 1 tablet(s) by mouth Daily at bedtime Disp
#*30 Tablet Refills:*0
2. Carvedilol 12.5 mg PO QAM
RX *carvedilol 12.5 mg 1 tablet(s) by mouth Daily in the morning
Disp #*30 Tablet Refills:*0
3. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
RX *cyclosporine modified 25 mg 2 capsule(s) by mouth twice a
day Disp #*120 Capsule Refills:*0
4. Furosemide 20 mg PO DAILY
RX *furosemide 40 mg 0.5 (One half) tablet(s) by mouth Daily
Disp #*15 Tablet Refills:*0
5. Glargine 22 Units Breakfast
Glargine 17 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Allopurinol ___ mg PO DAILY
7. Ascorbic Acid ___ mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 20 mg PO QPM
10. Calcitriol 0.25 mcg PO DAILY
11. Calcium Carbonate 500 mg PO BID
12. Cilostazol 100 mg PO QAM
13. Cilostazol 50 mg PO QHS
14. Esomeprazole Magnesium 40 mg oral BID
15. Ferrous Sulfate 325 mg PO DAILY
16. Levothyroxine Sodium 125 mcg PO DAILY
17. Mycophenolate Mofetil 500 mg PO BID
18. PredniSONE 5 mg PO DAILY
19. Ranolazine ER 500 mg PO BID
20. Vitamin D ___ UNIT PO DAILY
21.Outpatient Lab Work
Z94.0
___: CHEM10, Cyclosporin level
Please fax to Dr. ___ at ___.
22.Outpatient Lab Work
Z94.0
___: CHEM10, Cyclosporin level
Please fax to Dr. ___ at ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
========
Hypotension
Supine hypertension
Orthostatic hypotension
Secondary:
==========
Status-post kidney transplant, uncontrolled DMI, 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 care of you during your stay at ___
___. You were admitted for lightheadedness and
low pressure. This was likely due to your new blood pressure
medications and the water pills. Some of these symptoms are also
related to the longstanding diabetes that causes nerve damage
that prevents you blood vessels from maintaining a stable blood
pressure. You were give intravenous fluid and your blood
pressure improved. We have stopped your nifedipine and decreased
the dose of the carvedilol you were on. We restarted you on a
small dose of the water pills to keep you from accumulating
fluid. You should follow-up with your primary care physician
___ 2 days of discharge. This appointment has been scheduled
for you.
We wish you all the best!
Your ___ Team
Followup Instructions:
___
|
10030753-DS-41 | 10,030,753 | 27,987,271 | DS | 41 | 2199-06-02 00:00:00 | 2199-06-02 17:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan
Attending: ___.
Chief Complaint:
Lightheadedness/Nausea/Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman, with ___ s/p living kidney
transplant ___ on cyclosporine, cellcept, prednisone, CREST,
PE previously on warfarin, CAD (s/p ___ and OM ___,
labile blood pressures who presents with hypotension.
She notes that he has long-standing issues with orthostatic
hypotension. She checks her BP at home multiple times per day in
lying and standing positions, and will range from 180-200 while
lying, to 110-120 while standing, and she is sometimes
symptomatic with lightheadedness.
Although was feeling well on the morning of admission, for the
___ days prior to that she had been having multiple episodes of
vomiting. She had no fevers, abdominal pain, diarrhea. She
states that it is typical for her to have several-day bouts of
vomiting, which tend to resolve without treatment, possibly due
to gastroparesis.
The patient was at her cardiologist's office on the day of
admission, where she was getting fitted for outpatient
monitoring of her blood pressure, when she became lightheaded,
was found to be hypotensive. Initial BP was 113 systolic, which
fell to 72. She then had vomiting, and felt like she was going
to lose consciousness. She then had improvement of her symptoms
after being placed in the supine position her systolic BP
increased to 98 mmHg. Patient currently denies any symptoms.
She was admitted ___ to ___ after presenting with similar
symptoms of hypotension and dizziness after up-titration of her
home blood pressure medications. She was given IV fluids, and
nifedipine and Lasix were held, and her symptoms resolved,
although she was consistently orthostatic despite resting SBP in
the 200s, attributed to longstanding diabetes and autonomic
dysfunction. She was discharged on carvedilol, Lasix 20mg PO
daily.
Her past medical history is significant for poorly controlled
type 1 diabetes with onset around age ___, a left sided kidney
transplant in ___, coronary artery disease with prior MI. Her
most recent drug-eluting stent was placed in the LAD and
circumflex in ___. She also has a history of scleroderma
with CREST syndrome and has a questionable diagnosis of
antiphospholipid antibodies with pulmonary embolism. She has
chronic
gastroparesis and vomits frequently. There is a history of gout
and obstructive sleep apnea. She has multiple urinary tract
infections.
In the ED initial vitals were: 96.8 HR 86 BP 139/70 RR16 98RA
EKG: Sinus rhythm, 86, normal axis, normal intervals, ST
depression with T wave inversions in lead one, aVL. ST segment
depression in lateral leads
Imaging: CXR with No acute cardiopulmonary process.
Labs/studies notable for:
Hgb 9.8, Troponin 0.14 w/ CKMB 2, Creatinine 1.9 (at baseline).
Repeat troponin 0.11.
Patient was given: ASA 243 mg, PO Zofran 4mg
Vitals on transfer: 98.8 95 139/55 14 99% RA
On the floor she feels at her baseline. Overnight she received
Carvedilol 12.5mg x2 (home dose 25mg). Home Lasix was held.
Past Medical History:
1. CARDIAC RISK FACTORS
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___,
DES to LAD and Cx/OM ___
3. OTHER PAST MEDICAL HISTORY
End-stage renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
- Scleroderma w/ CREST syndrome
- Gastroparesis/GERD/Hiatal hernia
- Gout diagnosed ___ years ago
- OSA
-NOT ACCURATE: - Antiphospholipid antibody syndrome and remote
PE
history on Coumadin ___ - this diagnosis viewed unlikely per
___ hematology/oncology note; warfarin discontinued ___
Social History:
___
Family History:
Former smoker: ___ years, ___ ppd. Quit ___ years ago. Denies
etoh/drugs. Lives at home with daughter. Currently on
disabilities.
FAMILY HISTORY: Per OMR
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
==============================
VS: T 98.3, bp 158/67, hr 92, rr 20, spo2 95% on RA
GENERAL: Well developed, well nourished woman 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 6-7 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2.
III/VI systolic murmur at upper sternal borders
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-distended. Mild tenderness over renal
transplant in LLQ
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAMINATION:
===============================
Vitals: T=98.2 HR=100 BP=133/65 RR=18 O2= 94% on RA
Lying 164/73
sitting 123/68
standing 112/66
I/O= ___
Weight: 60.1
Weight on admission: 60.2
Telemetry: No events
GENERAL: Well developed, well nourished woman 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 6-7 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. III/VI systolic
murmur at upper sternal borders
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-distended. Mild tenderness over renal
transplant in LLQ
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS:
===============
___ 03:12PM BLOOD WBC-9.1 RBC-3.18* Hgb-9.8* Hct-30.2*
MCV-95 MCH-30.8 MCHC-32.5 RDW-13.7 RDWSD-47.5* Plt ___
___ 03:12PM BLOOD Neuts-85.7* Lymphs-5.2* Monos-7.4 Eos-1.1
Baso-0.2 Im ___ AbsNeut-7.81* AbsLymp-0.47* AbsMono-0.67
AbsEos-0.10 AbsBaso-0.02
___ 03:12PM BLOOD Plt ___
___ 04:48AM BLOOD ___ PTT-28.2 ___
___ 03:12PM BLOOD Glucose-83 UreaN-41* Creat-1.9* Na-143
K-4.0 Cl-106 HCO3-26 AnGap-15
___ 03:12PM BLOOD CK(CPK)-34
___ 03:12PM BLOOD CK-MB-2 cTropnT-0.14*
___ 09:40PM BLOOD cTropnT-0.11*
___ 04:48AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1
___ 09:00AM BLOOD Cyclspr-196
DISCHARGE LABS:
================
___ 06:05AM BLOOD WBC-8.4 RBC-2.95* Hgb-9.1* Hct-28.1*
MCV-95 MCH-30.8 MCHC-32.4 RDW-13.6 RDWSD-47.1* Plt ___
___ 06:05AM BLOOD Glucose-64* UreaN-48* Creat-2.0* Na-142
K-4.4 Cl-108 HCO3-22 AnGap-16
___ 06:05AM BLOOD Calcium-10.1 Phos-3.8 Mg-1.9
___ 08:45AM BLOOD Cyclspr-181
MICRO:
=======
___ 11:44 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
STUDIES/IMAGING:
================
CXR ___: No acute cardiopulmonary process.
RENAL TRANSPLANT US ___: 1. Patent renal transplant
vasculature. No hydronephrosis and no peritransplant fluid
collection identified.
2. Small amount of movable debris noted within the urinary
bladder which could represent sludge, infectious material or
blood. Correlation with urinalysis is suggested.
Brief Hospital Course:
___ with PMhx of ___ s/p living kidney transplant ___ on
cyclosporine, cellcept, prednisone, CREST, PE previously on
warfarin, CAD (s/p ___ and OM ___ who presents for
orthostatic hypotension and prescyncope.
#Orthostatic Hypotension/Syncope:
Patient became hypotensive to ___ with standing with associated
emesis at cardiology office and was referred to ___. Patient
with multiple admissions for symptomatic orthostatic hypotension
thought to be secondary to autonomic dysregulation likely with
component of vasovagal syncope. On presentation patient with
lying 160/70 and standing SBP 86/50. Carvedilol and Lasix with
discontinued and patient was started on Nifedipine 30mg CR with
improvement in orthostatics of 164/73 lying to 112/66 standing.
Patient was instructed to take Lasix 20mg if she gained more
than 3lbs in one day and if she has significant lower extremity
edema.
#Troponin elevation:
Patient with ST depression in I, TWI in AVL, slightly elevated
troponin to 0.14 (higher than prior checks) with flat MB and
baseline creatinine. Troponin trending down on recheck to 0.11.
She does have known CAD, with PI in LAD in ___, had 80%
stenosis with diagonal with stenosis as well. She denies chest
pain, likely demand ischemia in setting of labile pressures and
hypovolemia from emesis.
#Nausea/emesis:
Patient with emesis occurring with standing. Chronic issue for
patient thought to be secondary to gastroparesis. Also may have
component of vasovagal response to standing. She also had
improvement in nausea and emesis prior to discharge with change
in anti-hypertensive regimen.
# ___ on CKD
# S/p living unrelated donor kidney transplant ___:
Prior admission for ___ with renal bx showing diabetic changes
without signs of rejection. Her immunosuppressive regimen was
increased and she was discharged with a more aggressive
antidiabetic regimen and antihypertensive regimen. Had Cr
elevation to 2.6 thought to be due to hypovolemia. Improved to
2.0 (baseline 1.9) with small fluid bolus. Cyclosporine 12 hour
trough was 181 on ___, goal 45-100. Dose was reduced to
Cyclosporine (Neoral)25mg BID. Patient needs to have 12 hour
Cyclosporine trough drawn in one week (___). She was continued
on home prednisone 5mg PO daily, MMF 500mg BID. UA initially
with bacteria and WBCs, urine culture negative. Per renal may
need ace inhibitor, will determine if blood pressure can
tolerate.
# DM1: Patient with A1C 7.5% (___). Decreased ___ Lantus to 15
given low AM blood sugars. Updated insulin regimen below.
Glargine 22 Units Breakfast
Glargine 15 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
CHRONIC ISSUES
===============
# Hypothyroidism: recent TSH 0.69, Continue home levothyroxine
125 mcg QD.
# PE: Hx of provoked PE in 1990s, on warfarin until last
admission ___ at ___. Warfarin was stopped given hx of
GIB on warfarin and negative anti-cardiolipin AB on repeat
check.
# Gout: States she is no longer taking allopurinol ___ mg QD.
# HLD: Continue home atorvastatin 20 mg QD
# CREST: Omeprazole 40 mg BID while inpatient, discharged on
home PPI.
# PVD: Continue home cilostazol 100 mg QAM, 50 mg QPM
Proxy name: ___
___: SISTER Phone: ___
#Code status: Full
TRANSITIONAL ISSUES:
====================
-New Medications: Nifedipine CR 30mg daily, Lasix 20mg PRN if
she gains more than 3lbs or has significant lower extremity
edema.
-Stopped Medicaitons: Carvedilol, Lasix daily
-Changed Medications: Cyclosporine 25mg BID. Decreased ___ Lantus
to 15 given low AM blood sugars. Updated insulin regimen below.
Glargine 22 Units Breakfast
Glargine 15 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
-Discharge Cr: 2.0
- Please monitor orthostatic blood pressures. If patient
continues to have low pressures with standing can reduce dose of
Nifedipine.
- Recommend avoiding Carvedilol as this medication seemed to
exacerbate patient's orthostasis.
- Recommend follow up with autonomic neurology for evaluation of
patient's autonomic dysregulation.
--Consider outpatient stress testing given the demand troponin
seen in the setting of hypotension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Calcitriol 0.25 mcg PO DAILY
5. Calcium Carbonate 500 mg PO BID
6. Cilostazol 100 mg PO QAM
7. Cilostazol 50 mg PO QHS
8. Ferrous Sulfate 325 mg PO DAILY
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Mycophenolate Mofetil 500 mg PO BID
11. PredniSONE 5 mg PO DAILY
12. Ranolazine ER 500 mg PO BID
13. Vitamin D ___ UNIT PO DAILY
14. Esomeprazole Magnesium 40 mg oral BID
15. Carvedilol 25 mg PO QHS
16. Carvedilol 12.5 mg PO QAM
17. Furosemide 20 mg PO DAILY
18. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
19. Glargine 22 Units Breakfast
Glargine 17 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Furosemide 20 mg PO DAILY:PRN leg swelling
Please take this medication if your weight goes up by more than
3lbs in one day.
RX *furosemide 20 mg 1 tablet(s) by mouth Daily as needed Disp
#*30 Tablet Refills:*0
2. NIFEdipine CR 30 mg PO DAILY
RX *nifedipine [Afeditab CR] 30 mg 1 tablet(s) by mouth Daily
Disp #*30 Tablet Refills:*0
3. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
RX *cyclosporine modified [Neoral] 25 mg 1 capsule(s) by mouth
Twice daily Disp #*60 Capsule Refills:*0
4. Glargine 22 Units Breakfast
Glargine 15 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Ascorbic Acid ___ mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. Calcitriol 0.25 mcg PO DAILY
9. Calcium Carbonate 500 mg PO BID
10. Cilostazol 100 mg PO QAM
11. Cilostazol 50 mg PO QHS
12. Esomeprazole Magnesium 40 mg oral BID
13. Ferrous Sulfate 325 mg PO DAILY
14. Levothyroxine Sodium 125 mcg PO DAILY
15. Mycophenolate Mofetil 500 mg PO BID
16. PredniSONE 5 mg PO DAILY
17. Ranolazine ER 500 mg PO BID
18. Vitamin D ___ UNIT PO DAILY
19.Outpatient Lab Work
ICD 10: Z94.0
Please draw 12 hour cyclosporine trough on ___.
Fax to: Renal ___ fax ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Orthostatic hypotension
Secondary: Kidney transplant, acute kidney failure, troponin
elevation secondary to demand ischemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because had low blood pressures and
felt lightheaded. We think this is due to dysregulation of your
nervous system. It may have also been related to dehydration
from vomiting. We stopped your Carvedilol and started you on a
medication called Nifedipine.
You should stop taking your Lasix everyday. Weigh yourself every
morning and take your Lasix 20mg if weight goes up more than 3
lbs or you notice significant leg swelling. If you have to take
your Lasix please call your primary care physican. You should
also wear compression stockings to prevent blood from
accumulating in your legs.
Your Cyclosporin level was high so your dose was reduced. You
should take Cyclosporine (Neoral) 25mg twice daily. You will
need to have your Cyclosporine level checked in one week (___)
and the results should be sent to the Kidney ___.
Should you experience a recurrence or worsening of the symptoms
that originally brought you to the hospital, experience any of
the warning signs listed below, or have any other symptoms that
concern you, please seek medical attention.
It was a pleasure taking care of you!
Your ___ Care Team
Followup Instructions:
___
|
10030753-DS-42 | 10,030,753 | 24,506,973 | DS | 42 | 2199-07-23 00:00:00 | 2199-07-23 17:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan
Attending: ___.
Chief Complaint:
Right facial swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a history of ESRD s/p living renal transplant in ___
on immunosuppression, DM1, scleroderma/CREST, and CAD s/p MI
presenting with pre-septal cellulitis, course complicated by DKA
requiring MICU transfer, now with resolved DKA.
The patient notes that when she woke on ___, her eye felt
swollen and had significant redness on skin around her eyelid.
She notes that it worsened since that time, and was associated
with clear, teary discharge and crusting. She does note
antecedent rhinorrhea without sore, throat, cough or shortness
of breath. She developed a fever at home up to 101.9 which
prompted her to come in on ___. She states that her vision
may be slightly more blurry, but does not feel significantly
difference from her baseline blurry vision, given her diabetic
retinopathy and prior laser surgeries.
In the ED, her initial vitals were temp 99.4, HR 114, BP
127-64, RR 18, 98% on room air. Her labs were notable for WBC
1.8, Hg 10.3, platelets 227. Chem-7 Na 131, Cl 93, bicarb 18,
BUN 36, Cr 2.2, and Lactate 1.7. She had a chest x ray notable
for no acute cardiopulmonary process. She was given IV Cefepime,
IV Vancomycin. She was seen by renal transplant who recommended
isotonic bicarbonate 500cc/hour for two hours, given her slight
elevation in Creatinine, as well as:
-agree with optho consult
-CXR, blood cx, urine cx, CMV VL
-would cover broadly with IV vanc/ceftazidime
-hold MMF tonight and in the AM, continue cyclosporine 50mg BID
Optho consulted:
Concern for pre-septal cellulitis. Low suspicion of orbital
involvement given no pain with eye movements or proptosis.
-Dilated fundus examination shows extensive PRP scarring with
vitreous hemorrhage in the right eye that appears unchanged from
her last examination.
-recommended CT of the orbit
-antibiotics
- artificial tears as needed
- No heavy lifting, bending, straining or activities with rapid
head movement.
- Follow-up with ___ Ophthalmology as scheduled
- Vitals prior to transfer:
Temp. 98.7, HR 102, BP 134/68, RR 16, 100% RA
ROS negative for SOB, chest pain, nausea, or diarrhea. Patient
denies headache. She does endorse chronic nausea and vomiting on
multiple PRN's for this. Notes this is stable.
Past Medical History:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___
DES to LAD and Cx/OM ___
3. OTHER PAST MEDICAL HISTORY
End-stage renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
- Scleroderma w/ CREST syndrome
- Gastroparesis/GERD/Hiatal hernia
- Gout diagnosed ___ years ago
- OSA
-NOT ACCURATE: - Antiphospholipid antibody syndrome and remote
PE
history on Coumadin ___ - this diagnosis viewed unlikely per
___ hematology/oncology note; warfarin discontinued ___
Social History:
___
Family History:
Per OMR:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
VS: 99.6 PO 114 / 61 102 16 98 Ra
GENERAL: Right eye erythematous with swelling.
HEENT: EOMI, pain with eye movement
CARDIAC: RRR
PULMONARY: clear bilaterally, no wheezes or rubs
ABDOMEN: soft, non-tender to palpation
GENITOURINARY: no foley
EXTREMITIES: no edema
SKIN: no rash
NEUROLOGIC: CN grossly intact
========================
DISCHARGE PHYSICAL EXAM
========================
Vitals: T 98.0, BP 180/77 (lying), HR 89, RR 18, ___ 94 on room
air
General: Pleasant, well-appearing, lying in bed.
HEENT: Atraumatic with improving erythema around right eyelid,
now limited to ~1.5cm around upper/lower lids. Oropharynx clear.
Neck: Supple with no lymphadenopathy or jugular venous
distention
Lungs: Clear to auscultation bilaterally
CV: Regular rate/rhythm, with systolic ejection murmur heard
best at lower sternal border. No rubs or gallops.
Abdomen: Soft, nontender, nondistended
Ext: Warm, well-perfused with 1+ pitting edema bilaterally.
Neuro: Alert, oriented to self, place, time. Moving all
extremities spontaneously and purposefully.
Pertinent Results:
===============
ADMISSION LABS
===============
___ 11:38PM ___ PO2-135* PCO2-29* PH-7.29* TOTAL
CO2-15* BASE XS--10 COMMENTS-GREEN TOP
___ 11:13PM GLUCOSE-601* UREA N-49* CREAT-2.5*
SODIUM-125* POTASSIUM-5.2* CHLORIDE-88* TOTAL CO2-12* ANION
GAP-30*
___ 11:13PM CALCIUM-8.2* PHOSPHATE-5.2* MAGNESIUM-1.7
___ 04:31PM LACTATE-1.7
___ 04:30PM GLUCOSE-365* UREA N-36* CREAT-2.2*
SODIUM-131* POTASSIUM-4.7 CHLORIDE-93* TOTAL CO2-18* ANION
GAP-25*
___ 04:30PM estGFR-Using this
___ 04:30PM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-1.7
___ 04:30PM WBC-1.8*# RBC-3.36* HGB-10.3* HCT-31.6*
MCV-94 MCH-30.7 MCHC-32.6 RDW-13.0 RDWSD-44.5
___ 04:30PM NEUTS-3* BANDS-0 ___ MONOS-65* EOS-0
BASOS-0 ___ METAS-1* MYELOS-0 AbsNeut-0.05* AbsLymp-0.56*
AbsMono-1.17* AbsEos-0.00* AbsBaso-0.00*
___ 04:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
___ 04:30PM PLT SMR-NORMAL PLT COUNT-227
===============
DISCHARGE LABS
===============
___ 06:09AM BLOOD WBC-3.8* RBC-3.36* Hgb-10.1* Hct-30.1*
MCV-90 MCH-30.1 MCHC-33.6 RDW-13.9 RDWSD-45.4 Plt ___
___ 06:09AM BLOOD Neuts-64 Bands-0 Lymphs-18* Monos-16*
Eos-1 Baso-0 ___ Myelos-1* NRBC-2* AbsNeut-2.43
AbsLymp-0.68* AbsMono-0.61 AbsEos-0.04 AbsBaso-0.00*
___ 06:09AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 06:09AM BLOOD Plt Smr-NORMAL Plt ___
___ 06:09AM BLOOD Glucose-149* UreaN-46* Creat-2.3* Na-138
K-4.5 Cl-101 HCO3-28 AnGap-14
___ 06:09AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.8
___ 06:09AM BLOOD Cyclspr-PND
=============
MICROBIOLOGY
==============
___ 5:08 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
=========
IMAGING
=========
___ CHEST (PA & LAT)
FINDINGS:
There is minor right middle lobe atelectasis. No focal
consolidation is seen. No pleural effusion or pneumothorax is
seen. The cardiac and mediastinal silhouettes are stable. Right
upper quadrant surgical clips are seen, presumed prior
cholecystectomy.
IMPRESSION: No acute cardiopulmonary process.
___ CT ORBIT, SELLA & IAC W
IMPRESSION:
1. Pre-septal and periorbital soft tissue cellulitis without
drainable fluid collection or post-septal cellulitis.
___ CHEST (PORTABLE AP)
FINDINGS:
Compared to prior, there is a new right pleural effusion. There
is also
increased vascular congestion with mild pulmonary edema. There
is no
pneumothorax. Heart size is mildly enlarged.
IMPRESSION:
Mild pulmonary edema with a small right pleural effusion.
Brief Hospital Course:
___ with a history of ESRD s/p living renal transplant in ___
on immunosuppression, DM1, scleroderma/CREST, and CAD s/p MI
presenting with pre-septal cellulitis, course complicated by DKA
requiring MICU transfer, now with resolved DKA.
# DKA
The patient has a history of poorly controlled type 1 diabetes
with prior admissions for DKA. While on treatment for preseptal
cellulitis, she was found to have elevated blood sugars that
were non-responsive to subcutaneous insulin. She was transferred
to the MICU. Chem7 at 2300 on ___ showed glucose of 600, K of
5.2, HCO3 of 12, Gap of 25. She received an insulin bolus and
was started on a drip. She was also given bicarbonate. Her
glucose and gap improved on her insulin drip, so it was
discontinued. She was subsequently found to be hyperglycemic
again, so she was started on an insulin drip again, before
ultimately being transferred to subcutaneous insulin before her
transfer to the floor. Glucose was 103 and gap was 13 on
transfer to floor (___). She was followed by ___ while
inpatient, with adjustments made to her insulin regimen. Given
an episode of hypoglycemia one day prior to discharge, the
patient's insulin regimen was adjusted. She will follow up with
___ at her scheduled appointment within one week of
discharge.
# Pre-septal Cellulitis
Patient presented with right periorbital erythema without vision
changes from baseline and without pain on lateral gaze. She had
a CT scan which showed no orbital cellulitis. Ophthalmology was
consulted, who agreed that her presentation was consistent with
preseptal cellulitis. She was started on vancomycin and cefepime
on ___, given penicillin allergy. She did not have a reaction to
cefepime. She was later transitioned to
vancomycin/ceftriaxone/flagyl on ___, with improving
periorbital erythema and edema. MRSA screen was negative on
___, and vancomycin discontinued. On ___ she was transitioned
to cefpodoxime/flagyl in preparation for discharge with plan to
continue until her ID follow up appointment on ___.
# Leukopenia
On initial presentation, she was found to be leukopenic, in the
setting of a pre-septal cellulitis and immunosuppression. She
was treated with antibiotics as above, and her leukopenia
resolved. Her immunosuppressive medications were adjusted per
renal transplant recommendations. Her CBC with diff was trended.
Her leukopenia resolved prior to discharge. She will need her
CBC with diff checked within 1 week after discharge.
# ESRD s/p renal transplant w/metabolic acidosis (baseline Cr
1.8-2)
___ on CKD.
Patient presented with Cr of 2.2, which peaked at 2.9 in the
setting of DKA and infection. Her home mycophenylate was
stopped per renal transplant consult, and she was given IV
fluids and her DKA was treated as above. Her mycophenylate was
restarted at 250mg (half home dose) upon improvement of her DKA.
Her home cyclosporinge and prednisone were adjusted. Her home
calcitriol, bicarbonate, and calcium carbonate were continued.
CR lowered and stabilized at 2.3 on the floor. Her home dose of
MMF and prednisone were eventually resumed prior to discharge.
She was discharged on a lower dose of cyclosporine compared to
her home dose that she had previously been taking. She will need
her cyclosporine level to be checked within 1 week following
discharge with adjustments as indicated.
# Supine Hypertension with orthostasis
# Dysautonomia
The patient reported that this has been occurring for months,
likely secondary to her dysautonomia and potentially worsening
cardiac function. She was continued on home metoprolol. She was
started on QHS metoprolol tartrate to help with her supine
hypertension. She was also given support stockings as she wears
at home.
# Coronary Artery Disease s/p MI X2 and DES ___
She was continued on her home metoprolol, aspirin, atorvastatin,
cilostazol, ranolazine.
# Hyperlipidemia
She was continued on home atorvastatin.
# CREST
She was continued on home esomeprazole, metroclopramide, and
prochlorperazine
# Hypthyroidism
She was continued on home levothyroxine.
# History of Pulmonary Embolism
Patient had a history of provoked PE in 1990s, and was on
warfarin until last admission ___ at ___. Warfarin was
stopped given history of GI bleed on warfarin and negative
anti-cardiolipin AB on repeat check.
TRANSITIONAL ISSUES:
-treated preseptal cellulitis, discharged on cefpodoxime 200mg
q12h, flagyl 500mg q8h, with plan to continue PO abx until
scheduled ID follow-up on ___ at 10AM
-admitted to MICU for treatment of DKA in the setting of her
pre-septal cellulitis
-the patient's insulin regimen was adjusted per ___ recs. She
was discharged on a lower lantus dose compared to her home dose,
20U QAM with 8U at bedtime. Please adjust standing insulin
accordingly at ___ follow up appointment
-patient will need follow up labs drawn by ___ next week,
including CBC with diff, Chem 10, and cyclosporine level.
-the patient's cyclosporine dose was adjusted during her
hospitalization. She was discharged on 25mg q12h with plan to
recheck cyclosporine level on repeat labs next week. Please
follow up cyclosporine level and adjust accordingly.
-she was started on additional metoprolol QHS to help with her
supine hypertension. Please trend BP checks at outpatient follow
up visits
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 20 mg PO QPM
2. Calcitriol 0.25 mcg PO DAILY
3. CycloSPORINE (Sandimmune) 50 mg PO Q12H
4. Esomeprazole 40 mg Other BID
5. Furosemide 20 mg PO DAILY PRN WEIGHT GAIN weight gain
6. Glargine 22 Units Breakfast
Glargine 11 Units Bedtime
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Metoclopramide 10 mg PO QIDACHS
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Mycophenolate Mofetil 500 mg PO BID
11. PredniSONE 5 mg PO DAILY
12. Promethazine 25 mg PO DAILY PRN nausea
13. Ranolazine ER 500 mg PO BID
14. Ascorbic Acid ___ mg PO DAILY
15. Aspirin 81 mg PO DAILY
16. Calcium Carbonate 500 mg PO BID
17. Ferrous Sulfate 325 mg PO DAILY
18. Vitamin D ___ UNIT PO DAILY
19. Cilostazol 100 mg PO QAM
20. Cilostazol 50 mg PO QPM
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
RX *dextran 70-hypromellose (PF) [Tears Naturale Free (PF)] 0.1
%-0.3 % ___ drops to eyes prn Disp #*1 Bottle Refills:*2
2. Cefpodoxime Proxetil 200 mg PO Q12H
please continue until follow up appointment with ID on ___
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*20 Tablet Refills:*0
3. Metoprolol Tartrate 12.5 mg PO QHS
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
at bedtime Disp #*30 Tablet Refills:*0
4. MetroNIDAZOLE 500 mg PO Q8H
please take until follow up appointment with ID on ___
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
5. Ondansetron 4 mg PO Q8H
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
6. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
please call your transplant doctor for medication adjustment
RX *cyclosporine modified 25 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*60 Capsule Refills:*0
7. Glargine 20 Units Breakfast
Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR
20 Units before BKFT; 8 Units before BED; Disp #*30 Syringe
Refills:*0
8. Ascorbic Acid ___ mg PO DAILY
RX *ascorbic acid (vitamin C) 500 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
9. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet
Refills:*0
11. Calcitriol 0.25 mcg PO DAILY
RX *calcitriol 0.25 mcg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
12. Calcium Carbonate 500 mg PO BID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth twice a day Disp #*60 Tablet Refills:*0
13. Cilostazol 100 mg PO QAM
RX *cilostazol 100 mg 1 tablet(s) by mouth QAM Disp #*30 Tablet
Refills:*0
14. Cilostazol 50 mg PO QPM
RX *cilostazol 50 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*0
15. Esomeprazole 40 mg Other BID
RX *esomeprazole magnesium 40 mg 1 capsule(s) by mouth twice a
day Disp #*60 Capsule Refills:*0
16. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
17. Furosemide 20 mg PO DAILY PRN WEIGHT GAIN weight gain
RX *furosemide 20 mg 1 tablet(s) by mouth daily prn Disp #*30
Tablet Refills:*0
18. Levothyroxine Sodium 125 mcg PO DAILY
RX *levothyroxine 125 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
19. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
20. Mycophenolate Mofetil 500 mg PO BID
RX *mycophenolate mofetil 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
21. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
22. Promethazine 25 mg PO DAILY PRN nausea
RX *promethazine 25 mg 1 tablet by mouth daily prn Disp #*30
Tablet Refills:*0
23. Ranolazine ER 500 mg PO BID
RX *ranolazine [Ranexa] 500 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
24. Vitamin D ___ UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
25.Outpatient Lab Work
ICD 10: Z94.0 : Kidney transplant status
Chem 10, CBC with differential, Cyclosporine level
Date: please draw with ___ visit on ___ or ___
Please fax results to ___ at ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Preseptal Cellulitis
Diabetic Ketoacidosis (resolved)
End-stage renal disease with left-sided living kidney transplant
Diabetes Mellitus Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder
Hypertension
Autonomic Dysfunction/Dysautonomia
Secondary Diagnoses:
Dyslipidemia
Coronary Artery Disease
Scleroderma w/ CREST syndrome
Gastroparesis/GERD/Hiatal hernia
Gout
Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you. You were admitted because
of an infection in the skin around your eye, a condition called
pre-septal cellulitis. You were given antibiotics for this and
developed DKA during your treatment. You went to the MICU for
treatment of your DKA. You were given insulin and fluids and
your DKA eventually resolved. The swelling and redness around
your eye improved with IV antibiotic treatment. You were
discharged home with oral antibiotics to clear the infection.
Please continue to take all medications as prescribed, including
the oral antibiotics until your outpatient appointment with
Infectious Disease on ___. Please weigh yourself every morning,
call your doctor if weight goes up more than 3 lbs.
Please be sure to get your labs checked within one week of
hospital discharge. A prescription has been written for ___ to
draw your labs next week, with instructions to fax results to
Dr. ___.
We wish you the best in your health.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10030753-DS-45 | 10,030,753 | 21,257,920 | DS | 45 | 2199-11-29 00:00:00 | 2199-11-30 08:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ female with ESRD s/p LRRT ___, (bl Cr 1.5-2.0; bx w
diabetic nephropathy and grade 2 IFTA ___, CAD s/p DES ___,
___, HTN, CREST syndrome, T1DM, who presents with shortness
of breath found to have volume overload, hyperglycemia, and
sepsis in the ED. Of note, patient was recently admitted
___ on the kidney transplant service due to shortness of
breath. This is attributed to acute decompensated systolic
heart failure in the setting of dietary noncompliance. ACS was
ruled out. She had a repeat that admission that showed a newly
depressed EF of 40%. Cardiology was consulted and her meds were
altered. Specifically, she was discontinued on metoprolol,
furosemide, carvedilol; nitro patch, and hydralazine were added,
and home cyclosporine was increased. She subsequently followed
up with cardiology since that visit and Lasix 40 mg twice daily
was added.
In ED initial VS: T ___ 26 96% Nasal Cannula
Exam: none
Labs significant for:
Patient was given:
IV Ondansetron 4 mg
IV Vancomycin
IV DRIPNitroglycerin (0.35-3.5 mcg/kg/min ordered)Started 0.4
IV Piperacillin-Tazobactam
PO Acetaminophen 1000 mg
IV Vancomycin 1000 mg
IV Levofloxacin 750 mg(chosen given pcn allergy)
IV insulin regular 10
Imaging notable for:
CXR 1. Compared to ___, persistent moderate
cardiomegaly and increased vascular congestion, now with
moderate bilateral pulmonary edema. 2. Small bilateral pleural
effusions.
Consults:
VS prior to transfer: T 102.1 122 177/78 26 96% Nasal Cannula
On arrival to the MICU, patient reports her breathing is mildly
improved
Past Medical History:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___
DES to LAD and Cx/OM ___
3. OTHER PAST MEDICAL HISTORY. End-stage renal disease ___
diabetes s/p L-sided living kidney transplant in ___
- Scleroderma w/ CREST syndrome
- Gastroparesis/GERD/Hiatal hernia
- Gout diagnosed ___ years ago
- OSA
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
Admission exam:
VITALS: T 98.2 108 156/24 26 96% Nasal Cannula
GENERAL: Alert, oriented, moderately uncomfortable appearing
HEENT: Sclera anicteric, dry MM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: bilateral rales in bases bilaterally; no rhonchi or
wheeze
CV: tachycardic, regular rhythm, no rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rash
NEURO: no tremor, no asterixis, CNII-XII intact, no neck
stiffness, neg Kernig's
Discharge exam:
VS: 109 / 69
Standing 113 98
GENERAL: NAD
HEENT: AT/NC, MMM, no JVD
HEART: RRR, S1/S2, II/VI systolic murmur heard best at USB and
apex
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: grossly intact
PSYCH: Alert, responsive, appropriate responses
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission labs:
___ 05:06AM BLOOD WBC-11.9* RBC-3.09* Hgb-9.5* Hct-28.4*
MCV-92 MCH-30.7 MCHC-33.5 RDW-12.8 RDWSD-42.5 Plt ___
___ 05:06AM BLOOD Neuts-86.7* Lymphs-4.5* Monos-7.1
Eos-0.9* Baso-0.3 Im ___ AbsNeut-10.28* AbsLymp-0.53*
AbsMono-0.84* AbsEos-0.11 AbsBaso-0.04
___ 05:06AM BLOOD ___ PTT-28.4 ___
___ 05:06AM BLOOD Glucose-738* UreaN-48* Creat-2.3* Na-135
K-3.9 Cl-93* HCO3-25 AnGap-17*
___ 05:06AM BLOOD ALT-9 AST-8 AlkPhos-116* TotBili-0.4
___ 10:21AM BLOOD ALT-7 AST-10 LD(LDH)-367* AlkPhos-84
TotBili-0.5
___ 05:06AM BLOOD ___
___ 05:06AM BLOOD cTropnT-0.16*
___ 05:06AM BLOOD Lipase-10
___ 05:06AM BLOOD Albumin-3.4* Calcium-9.8 Phos-3.4 Mg-1.7
___ 05:25AM BLOOD Cyclspr-129
___ 05:53AM BLOOD Cyclspr-181
___ 02:50PM BLOOD freeCa-1.04*
___ 05:17AM BLOOD ___ pO2-47* pCO2-41 pH-7.43
calTCO2-28 Base XS-2
___ 06:45AM URINE RBC-4* WBC-19* Bacteri-FEW* Yeast-NONE
Epi-0
___ 06:45AM URINE Color-Straw Appear-Clear Sp ___
Notable labs:
___ 10:21AM BLOOD WBC-10.4* RBC-2.74* Hgb-8.7* Hct-25.5*
MCV-93 MCH-31.8 MCHC-34.1 RDW-13.1 RDWSD-44.2 Plt ___
___ 05:25AM BLOOD WBC-7.0 RBC-2.91* Hgb-9.0* Hct-27.5*
MCV-95 MCH-30.9 MCHC-32.7 RDW-13.3 RDWSD-45.5 Plt ___
___ 05:12AM BLOOD WBC-8.1 RBC-3.06* Hgb-9.4* Hct-29.6*
MCV-97 MCH-30.7 MCHC-31.8* RDW-13.2 RDWSD-46.5* Plt ___
___ 12:22AM BLOOD ___ PTT-30.7 ___
___ 05:00AM BLOOD ___ PTT-29.9 ___
___ 10:21AM BLOOD ALT-7 AST-10 LD(LDH)-367* AlkPhos-84
TotBili-0.5
___ 10:21AM BLOOD Glucose-431* UreaN-47* Creat-2.5* Na-138
K-3.6 Cl-97 HCO3-22 AnGap-19___ 05:25AM BLOOD Glucose-158* UreaN-51* Creat-2.8* Na-143
K-3.6 Cl-101 HCO3-29 AnGap-13
___ 05:00AM BLOOD Glucose-188* UreaN-46* Creat-2.3* Na-144
K-3.6 Cl-103 HCO3-31 AnGap-10
___ 05:12AM BLOOD Glucose-65* UreaN-43* Creat-2.3* Na-144
K-4.3 Cl-102 HCO3-33* AnGap-9
___ 05:42AM BLOOD Cyclspr-198
___ 05:50AM BLOOD Cyclspr-73*
___ 09:52AM BLOOD Cyclspr-70*
___ 09:04AM BLOOD Cyclspr-228
Discharge labs:
___ 06:00AM BLOOD WBC-7.6 RBC-3.00* Hgb-9.4* Hct-28.7*
MCV-96 MCH-31.3 MCHC-32.8 RDW-13.0 RDWSD-44.7 Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-196* UreaN-38* Creat-2.4* Na-141
K-4.4 Cl-97 HCO3-34* AnGap-10
___ 06:00AM BLOOD Calcium-10.1 Phos-3.5 Mg-1.8
___ 09:00AM BLOOD Cyclspr-79*
MICROBIOLOGY:
___ 6:45 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
REPORTS: CXR ___
FINDINGS:
The size of the cardiac silhouette is enlarged. There is a
small left pleural effusion with subjacent
atelectasis/pneumonia. The right lung is grossly clear. There
is no pneumothorax or right pleural effusion.
IMPRESSION:
New opacities at the left lung base are reflective of a pleural
effusion with subjacent atelectasis/pneumonia.
CXR ___
FINDINGS:
Compared to ___, the cardiac silhouette remains
moderately
enlarged. There is increased vascular congestion with moderate
bilateral
pulmonary edema. Small bilateral pleural effusions are again
seen. No focal infiltrates or pneumothorax.
IMPRESSION:
1. Compared to ___, persistent moderate cardiomegaly
and increased vascular congestion, now with moderate bilateral
pulmonary edema.
2. Small bilateral pleural effusions.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a PMHx of ESRD s/p
living renal transplant in ___, DM, and h/o multiple MDR UTIs
(Klebsiella, E.coli, Enterococcus), sclerodermda/CREST and chart
history antiphospholipid antibody syndrome with h/o remote PE in
___, CAD s/p MI x 2 and DES ___ who presents to the
hospital with dyspnea and hypertensive emergency as well as
fever.
Acute issues:
# Hypertensive emergency: Patient presented with progressive
dyspnea since recent discharge, weight gain, and orthopnea, and
she was found to have hypertensive emergency, acute cardiogenic
pulmonary edema, causing hypoxemic respiratory distress. Her
respiratory status improved with control of blood pressure.
Ineffective control of blood pressure and hypervolemia were the
driving factors for her presentation. Her BP is very elevated
while supine but difficult to control due to worsening of
orthostasis when on antihypertensives. Her diuretic and blood
pressure regimen was titrated while in-house and she was
discharged with SBPs in 170s-180s while supine, 80s-100s while
standing. She occasionally still got dizzy with these low blood
pressures. Physical therapy worked with her and felt that other
than her symptomatic hypotension, her strength and mobility was
stable but did recommend home physical therapy.
#Fever: Patient was febrile to 102.5 on the day of admission but
was otherwise asymptomatic without signs of infection.
Antibiotics were discontinued in light of cultures without
complications. She did not have any further fevers.
# ESRD s/p renal transplant ___, Cr baseline of 1.5-2.0,
indicating allograft CKD. Creatinine was slightly elevated at
2.5 compared to baseline ~2.0. Her ___ is likely related to
hypertensive urgency and improved with BP control. Her discharge
creatinine was 2.4.
Chronic issues:
#Immunosuppression: Patient was maintained on her home dosages
of prednisone and MMF. Her cyclosporine regimen was titrated so
that her blood cyclosporine level was within goal. She was
discharged on 25mg qAM and 50mg qPM.
# Type 1 Diabetes: Maintained on insulin regimen which was
titrated while in-house in setting of hypoglycemia. ___
followed her as an inpatient. She was discharged on 15U Toujeo
in the AM and ___ (twice daily) as well as 6U Humalog with meals
and sliding scale, per ___ recommendations, with follow-up
within a week.
# Hypothyroidism: Maintained on home synthroid
# CAD s/p DES: Maintained on home aspirin, atorvastatin, and
ranolazine
# Peripheral arterial disease: Maintained on home cilostazol
# Gout: Maintained on home allopurinol
# Health Maintenance: Maintained on home calcium carbonate and
vitamin D
Transitional issues:
STOPPED MEDICATIONS:
- Amlodipine
- Carvedilol- patient reported fatigue with this medication and
would like to avoid beta blockers in the future
- Losartan (holding)
CHANGED MEDICATIONS:
- Hydralazine
- Cyclosporine
- Furosemide
- Insulin
[ ] Discharge weight 130.5 lbs. Weigh patient and assess for
adequacy of diuretic regimen at next appointment.
[ ] Patient has been instructed that she can take one additional
dosage of 20mg Lasix PO if needed for significant weight gain,
shortness of breath, or swelling in her legs. However, she
should call her doctor immediately.
[ ] Losartan was held due to symptomatic hypotension as well as
elevated creatinine. Consider restarting at discharge at next
PCP or cardiology appointment if additional antihypertensive is
needed.
[ ] Patient was discharged with home ___ and ___
[ ] Measure BP and assess for continued autonomic lability. Of
note, patient continues to be symptomatic (dizzy, lightheaded)
with sitting/standing.
# Communication:
- ___ (HCP/sister): h ___ c ___
# Code: Full, confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Calcitriol 0.25 mcg PO DAILY
7. Calcium Carbonate 500 mg PO BID
8. Ferrous Sulfate 325 mg PO DAILY
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Mycophenolate Mofetil 500 mg PO BID
11. PredniSONE 5 mg PO DAILY
12. Ranolazine ER 500 mg PO BID
13. Vitamin D ___ UNIT PO DAILY
14. Cilostazol 100 mg PO QAM
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. Promethazine 25 mg PO DAILY PRN nausea
17. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
18. Esomeprazole 40 mg Other BID
19. Carvedilol 3.125 mg PO BID
20. HydrALAZINE 25 mg PO QHS
21. Furosemide 40 mg PO BID
22. Losartan Potassium 25 mg PO DAILY
Discharge Medications:
1. Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Toujeo 15 Units Breakfast
Toujeo 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM
RX *cyclosporine modified 25 mg 1 capsule(s) by mouth Twice a
day Disp #*90 Capsule Refills:*0
3. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM
4. Furosemide 20 mg PO BID
RX *furosemide 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. HydrALAZINE 50 mg PO QHS
RX *hydralazine 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
6. Allopurinol ___ mg PO DAILY
7. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
8. Ascorbic Acid ___ mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 20 mg PO QPM
11. Calcitriol 0.25 mcg PO DAILY
12. Calcium Carbonate 500 mg PO BID
13. Cilostazol 100 mg PO QAM
14. Cilostazol 50 mg PO QPM
15. Esomeprazole 40 mg Other BID
16. Ferrous Sulfate 325 mg PO DAILY
17. Levothyroxine Sodium 125 mcg PO DAILY
18. Mycophenolate Mofetil 500 mg PO BID
19. Ondansetron 4 mg PO Q8H:PRN nausea
20. PredniSONE 5 mg PO DAILY
21. Promethazine 25 mg PO DAILY PRN nausea
22. Ranolazine ER 500 mg PO BID
23. Vitamin D ___ UNIT PO DAILY
24. HELD- Losartan Potassium 25 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until your doctor tells
you to
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Hypertensive emergency
- Autonomic lability
Secondary diagnosis:
- Type 1 Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. ___,
Why were you admitted?
- You were admitted for elevated blood pressures that were
causing you to have trouble breathing
What happened in the hospital?
- We adjusted your medications to better control your blood
pressures
- We also adjusted your water pill regimen (diuretics) so that
your weight was back to normal at discharge
What should you do when you leave the hospital?
- Please remember to take precautions when standing- stand
slowly and be careful about falling!
- Please wear compression stockings whenever sitting or standing
to increase your blood pressure
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs in 1 day. If needed (you notice trouble breathing,
increased swelling, or weight gain) you can take an extra dose
of your Lasix 20mg once, but please call your doctor too.
It was a pleasure taking care of you! We wish you the best.
- Your ___ Team
Followup Instructions:
___
|
10030753-DS-48 | 10,030,753 | 20,090,856 | DS | 48 | 2200-05-29 00:00:00 | 2200-05-30 06:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ___
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___.
Chief Complaint:
Traumatic Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old woman with multiple medical comorbidities,
including CAD s/p multiple ___ recently ___ on
ticragelor and aspirin, DM1 c/b ESRD s/p renal transplant on
immunosuppressing agents, who presented after unwitnessed fall
and was found to have left subarachnoid hemorrhage.
History provided by patient and family (niece who is a ___
___). Per patient, she ___ been getting progressively weaker
over the past few months, noting that she never recovered to her
baseline following her coronary angioplasty on ___, which
included PCI of Cx and OM with DES. Of note, she ___ a
complicated cardiac history which includes DES to LAD (___) and
Cx/OM ___ DES to LAD ___.
Patient reports not being able to mobilize around the house as
well as she used to due to her decreased sensation, which ___
been at baseline in the setting of dysautonomia. She reports
frequently having her knees buckle under her. She also ___ been
having episodes of orthostasis after taking furosemide for her
CHFrEF (EF41% ___. In the days prior to her fall, the patient
notes that her continuous glucose monitor was malfunctioning,
reading blood glucose levels of ___ with corresponding finger
sticks in the 200s. For this reason, she discontinued her
continuous glucose monitor. She says that she got up in the
middle of the night to walk to the bathroom and fell to the
floor
on her right side. She does not recall how she felt prior to her
fall. She does not remember feeling dizzy or hot and she did not
wake up sweating. She had no incontinence or tongue lacerations.
She did endorse right-sided pain and pulled herself up to
standing. The next day she still felt sick with nausea,
diarrhea,
right-sided rib pain and was worried about having a rib
fracture.
She called her niece (a nurse) who recommended that she call EMS
due to the snow storm. She was initially brought to ___
where she was found to have glucose 400s with NCHCT demonstrated
right SAH. She was transferred to ___ for further management.
She was initially admitted to the ICU for monitoring of her
subarachnoid hemorrhage and correction of nonketotic
hyperosmolar hyperglycemia. Repeat non con head CT was stable
and her neurological exam remained stable. Her hyperglycemia
resolved s/p transient control with IV insulin. She was deemed
clinically stable to transfer to the general floor after one day
in the ICU for medical management and support of her labile
blood glucose levels. Cardiac workup notable for troponin 0.18,
downtrending to 0.17, with normal CK and without signs of
ischemic changes on EKG.
On admission to ICU:
- insulin gtt transitioned off, blood glucose labile (40s, then
stable on humalog and lantus); ___ consulted.
- repeat non-con head CT unchanged with stable neuro exam
- received 1U Platelets, 1U PRBC for Hgb 6.7, PLT 260s while on
anti-platelet with appropriate correction
Past Medical History:
Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
Hypertension
Dyslipidemia
CAD with PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA
___ DES to LAD and Cx/OM ___. Then DES to LAD in ___ and ___ PCI of Cx and OM with ___
___ w/ CREST syndrome
Gastroparesis
GERD
Hiatal hernia
Gout
OSA
End-stage renal disease due diabetes s/p L-sided living kidney
transplant in ___
anemia
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
Admission exam:
T:98.2 BP:164/75 HR:97 RR:16 O2Sats:99%
Gen:
HEENT: Pupils:4mm bilaterally EOMs Full
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and ___.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light sluggishly,4mm to
3 mm bilaterally, hx of Laser eye surgery.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Unable to assess pronator drift r/t right rib pain.
Motor:
Patient with generalized weakness
TrapDeltoidBicepTricepGrip
Right 4 4 4 4 4
Left 4 4 4 4 4
IPQuadHamATEHLGast
Right4 4 4 4 2 4
Left4 4 4 4+ 2 4
*Exam limited r/t pain
Sensation: peripheral neuropathy to bil hands and bilateral
lower
extremity from knees down
DISCHARGE EXAM:
VITALS: 98.5F 128/65 83 18 94% FSBG 223
General: alert, oriented, no acute distress, flattened affect
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, holosystolic murmur
heard best in the left upper sternal border, no rubs and gallops
Abdomen: Diffusely distended and tympanitic, tender in RUQ near
ribs, no rebound tenderness or guarding, organomegaly not
assessed due to distention
GU: Foley in place for "straight cath"
Ext: warm, several scabbed lesions appreciated on feet, no
edema
Neuro: GCS 15, ___ strength in lower extremities bilaterally
Pertinent Results:
___ 09:01AM BLOOD WBC-4.7 RBC-2.77* Hgb-8.4* Hct-25.4*
MCV-92 MCH-30.3 MCHC-33.1 RDW-15.1 RDWSD-49.7* Plt ___
___ 08:13PM BLOOD Neuts-96.2* Lymphs-1.9* Monos-1.1*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-4.58 AbsLymp-0.09*
AbsMono-0.05* AbsEos-0.01* AbsBaso-0.01
___ 09:01AM BLOOD Plt ___
___ 09:01AM BLOOD Glucose-59* UreaN-56* Creat-2.3* Na-145
K-3.7 Cl-117* HCO3-13* AnGap-15
___ 01:50AM BLOOD Glucose-174* UreaN-57* Creat-2.3* Na-143
K-3.8 Cl-115* HCO3-12* AnGap-16
___ 09:01AM BLOOD CK(CPK)-145
___ 09:01AM BLOOD CK-MB-4 cTropnT-0.17*
___ 01:50AM BLOOD CK-MB-3 cTropnT-0.18*
___ 09:01AM BLOOD Calcium-7.3* Phos-2.7 Mg-2.5
___ 01:50AM BLOOD Calcium-6.9* Phos-2.5* Mg-1.8
___ 08:13PM BLOOD Calcium-7.2* Phos-2.5* Mg-0.7*
NCHCT:
FINDINGS:
Re-demonstrated is right sided subarachnoid hemorrhage, centered
in the
sylvian fissure. No extension or new hemorrhage is identified.
Basal ganglia calcifications are unchanged. No new large
territorial infarct or mass effect. There is prominence of the
ventricles and sulci suggestive of involutional changes.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable.
IMPRESSION:
-Essentially unchanged examination from 11 hours prior.
___ MRA:
IMPRESSION:
1. Study is moderately degraded by motion.
2. New left SCA focal occlusion versus high-grade stenosis
compared to ___
prior exam.
3. New nonocclusive irregularity of right M1 segment compared to
___ prior
exam, likely artifactual as described.
4. Otherwise grossly patent circle of ___ as described.
___ CT Torso
1. Nonspecific small volume ascites along the left
paracolic gutter and spleen. Splenic or colonic injury cannot be
excluded on this unenhanced exam. Recommend contrast-enhanced CT
or MRI if possible to further evaluate.
2. 2.1 x 1.4 cm hypodensity in the region of the pancreatic head
is probably a pancreatic lesion rather than duodenal
diverticulum. 1 cm exophytic hypodensity off anterior aspect of
the pancreatic body. No main pancreatic ductal dilation. Lesions
are incompletely characterized without intravenous contrast and
a
contrast enhanced CT or MRI if possible is recommended to
further
evaluate and exclude
malignancy.
3. Nonspecific mesenteric fat stranding and multiple scattered
prominent lymph nodes throughout the abdomen and pelvis, AP and
not enlarged by size criteria.
4. Mild soft tissue fat stranding along the right flank. No
evidence of rib fracture.
5. Anemia.
6. Prominent main pulmonary artery suggests sequelae of chronic
pulmonary hypertension.
7. Status post left lower quadrant renal transplant, stable in
appearance. Markedly atrophic native kidneys.
8. Markedly distended urinary bladder.
Discharge labs:
___ 06:35AM BLOOD WBC-7.1 RBC-2.84* Hgb-8.6* Hct-25.7*
MCV-91 MCH-30.3 MCHC-33.5 RDW-15.7* RDWSD-51.2* Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:35AM BLOOD Glucose-214* UreaN-70* Creat-2.6* Na-140
K-4.2 Cl-105 HCO3-19* AnGap-16
___ 06:35AM BLOOD Calcium-8.0* Phos-4.2 Mg-1.7
___ 06:35AM BLOOD Cyclspr-75*
Brief Hospital Course:
___ year old woman with multiple medical comorbidities, including
CAD s/p multiple ___ recently ___ on ticragelor and
aspirin, DM1 c/b ESRD s/p living donor renal transplant on
immunosuppressing agents, who presented after unwitnessed fall
and was found to have left subarachnoid hemorrhage. Etiology of
her SAH thought to be traumatic in the setting of her fall. Fall
was most likely related to hyperglycemia with component of
orthostatic hypotension/dysautonomia.
#Left ___
Patient presented after traumatic fall, and was admitted to the
Neuro ICU for monitoring of a subarachnoid hemorrhage and
correction of nonketotic hyperosmolar hyperglycemia. Fall was
likely secondary to labile blood sugars with components of
dysautonomia and orthostatic hypotension. EKG was reassuring for
arrhythmia as cause of syncope. No incontinence or tongue
lacerations or report of post-ictal state so seizure unlikely.
Repeat non con head CT showed stability of her bleed, and her
neurological exam remained stable. She was deemed clinically
stable to transfer to the general floor after one day in the ICU
for medical management. On the floor, a repeat MRA brain w/o
contrast that showed grossly patent circle of ___ without
concern for aneurysm. Patient complained of some left sided
lower extremity weakness, however trended Neuro exams were found
to be stable and not significant for new weakness. Neurosurgery
was consulted for management of ___ and trending of Neuro exam.
Blood pressures were closely monitored for a goal of systolic
<160.
Fall was believed likely traumatic. Low suspicion for aneurysmal
rupture. Etiology of fall thought to be related to labile blood
glucose levels with exacerbation from underlying dysautonomia.
Unlikely to be syncopal event from cardiac etiology based on
normal EKG, and normal cardiac enzymes. Fall could be related to
unwitnessed seizures, possibly triggered by labile glucose
levels, although no incontinence or tongue lacerations and no
documentation or report of postictal state. Patient was given
lidocaine patches and analgesics for pain ___ contusions from
fall. ___ consulted for weakness, recommendation for rehab.
#Supine Hypertension/Orthostatic Hypotension/Dysautonomia
Patient had very labile blood pressures while in-house ranging
from 110-202 systolic. Per Neuro-surgery, patient was not at
risk for SAH re-bleed, however, goal to keep systolic <160 to
prevent increased intracranial pressures. In consultation with
Renal Transplant, long-acting anti-hypertensives were favored
for better monitoring of pressures throughout the day. Home
Metoprolol succinate was transitioned to Metoprolol XL 100 mg,
and home Hydralazine 50 mg qHS was maintained throughout
admission, however pressures continued to be significant for
supine hypertensive urgency. Orthostatic vitals were done over
the course of 2 days, and patient was found to be orthostatic
intermittently. CCB were considered as additional agents,
however patient reports significant orthostatic hypotension with
these agents. Captopril was deemed to be too short-acting. A
trial of Losartan was considered, however, given patient's
intermittent orthostatic vitals, high risk of falls, and
pressures in target range of 130-150's systolic when
sitting/standing, an additional agent was not started but may be
considered in the outpatient setting. She was treated with 50mg
PO hydralazine as needed.
#Type 1 Diabetes Mellitus
Patient presented with hyperglycemia to the 600's. She was
brought to the Neuro ICU for her SAH, where an insulin drip
rapidly corrected her blood sugars to the 40-200's. On the
floor, Lantus was restarted in consultation with ___
___, and insulin regimen was dosed daily to good effect. She
maintained normal to low normal blood sugars with Lantus 10U qAM
+/- 5UqPM, ___ fixed dose Humalog at meals +/- ISS. Prior to
discharge she was receiving 8U AM, her Humalog dose was 2U with
meals.
#Incidental Pancreatic Mass
A non-con CT Torso at ___ was significant for 2.1 x
1.4 cm hypodensity in the region of the pancreatic head and a 1
cm exophytic hypodensity off anterior aspect of the pancreatic
body, cannot r/o malignancy. Masses were poorly characterized
without contrast, however patient's ESRD and transplanted kidney
limited imaging modalities to fully characterize the findings.
GI was consulted for an esophageal ultrasound, however, it was
recommended waiting ___ weeks for outpatient EUS to prevent SAH
re-bleed in the setting of increased intracranial pressure ___
anesthesia for the procedure.
#Anemia
Admission H/H of 7.2/21.8 which downtrended to 6.2/19.4. Patient
was given a unit of pRBCs to good effect. Outpatient notes
significant for chronic anemia. Iron/anemia labs significant for
low-normal iron with low iron/TIBC ratio (19%), normal B12, a
low-normal folate, and elevated ferritin. Patient started on
multivitamins and folate supplements. A stool guaiac was ordered
but could not be performed due to lack of specimen while in
house. Recommend hematology work-up as outpatient.
#Gastroparesis
#Nausea/Vomiting/Diarrhea
Patient reported weeks of nausea, vomiting, and diarrhea prior
to admission, though patient did not experience these symptoms
on the medical floor. An infectious work-up was negative. Prior
nausea/vomiting likely secondary to diabetic gastroparesis and
elevated blood glucose at home. N/V likely not related to SAH
given chronic time course.
#Neurogenic Bladder
Patient ___ neurogenic bladder secondary to Diabetes
complications, for which she straight caths at home. Patient was
bladder scanned regularly and straight-cathed appropriately.
#CAD/HFREF
Hx of CAD, no s/p multiple Percutaneous coronary interventions.
Resumed home ASA/Brillinta after repeat imaging showed stability
of SAH. Continued home furosemide 20mg PRN volume exam, however
patient remained euvolemic in-house.
# ESRD s/p LDRT ___
Continued home immunosuppression, cyclosporine, MMF, and
prednisone. Serum cyclosporine and creatinine were monitored
daily. Low bicarb- likely secondary to GI and renal losses- was
treated with sodium bicarbonate. Renal transplant following
throughout admission.
=============================
Transitional Issues
=============================
[] Pancreatic mass: CT Torso at ___ with incompletely
characterized pancreatic lesions not noted on prior CT torso. GI
to schedule esophageal US as outpatient and pt ___ appointment
with Dr. ___ GI on ___.
[]f/u ___ clinic with Dr. ___. Please call ___
for appointment.
[]f/u with Hematology for chronic anemia, appointment ___ been
scheduled
[]Patient will need to call number on back of CGM to order new
CGM from Dexicom
[]Consider DCing Cilostazol, as may be contra-indicated in ___
patients
[]Consider starting Losartan for elevated pressures if not
orthostatic as outpatient.
[]Pt will need to call ___ to schedule an appointment
with Dr. ___ in ___ clinic.
[] Foley was placed for urinary retention of 1000cc iso patient
preference for foley over straight catherization; please perform
void trial at rehab
[] continue to monitor cyclosporine level, Goal 75-125.
[] Pt intermittently required extra doses of hydralazine 50mg PO
to control blood pressures in the 180s-200s systolic
[] check weekly chemistry levels and assess if sodium
bicarbonate dose is adequate
[] consider IV iron if patient still iron deficient since PO
iron can be very constipating
I have seen and examined Ms. ___, reviewed the findings,
data, and plan of care documented by Dr. ___
___, MD dated ___ and agree, except for any
additional comments below.
Ms. ___ is clinically stable for discharge today, ___.
The total time spent today on discharge planning, counseling and
coordination of care today was greater than 30 minutes.
___, MD
___ of ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Calcitriol 0.25 mcg PO DAILY
7. Calcium Carbonate 500 mg PO BID
8. Cilostazol 50 mg PO QPM
9. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
10. Esomeprazole 40 mg Other BID
11. Ferrous Sulfate 325 mg PO DAILY
12. HydrALAZINE 50 mg PO QHS
13. Levothyroxine Sodium 125 mcg PO DAILY
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. Mycophenolate Mofetil 500 mg PO BID
16. PredniSONE 6 mg PO DAILY
17. Promethazine 25 mg PO DAILY PRN nausea
18. Ranolazine ER 500 mg PO BID
19. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
20. Vitamin D ___ UNIT PO DAILY
21. Cilostazol 100 mg PO QAM
22. Furosemide 20 mg PO DAILY
23. melatonin 10 mg oral QHS
24. Metoprolol Succinate XL 25 mg PO DAILY
25. naftifine 2 % topical BID To soles of feet and between toe
webs
26. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
27. Toujeo SoloStar (insulin glargine) 36 Units subcutaneous Q
Breakfast
28. Captopril 12.5 mg PO BID PRN SBP > 160
29. trimethobenzamide 300 mg oral BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. FoLIC Acid 1 mg PO DAILY
4. Glargine 8 Units Breakfast
Humalog 2 Units Breakfast
Humalog 2 Units Lunch
Humalog 2 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Multivitamins 1 TAB PO DAILY
6. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Severe
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*10 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Sodium Bicarbonate 1300 mg PO TID
9. Furosemide 20 mg PO DAILY
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Allopurinol ___ mg PO DAILY
12. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
13. Ascorbic Acid ___ mg PO DAILY
14. Aspirin 81 mg PO DAILY
15. Atorvastatin 20 mg PO QPM
16. Calcitriol 0.25 mcg PO DAILY
17. Calcium Carbonate 500 mg PO BID
18. Cilostazol 50 mg PO QPM
19. Cilostazol 100 mg PO QAM
20. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
21. Esomeprazole 40 mg Other BID
22. Ferrous Sulfate 325 mg PO DAILY
23. HydrALAZINE 50 mg PO QHS
24. Levothyroxine Sodium 125 mcg PO DAILY
25. Lidocaine 5% Patch 1 PTCH TD QAM
26. melatonin 10 mg oral QHS
27. Mycophenolate Mofetil 500 mg PO BID
28. naftifine 2 % topical BID To soles of feet and between toe
webs
29. PredniSONE 6 mg PO DAILY
30. Promethazine 25 mg PO DAILY PRN nausea
31. Ranolazine ER 500 mg PO BID
32. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
33. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
34. Trimethobenzamide 300 mg oral BID
35. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Subarachnoid Hemorrhage
Nonketotic hyperosmolar hyperglycemic state
Type 1 Diabetes Mellitus
Hypertension
Orthostatic Hypotension
Neurogenic Bladder
ESRD status post living donor transplant
Anemia
Secondary diagnoses:
Gastroparesis
Pancreatic mass
CAD s/p ___ Failure with reduced ejection fraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ were admitted to the hospital after ___ suffered from a head
injury when ___ fell. ___ were initially admitted to the
neurosurgery ICU because ___ suffered from a small amount of
blood in your brain (subarachnoid hemorrhage), which occurred
when ___ hit your head.
On admission to the hospital, we found that your blood sugar
levels were high. We think that changes in your blood sugar
levels may have contributed to your fall. We adjusted your
insulin and were able to keep your blood sugars in a normal
range.
We initially held your aspirin and brilanta but restarted it on
___. We imaged your brain arteries to obtain a more
comprehensive picture of the blood in your head. Your MRA showed
that the bleeding had stopped and that your brain arteries were
not clogged. We recommend that ___ try to keep your blood
pressure below 160 to protect your brain from having another
bleed.
While ___ were at ___ ___ had a picture taken of
your belly which showed a pancreatic mass. We cannot tell what
this mass is because the quality of the picture was limited.
Unfortunately, we cannot improve the quality of the picture
because it may cause damage to your kidney transplant.
Therefore, we have scheduled ___ for an outpatient esophageal
ultrasound- another type of picture that will not hurt your
kidneys- to try to get a better look at your pancreas. We were
not able to do this in the hospital because we were worried that
if ___ vomited while getting the anesthesia needed for the
ultrasound, it might make your brain bleed worse. It will be
safer to get this ultrasound done in a week or so when ___ have
healed more.
What ___ should do when ___ get home:
-Work on getting stronger at rehab.
-Continue to monitor your blood pressure and take your blood
pressure medications. Try to keep your blood pressure in the
120-150's to protect your brain from re-bleeding.
-Continue to monitor your blood glucose closely, and take your
insulin. ___ will need a new continuous glucose monitor. Please
call the phone number on the back of your current CGM to order a
new one.
-Follow up in the dysautonomia, hematology, GI, traumatic brain
injury clinics to make sure that ___ are healing well.
-Take great care when ___ get up from lying down or sitting to
prevent yourself from falling again.
Medication changes on this admission:
-We changed your metoprolol succinate to 100 mg Metoprolol XL.
XL is the longer acting form of the medication and will help
control your blood pressure.
-We changed your insulin to 8U Lantus in the morning and 2U
Humalog before meals
Thank ___ for allowing us to participate in your care.
Take Care,
Your SIRS General ___ ___ Team
Followup Instructions:
___
|
10030753-DS-49 | 10,030,753 | 22,045,511 | DS | 49 | 2200-06-19 00:00:00 | 2200-06-19 18:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___.
Chief Complaint:
Weight gain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with DM1, CAD and dysautonomia presents from rehab with
sudden onset of lower extremity swelling and pain.
Yesterday evening, the patient noticed the sudden onset ___
pain and swelling that is described as throbbing. She does not
note any exacerbating factors but does not alleviation with
movement. This morning, she noticed progression of the pain to
her lower back.
She ___ no fevers or chills. She notes no chest pain,
palpitations or dyspnea. She ___ no cough, wheezing or
orthopnea.
+n/v for over ___ year. She ___ had large, loose, watery bowel
movements ___ times per day for the last week. She stats her
blood glucose ___ been under good control.
Of note, the patient was hospitalized at ___ from ___
after suffering a SAH after a mechanical fall. The etiology of
the fall was attributed to labile blood sugars and blood
pressures due to dysautonomia. Her hospital course was
complicated by HHS and labile blood pressures. She was seen by
___ and ___ blood sugars were controlled with an insulin gtt
and eventually transitioned to Lantus 8u qAM and 2U Humalog at
meals with sliding scale. . Regarding her labile blood
pressures,
this was thought to be from dysautonomia due to her poorly
controlled DM1. She was started on metoprolol succinate and
hydralazine
In the ED, initial VS were:
T 97.5 HR 83 BP 147/63 R 16 SpO2 99% RA
Exam notable for:
2+ pitting edema to mid calf, swelling diffuse up legs with
scattered petechiae, no CVA tenderness, no midline tenderness
ECG: NSR Rate 83. L-axis Normal Intervals, QTc 450. No
significant change from prior
Labs showed:
145|106|53
-----------<84
4.2|24|2.1
Ca: 7.8 Mg: 1.0 P: 3.3
ALT: 17 AP: 86 Tbili: 0.3 Alb: 2.7
AST: 20 Lip: 9
Lactate:1.6
Trop-T: 0.14 CK: 130 MB: 3
___: ___
7.3
8.2>----<382
23.4
Imaging showed:
___ Liver Or Gallbladder Us
No evidence of biliary obstruction or portal vein thrombosis
___ Chest (Pa & Lat)
IMPRESSION:
No acute cardiopulmonary abnormality.
Consults:
Per Renal Transplant: cyclosporine(neoral) 25 mg bid. Goal
75-125. Cyclosporine AM trough level daily MMF 500 mg bid.
Prednisone 6 mg daily.
Patient received:
___ 17:25 IV Magnesium Sulfate
___ 17:51 IV Furosemide 20 mg
___ 18:30 IV Magnesium Sulfate 2 gm
___ 20:00 SC Insulin Not Given per Sliding Scale
___ 20:17 PO/NG Ondansetron 4 mg
On arrival to the floor, patient reports no dyspnea and
improvement of her leg pain.
Past Medical History:
Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
Hypertension
Dyslipidemia
CAD with PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA
___ DES to LAD and Cx/OM ___. Then DES to LAD in ___ and ___ PCI of Cx and OM with ___
___ w/ CREST syndrome
Gastroparesis
GERD
Hiatal hernia
Gout
OSA
End-stage renal disease due diabetes s/p L-sided living kidney
transplant in ___
anemia
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION EXAM
VS: T 97.9 BP 137/59 HR 87 R 16 SpO2 97 Ra
GEN: NAD, speaking comfortably lying flat in bed
HEENT: Clear OP, moist mucous membranes
___: Regular, II/VI SEM, JVP at mid-neck at 45 degrees
+Hepatojugular reflex
RESP: RRR, no wheezing, crackles or rhonchi. No increased WOB
ABD: NTND, no HSM
EXT: Warm, Pitting edema to mid thigh bilaterally.
NEURO: CN IV-XII intact. Pupils dilated and minimally-reactive
to
light (baseline).
SKIN: Fine, scattered erythematous erosions L medial thigh, R
lateral thigh with overlying crusting. No excoriations. No
lesions in web spaces. Small 1cm linear abrasion over L small
toe
and 1cm, circular, erythematous macule with overlying scab over
L
great toe.
DISCHARGE EXAM
Pertinent Results:
ADMISSION LABS
=================
___ 04:00PM BLOOD WBC-8.2 RBC-2.52* Hgb-7.3* Hct-23.4*
MCV-93 MCH-29.0 MCHC-31.2* RDW-21.2* RDWSD-70.5* Plt ___
___ 04:00PM BLOOD Glucose-84 UreaN-53* Creat-2.1* Na-145
K-4.2 Cl-106 HCO3-24 AnGap-15
___ 04:00PM BLOOD CK-MB-3 cTropnT-0.15* ___
___ 04:00PM BLOOD Albumin-2.7* Calcium-7.8* Phos-3.3
Mg-1.0*
___ 04:00PM BLOOD Cortsol-3.1
___ 04:22PM BLOOD Lactate-1.6
___ 09:16AM URINE Blood-NEG Nitrite-NEG Protein-100*
Glucose-150* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 09:16AM URINE Hours-RANDOM Creat-39 Na-85 Mg-<1.4
Albumin-242.0 Alb/Cre-6205.1*
___ 09:16AM URINE Osmolal-395
INTERVAL LABS
=================
DISCHARGE LABS
=================
MICROBIOLOGY
=================
CMV IgG ANTIBODY (Final ___:
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
<4 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results.
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
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 O157:H7 found.
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING
=================
RUQUS ___:
No evidence of biliary obstruction or portal vein thrombosis.
CXR ___
No acute cardiopulmonary abnormality.
Rib Series ___
1. Right lower lobe atelectasis versus early infiltrate,
slightly worse.
Follow up to resolution is recommended to exclude pneumonia.
2. No displaced rib fracture.
Renal US ___
1. Elevated resistive indices similar to the prior study with
differential
which may include acute tubular necrosis and rejection.
2. Patent vasculature, no hydronephrosis.
TTE ___
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. There is moderate symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] There is
moderate pulmonary artery systolic hypertension. There is a
small pericardial effusion. The effusion appears
circumferential.
IMPRESSION: Moderate left ventricular hypertrophy with low
normal global systolic function. Small pericardial effusion
without echo evidence of tamponade. Moderate pulmonary
hypertension.
Compared with the prior study (images reviewed) of ___
global left ventricular systolic function is improved. Moderate
pulmonary hypertension is seen. As before amyloid cardiomyopathy
should be considered).
CXR ___
Cardiomegaly is severe, minimally improved since previous
examination. Right
pleural effusion ___ increased. There is no overt pulmonary
edema, mild
vascular congestion is better than on ___. No
pneumothorax.
Brief Hospital Course:
Ms. ___ is a ___ female with history of HFrEF (EF
41%) ESRD s/p LURT ___ longstanding DMI on CellCept,
Neoral, and prednisone, CAD s/p multiple ___ recently on
___ on aspirin and ticagrelor, CREST, remote PE,
dysautonomia with orthostatic hypotension, recent fall with
right sided SAH, recently seen new pancreatic head mass on CT
A/P, who presented with a 1 week history of lower extremity
swelling and weight gain admitted for acute on chronic HFrEF
exacerbation requiring IV diureses subsequently transitioned to
PO lasix 20 with a contingency for an extram 20mg for lower
extremity edema, with plan for GI follow-up for ongoing work-up
of incidental pancreatic mass. Of note patient requested to be
discharged despite remaining volume overloaded with ___ on CKD
with plan for outpatient ongoing diuresis and renal monitoring.
On the day of discharge the patient was very insistent on being
discharged so that she could be able to attend to very special
family ___. We discussed this with the renal transplant team
as well. Together we both felt that was ongoing medical
management and optimization that should be done but in an
attempt to meet her wishes and give her some quality life time
we were willing to make a compromise on a plan to discharge her
with full disclosure to her that she was not quite as optimized
as possible. We also created a plan to treat her UTI in the
outpatient setting for a total 14 days of treatment end of
treatment would be ___. She will also need to eat a very low
sodium diet of 2gram max per day and have her renal function
assessed and have her results faxed to the BI renal team. We
will also gave her a rx for Lasix 20mg daily with extra 20mg for
leg swelling.
ACUTE ISSUES
===================
#Acute on chronic HFrEF - Patient ___ a history of HFrEF EF 41%
who initially presented with a one week history of worsening
lower extremity swelling and weight gain found to be volume
overloaded on exam with BNP 22,235 on admission. The trigger for
her acute on chronic HFrEF exacerbation was unclear. Her EKG
showed no ischemic changes, troponins were at baseline with flat
CK-MB. She was initially diuresed with intermittent IV lasix 80
boluses, however subsequently had worsening renal function.
Diureses was subsequently held however renal functioned
continued to worsen, thought to be attributed to cardiorenal
syndrome and concomitant UTI per below. CXR showed worsening
right sided pleural effusion. In consultation with transplant
nephrology, she was subsequently diuresed with 80mg IV Lasix X2
which did not show a large improvement in the Cr. and she was
transitioned to PO 20mg lasix daily with contingency for extra
dose of 20mg for ___ edema. Discharge weight was 60.4kg and
discharge creatinine was 3.4. Plan for ongoing outpatient
diuresis with PO regimen and continued renal monitoring.
___ on CKD
#ESRD s/p renal transplant:
With history of ESRD in the setting of long standing DMI, s/p
LURT ___ maintained on cellcept, cyclosporine and prednisone.
Baseline Cr over the last 6 months ranged between 2.0-2.5. Renal
US showed elevated resistive indices, stable from prior with no
evidence of hydronephrosis. Per above, she had worsening renal
function despite periods of aggressive diuresis as well as
rising Cr when holding diuretics. Upon discharge, it seemed as
though her ___ was most likely due to over diuresis as she was
nearly back to her baseline weight w/very little ___ edema. This
being the case in her fluid status was incongruent with her
worsening creatinine to 3.4 on day of discharge. Ultimately we
felt that a large component of her increasing creatinine was not
solely based on a pre-renal picture or CRS but likely a
component of chronic renal graft rejection. There was no
evidence of ATN on urinalysis. She was continued on MMF 500mg
BID, neoral 25mg BID with goal cyclosporin level 40-100, and
continued on prednisone 6mg daily.
#Incidental Pancreatic Mass: Recent Non-con CT Torso at ___
___ was significant for a 2.1 x 1.4 cm hypodense mass in the
region of the pancreatic head and a 1 cm exophytic hypodensity
off anterior aspect of the pancreatic body, suspicious for
malignancy. She was initially planned for an outpatient EUS on
___. GI was consulted for possible inpatient EUS, however
after multi-disciplinary meeting involving radiology, per GI
mass appeared more consistent with IPMN. Plan for interval MRCP
in 4 weeks from now (6 weeks from original CT to evaluate for
interval change. Of note, any additional advanced imaging will
be limited by current renal function given inability to use
contrast, and if biopsy is pursued, will have to consider
holding ticagrelor given she is on DAPT for recent ___
in ___. Follow-up will be arranged with Dr. ___ in
___ weeks.
#UTI - Urine culture ___ growing E. Coli. She was initially
started on ceftriaxone and subsequently transitioned to p.o.
cefpodoxime, with plan for 14 day total course given her history
of renal transplant end of treatment for ___.
#Anemia - History of chronic anemia with baseline Hb 7.0-8.0.
Initial Hb on admission was 6.8 and she recieved 1U PRBC with
post-transfusion Hb 9.5. There was no evidence of hemolysis.
Anemia was thought to be inflammatory also in the setting of her
CKD. She was started on IV ferric gluconate x 4 doses given her
transferrin saturation of 19%. Plan to follow-up with GI per
above.
#Subarachnoid hemorrhage
#Intracranial stenosis - Patient had a recent admission for
mechanical fall and subsequent SAH. No neurosurgical
intervention was performed and goal SBP remains <160. She ___
had very difficult to control blood pressure given her history
of chronic orthostatic hypotension and dysautonomia. She was
continued on aspirin 81 mg daily, atorvastatin 20 mg daily, home
hydralazine was uptitrated from 50mg PO QHS to 75mg TID given
frequent SBP ranging 160-200, and continued on home metoprolol
succinate 125 mg daily.
#Orthostatic Hypotension
#Dysautonomia - Patient ___ a well-documented history of severe
orthostatic hypotension and dysautonomia. On previous discharge
in consultation with renal transplant, she was maintained on a
regimen of hydralazine 50 mg daily, and metoprolol succinate 125
mg daily. Her blood pressure was better controlled on longer
acting agents, and she previously ___ not tolerated CCB,
captopril due to her severe orthostatic hypotension. Her
antihypertensives were uptitrated to hydralazine 75 mg TID and
continued metoprolol succinate 125 mg daily per above. We were
unable to start an ___ given her ___ on CKD per above.
#Skin findings - Patient was found to have multiple skin
findings including an erythematous erosions on L medial thigh
and R lateral thigh with overlying crusting. RUQUS was initially
obtained on admission in the setting of her petechial appearing
rash, ___ swelling to evaluate for PVT which was negative. She
also had a left MTP
erythematous macule which was non-cellulitic appearing and
unlikely to be an abscess. She initially came in on levofloxacin
for this possibly infected diabetic ulcer per her rehab,
antibiotics were not continued given low suspicion for
underlying infection.
# Diarrhea - Patient initially endorsed a one week history of
diarrhea approximately ___ episodes daily, last episode 2 days
prior to admission. She had received a 2 day history of levaquin
for possible diabetic foot ulcer per above. Stool cultures and
CMV were negative.
CHRONIC ISSUES
==========================
#CAD - History of CAD s/p multiple ___ recently ___.
Prior data reveal EF 41% and s/p Cath on ___ showed normal
LM, 40% proximal LAD, 80% distal lesion beyond previous stent.
She also had a 80% mid LCx lesion with planned staged cath. She
underwent successful PTCA and DES x1 to distal LAD lesion in
___. She was continued on aspirin 81 mg daily, ticagrelor
90mg BID, ranolazine 500mg ER BID, atorvastatin 20mg daily. Home
cilostazol was resumed on discharge.
#DM1: Long-standing history of diabetes mellitus type 1,
complicated by dysautonomia, neurogenic bladder and
gastroparesis. She was maintained on home glargine 24 units QAM.
Home Humalog 2 units TID with meals was discontinued given
hypoglycemia during hospitalization. Was also placed on insulin
sliding scale.
#Neurogenic Bladder - Patient ___ neurogenic bladder secondary
to DM Type 1, and intermittently straight caths at home. She had
a Foley placed for a brief period of time during hospitalization
given subjective urinary hesitancy and inability to obtain
accurate I/O's, which was later pulled.
#Hypothyroidism: She was continued on home levothyroxine 125mcg
daily.
TRANSITIONAL ISSUES
===========================
[ ] New/Changed Medications
- Hydralazine increased from 50 QHS to 75 mg TID given
hypertension
- Started on cefpodoxime for UTI to continue for 14 day total
course (end date ___
- Sodium bicarbonate 1300mg PO TID discontinued metabolic
alkalosis
[ ] Repeat BMP, Cr in 3 days to monitor creatinine trend and fax
results to outpatient renal team at ___
[ ] discharged to complete a 14 day course of PO abx last day of
treatment for UTI in a renal transplant patient will be ___
of cefpodoxime
[ ] Consider ongoing up titration of PO diuretic as indicated
given remains volume overloaded
[ ] MRCP in 4 weeks to further evaluate pancreatic mass,
possible IPMN, and follow-up with Dr. ___ in ___ weeks
[ ] If pursuing pancreatic biopsy, will need to consider holding
ticagrelor in consultation with cardiology given recent DES in
___
[ ] Goal SBP <160 given recent SAH, consider outpatient up
titration of antihypertensives as indicated
[ ] Consider re-starting sodium bicarbonate at transplant
nephrology follow-up if indicated
[ ] Discharge diuretic 20mg Lasix po daily plus additional PRN
dose 20mg for lower extremity edema
[ ] Discharge weight 60.4 kg
[ ] Discharge creatinine 3.4
#CONTACT:
Name of health care proxy: ___: SISTER
Phone number: ___
Cell phone: ___
#CODE: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Cilostazol 50 mg PO QPM
4. Cilostazol 100 mg PO QAM
5. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
6. HydrALAZINE 50 mg PO QHS
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Metoprolol Succinate XL 125 mg PO DAILY
10. Mycophenolate Mofetil 500 mg PO BID
11. PredniSONE 6 mg PO DAILY
12. Promethazine 25 mg PO DAILY PRN nausea
13. Ranolazine ER 500 mg PO BID
14. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
15. Acetaminophen 1000 mg PO Q6H
16. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
17. FoLIC Acid 1 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Severe
20. Polyethylene Glycol 17 g PO DAILY:PRN constipation
21. Sodium Bicarbonate 1300 mg PO TID
22. Trimethobenzamide 300 mg oral BID
23. Vitamin D ___ UNIT PO DAILY
24. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
25. Atorvastatin 20 mg PO QPM
26. Ferrous Sulfate 325 mg PO DAILY
27. Furosemide 20 mg PO DAILY
28. melatonin 10 mg oral QHS
29. naftifine 2 % topical BID To soles of feet and between toe
webs
30. Calcium Carbonate 500 mg PO BID
31. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
32. Allopurinol ___ mg PO DAILY
33. Glargine 24 Units Breakfast
aspart 2 Units Breakfast
aspart 2 Units Lunch
aspart 2 Units Dinner
Insulin SC Sliding Scale using aspart Insulin
34. Omeprazole 40 mg PO BID
35. Ondansetron 4 mg PO Q8H:PRN nausea
36. Toujeo SoloStar U-300 Insulin (insulin glargine) 300 unit/mL
(1.5 mL) subcutaneous QAM
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO Q24H urinary tract infection
Duration: 10 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth once daily Disp #*10
Tablet Refills:*0
2. Furosemide 20 mg PO DAILY
take an additional pill of 20mg in addition to your daily dose
if your legs become swollen
RX *furosemide 20 mg 1 tablet(s) by mouth one tablet daily Disp
#*60 Tablet Refills:*1
3. HydrALAZINE 75 mg PO TID
RX *hydralazine 25 mg 3 tablet(s) by mouth three times a day
Disp #*126 Tablet Refills:*0
4. Glargine 24 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Acetaminophen 1000 mg PO Q6H
6. Allopurinol ___ mg PO DAILY
7. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 20 mg PO QPM
10. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
11. Calcitriol 0.25 mcg PO DAILY
12. Calcium Carbonate 500 mg PO BID
13. Cilostazol 50 mg PO QPM
14. Cilostazol 100 mg PO QAM
15. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
16. Ferrous Sulfate 325 mg PO DAILY
17. FoLIC Acid 1 mg PO DAILY
18. Levothyroxine Sodium 125 mcg PO DAILY
19. Lidocaine 5% Patch 1 PTCH TD QAM
20. melatonin 10 mg oral QHS
21. Metoprolol Succinate XL 125 mg PO DAILY
22. Multivitamins 1 TAB PO DAILY
23. Mycophenolate Mofetil 500 mg PO BID
24. naftifine 2 % topical BID To soles of feet and between toe
webs
25. Omeprazole 40 mg PO BID
26. Ondansetron 4 mg PO Q8H:PRN nausea
27. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Severe
28. Polyethylene Glycol 17 g PO DAILY:PRN constipation
29. PredniSONE 6 mg PO DAILY
30. Promethazine 25 mg PO DAILY PRN nausea
31. Ranolazine ER 500 mg PO BID
32. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
33. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
34. Toujeo SoloStar U-300 Insulin (insulin glargine) 300
unit/mL (1.5 mL) subcutaneous QAM
35. Trimethobenzamide 300 mg oral BID
36. Vitamin D ___ UNIT PO DAILY
37. HELD- Sodium Bicarbonate 1300 mg PO TID This medication was
held. Do not restart Sodium Bicarbonate until you follow-up with
your transplant nephrologist
38.Outpatient Lab Work
Please check a BMP (Na, K, Cl, HC03, BUN and Creatinine) for
this patient on ___ and fax these results to ___.
Thank you.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- Acute on chronic HFrEF
- ___ on CKD
- UTI
- Incidental Pancreatic Mass
SECONDARY DIAGNOSIS
- ESRD s/p LURT
- SAH
- DM1
- Orthostatic hypotension
- Dysautonomia
- Anemia
- CAD
- Neurogenic Bladder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Was a pleasure taking care of your ___
___.
Why did you come to the hospital?
-You initially came to the hospital because of worsening lower
extremity swelling and weight gain
What happened during your hospitalization?
-You were given medications through your IV in order to help
remove extra fluid because of your heart failure exacerbation
-You were given antibiotics for a UTI
-You were evaluated by the gastroenterology team to further
workup your possible pancreatic mass, you will obtain a MRI in 4
weeks and follow-up with Dr. ___ in ___ weeks
What should you do when you leave the hospital?
-Continue to take all your medications as prescribed
- It is very important that you stick to a very strict low
sodium diet.
- This is of utmost importance, you should try to eat less
than 2 grams of sodium per day. 1 piece of toast ___ about 500mg
of sodium or a quarter of the total daily salt that you should
eat in your diet.
- please avoid canned foods, processed foods or meats and
restaurant foods.
- Get blood work checked in 3 days and have your labs sent to
you kidney doctors at ___ at ___
-Weigh yourself daily, if your weight goes up by more than 2
pounds in 1 day or 5 pounds in 1 week, call your PCP
-___ with your primary care physician ___ 1 week
-Keep all your other scheduled healthcare appointments listed
below
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10030753-DS-51 | 10,030,753 | 21,062,398 | DS | 51 | 2200-08-21 00:00:00 | 2200-08-21 19:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ Female with ESRD (s/p LURT ___ on
immunosuppression), anemia (weekly transusions and epo
injections), CAD s/p ___ 4 (most recently ___, HFrEF (55%
EF ___, HTN, T1DM (A1c 9.9% ___, and h/o multiple MDR
UTIs (Klebsiella, E.coli, Enterococcus), sclerodermda/CREST and
chart history antiphospholipid antibody syndrome (but on
evaluation by hematology does not appear to meet diagnostic
criteria) with h/o remote PE in ___, presenting with 3
witnessed
pre-syncopal episodes.
Reports was sitting on the couch - feeling nauseated, and tired,
and lightheaded. Reports most of the afternoon wasn't feeling
well. Report tried to get up to go to the bathroom but couldn't
make it bc was getting really disoriented and dizzy and felt
like
she was going to pass out. Reports around 5 pm daughter was
trying to help her. Tried on rollator and kept slumping over,
feeling transiently out of it, not responding. She denies losing
consciousness during these episodes. Reports 3 episodes of
slumping over. Denies chest pain, palpitations. Reports feels
similar to when had orthostatic episodes in the past. Reports
was
feeling SOB when was trying to get into bed. She did not feel
chest tightness or pain. She was not diaphoretic.
Reports when woke up this morning took BP and was 130/65 which
is
low for her. Reports skipped metoprolol this morning from the
low
bp and all day every time stood up was so lightheaded. Denies
cough. Reports has issue with vomiting but this has been at her
baseline; she has not seen blood in her vomitus. Denies BRBPR or
melena. Reports saw cardiology on ___ and was put back on 20
mg lasix daily. Denies SOB now, chest pain.
Of note, the pt reports she is also being worked up for a 4 cm
pancreatic mass with plans for biopsy in ___ once she can stop
taking DAPT (6 mos after her DES). She also reports that she has
been increasingly pruritic and that family members have noted
that she appears to have a more yellow complexion. She has also
had a 20 pound unintentional weight loss.
Past Medical History:
-CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA
___ DES to LAD and Cx/OM ___ DES to LAD ___
PCI of Cx and OM with ___
-___ renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
-Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
-Hypertension
-Dyslipidemia
-Scleroderma w/ CREST syndrome
-Gastroparesis/GERD/Hiatal hernia
-Gout diagnosed ___ years ago
-OSA
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION EXAM:
==============
GENERAL: Yellow complexion, NAD
HEENT: AT/NC, EOMI, PERRL, scleral icterus present, pink
conjunctiva, MMM, no sublingual icterus noted
NECK: supple, no LAD, no JVD
HEART: RRR, normal S1 and S2, II/VI holosystolic murmur, no
gallops or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: BS+, distended abdomen without fluid wave, mildly TTP
in
supraumbilical and suprapubic regions, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: Jaundiced, warm and well perfused, no excoriations or
lesions, no rashes
DISCHARGE EXAM;
=============
Temp: 98.9 (Tm 98.9), BP: 160/75 (96-175/60-107), HR: 94
(80-96),
RR: 20 (___), O2 sat: 97% (96-100)
GENERAL: Lying comfortably in bed
HEENT: AT/NC, EOMI, PERRL, scleral icterus present, pink
conjunctiva, MMM, no sublingual icterus noted
NECK: supple, no LAD, no JVD
HEART: RRR, normal S1 and S2, II/VI holosystolic murmur, no
gallops or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: BS+, distended abdomen without fluid wave, mildly TTP
in
supraumbilical and suprapubic regions, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
Pertinent Results:
ADMISSION LABS:
-------------------
___ 07:05PM BLOOD WBC-8.1 RBC-1.91* Hgb-5.8* Hct-17.9*
MCV-94 MCH-30.4 MCHC-32.4 RDW-18.6* RDWSD-61.7* Plt ___
___ 07:05PM BLOOD Glucose-288* UreaN-68* Creat-2.3* Na-138
K-3.6 Cl-109* HCO3-16* AnGap-13
___ 07:05PM BLOOD CK-MB-4 ___
___ 07:05PM BLOOD Calcium-7.7* Phos-3.6 Mg-1.5*
RADIOLOGY:
Transplant US ___:
The left iliac fossa transplant renal morphology is normal.
Specifically, the
cortex is of normal thickness and echogenicity, pyramids are
normal, there is
no urothelial thickening, and renal sinus fat is normal. There
is no
hydronephrosis and no perinephric fluid collection.
No diastolic flow is detected within the intrarenal arteries
with a resistive
index of 1.0. The main renal artery shows an abnormal waveform,
with prompt
systolic upstroke but without continuous diastolic flow. Peak
systolic
velocity of 51.8 centimeters/second is seen in the main renal
artery.
Vascularity is symmetric throughout transplant. The transplant
renal vein is
patent and shows normal waveform.
IMPRESSION:
1. No diastolic flow within the intrarenal arteries with
resistive index of 1,
new since ___ with lack of continuous diastolic flow
within the main
renal artery.
2. Patent main renal vein.
3. No hydronephrosis or perinephric fluid collection.
MICRO:
Urine culture: No growth
DISCHARGE LABS:
___ 05:00AM BLOOD WBC-6.4 RBC-2.86* Hgb-8.8* Hct-26.2*
MCV-92 MCH-30.8 MCHC-33.6 RDW-18.1* RDWSD-59.3* Plt ___
___ 05:00AM BLOOD ___ PTT-28.6 ___
___ 05:00AM BLOOD Glucose-433* UreaN-71* Creat-2.5* Na-138
K-4.8 Cl-109* HCO3-18* AnGap-11
___ 05:00AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.7
___ 09:35AM BLOOD Cyclspr-68*
Brief Hospital Course:
___ woman with transfusion-dependent anemia on epo, CAD
s/p DESx4 (most recent ___, HFrEF (EF now 55%), ESRD ___
T1DM s/p LURT PMH HFrEF (EF 41%), ESRD ___ T1DM s/p LURT ___
(on cellcept, prednisone, and cyclosporine), CREST/systemic
sclerosis and dysautonomia with orthostatic hypotension who
presented with presyncope, found to be profoundly anemic. She
was transfused and volume resuscitated with normalization of her
orthostatic vital signs and was discharged home with close
heme/onc follow up.
ACUTE ISSUES:
===============
#Syncope: The patient's symptoms and presentation all seemed
most consistent with orthostasis, particularly given orthostatic
VS on check ___. However, given her extensive cardiac history
including a recent MI, she was a monitored on telemetry for
evidence of arrhythmia. Her telemetry remained without any
events. She was volume resuscitated gently given her history of
heart failure. Her orthostatic vital signs were trended and
ultimately normalized after IVF and PRBCs.
# Type II NSTEMI: The patient had a troponin of 0.2 on admission
which downtrended to 0.___K-MB. She did not
complain of any chest pain or anginal symptoms on admission. In
the setting of her acute anemia (discussed below) she did have
some EKG changes including ST segment depressions in her lateral
precordial leads. However, with the resolution of her underlying
anemia her EKG changes resolved. Her home regimen consisting of
ASA 81mg daily, Ticagrelor 90mg BID, Ranolazine 500mg ER BID,
cilostazole 100mg qAM, 50mg qPM was continued on discharge. No
statin due to interaction with immunosuppression.
#Anemia: The patient's baseline Hgb is ___. Iron studies
conducted on previous admission suggest anemia of chronic
inflammation; reduced renal function and low epo also likely
cause. She is being followed closely as an outpatient by
heme/onc, and is currently getting weekly transfusions of one
unit of packed red blood cells and epo. She had no signs of
active bleeding during her hospitalization, and her Hgb remained
stable following the transfusion of two units of pRBCs.
#Pancreatic mass
The patient has a known pancreatic mass detected on abd CT
___ s/p fall. Pt awaiting biopsy in ___ mos s/p ___
___ when she can stop DAPT. Very concerning for malignancy
given pt reporting full body pruritus, unintentional weight
loss, malaise, early satiety, and gnawing abdominal pain. LFTs
not concerning right now for any obstructive process.
#HFrEF: LVEF 55% on admission in ___, recovered from 40%. At
that time discharged on Lasix 40mg PO BID, Metoprolol succinate
50mg PO daily, Hydralazine 50mg PO BID. Her weight on discharge
was 56.97, which is her current admit weight. On this admission,
she displayed no signs/sx of volume overload. Her lasix was held
on admission given her recent syncopal episodes. Ultimately, her
discharge heart failure regimen was as follows:
#Pyuria
The patient has a history of MDR UTIs. Her urine culture was
negative on admission and she was not treated with antibiotics.
CHRONIC ISSUES:
===============
#ESRD s/p Transplant: Ongoing CKD likely related to poorly
controlled T1DM. Discharge creatinine was 2.5.
# DM1:
Poorly controlled, most recent A1c 9.9% at ___ on ___,
with multiple sequelae. Patient was hyperglycemic during her
hospital stay while off her home ___, however on the day
prior to discharge was transitioned to 25u of glargine with
better control of her sugars. At discharge her home insulin
regimen was continued.
# Hypothyroidism: Continued on home levothyroxine
# Gout: Continued on home allopurinol
TRANSITIONAL ISSUES:
==================
[ ] follow up CBC and transfusion per heme/onc, next scheduled
for ___
[ ] Lasix was held in setting of hypovolemia on presentation
[ ] renal transplant showed no diastolic flow within the
intrarenal arteries with resistive index of 1, new since ___ with lack of continuous diastolic flow within the main
renal artery. This was discussed with radiology who reported the
artery remained patent.
[ ] consider uptitration of home ___ given hyperglycemia
while in the hospital
# CODE: Presumed FULL
# CONTACT: ___ (SISTER) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. melatonin 10 mg oral QHS
2. naftifine 2 % topical BID To soles of feet and between toe
webs
3. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Allopurinol ___ mg PO DAILY
6. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
7. Aspirin 81 mg PO DAILY
8. Calcitriol 0.25 mcg PO DAILY
9. Calcium Carbonate 500 mg PO BID
10. Cilostazol 25 mg PO QPM
11. Cilostazol 50 mg PO QAM
12. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
13. Ferrous Sulfate 325 mg PO DAILY
14. FoLIC Acid 1 mg PO DAILY
15. Furosemide 20 mg PO DAILY
16. Levothyroxine Sodium 125 mcg PO DAILY
17. Lidocaine 5% Patch 1 PTCH TD QAM
18. Multivitamins 1 TAB PO DAILY
19. Mycophenolate Mofetil 500 mg PO BID
20. Omeprazole 40 mg PO BID
21. PredniSONE 5 mg PO DAILY
22. Promethazine 25 mg PO TID:PRN nausea
23. Ranolazine ER 500 mg PO BID
24. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
25. ___ SoloStar U-300 Insulin (insulin glargine) 24 units
subcutaneous QAM
26. trimethobenzamide 300 mg oral TID:PRN nausea
27. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Aspirin 81 mg PO DAILY
4. Calcitriol 0.25 mcg PO DAILY
5. Calcium Carbonate 500 mg PO BID
6. Cilostazol 25 mg PO QPM
7. Cilostazol 50 mg PO QAM
8. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
9. Ferrous Sulfate 325 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Levothyroxine Sodium 125 mcg PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. melatonin 10 mg oral QHS
14. Metoprolol Succinate XL 50 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Mycophenolate Mofetil 500 mg PO BID
17. naftifine 2 % topical BID To soles of feet and between toe
webs
18. Omeprazole 40 mg PO BID
19. PredniSONE 5 mg PO DAILY
20. Promethazine 25 mg PO TID:PRN nausea
21. Ranolazine ER 500 mg PO BID
22. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
23. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
24. Toujeo SoloStar U-300 Insulin (insulin glargine) 24 units
subcutaneous QAM
25. trimethobenzamide 300 mg oral TID:PRN nausea
26. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Anemia of chronic inflammation
Secondary diagnosis:
- End stage renal disease s/p renal transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because:
- You were having episodes of passing out
- Your blood counts were very low
While you were admitted:
- You had blood transfusions which improved your blood counts
- Your blood pressure was checked with sitting and standing to
make sure it was not dropping
- Your home blood pressure medications were adjusted
- You worked with our physical therapists
- When your blood counts were stable, you were discharged home
with close follow up with your cardiologist and blood doctor
___ you leave:
- Please take all of your medications as prescribed
- Please attend all of your follow up appointments as scheduled
It was a pleasure to care for you during you hospitalization!
Your ___ care team
Followup Instructions:
___
|
10030753-DS-54 | 10,030,753 | 27,165,162 | DS | 54 | 2200-11-25 00:00:00 | 2200-11-26 13:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Cath ___
History of Present Illness:
INITIAL ED PRESENTATION:
=======================
Ms. ___ is a ___ y/o female with a history of ESRD (s/p LURT
___ on immunosuppression), anemia (weekly transusions and epo
injections), CAD s/p ___ 4 (most recently ___, HFpEF (EF
55% ___, IPMN (___), HTN, T1DM, and h/o multiple MDR UTIs
(Klebsiella, E.coli, Enterococcus), scleroderma/CREST who
presents with diarrhea and abdominal pain.
The patient was recently treated with Bactrim for a UTI about a
week ago. Around that same time, the patient began having
diarrhea and abdominal pain. The pain is described as ___,
located over the lower bilateral quadrants. It is intermittent
without known triggers. Nothing makes it worse, including food
or
movements. She has also had profuse diarrhea, described as large
volume episodes occurring almost every hour. It has been
associated with fecal urgency. No hematochezia or melena. She
reports decreased enteral intake over this time. No new nausea,
vomiting, fever, chills, dysuria or hematuria. No history of
similar symptoms or c.diff infections. No recent travel, sick
contacts, new foods or medications.
Patient was seen at ___ on ___. She was given
1L
IVF with plan to follow up at ___ for repeat labs in a day.
She continued to have symptoms. On ___, she developed new
right-sided chest pain described as ___, dull/ache while
sleeping. Her pain was unchanged with palpation, deep breaths,
or
movement and it felt similar to prior cardiac pain. She took SL
nitro with resolution. She also began feeling lightheaded,
particularly with bowel movements. Given her ongoing symptoms
and
new chest pain, she presented to the ___ ED.
In the ED, initial VS were: T 97.6, HR 86, BP 126/73, RR 12,
SpO2
100% RA
NEUROLOGY CONSULT ___:
========================
Ms. ___ sister notes that while admitted here in the CCU,
starting ___ hours ago, Ms. ___ began develop instances of
pausing mid activity. She has a video that documents Ms. ___
eating soup; she is shown to pause mid bite with the spoon held
in the air for ~6 seconds before returning to a conversation she
was having, speaking fluently. This happened twice in the span
of
a ~30 second video. Her sister reports that Ms. ___ had no
memory of these event at the time, was not frustrated by them.
Nothing similar to this has happened in the past. Over the
course
of today, she has become less fluent, primarily only speaking in
yes/no answers, and not always consistently. She also had been
sleepy, often lying with her eyes closed but still awake. She
has
also started to experience body jerks which occur almost every
minute in both the arms and legs. These have not changed in
frequency since onset.
Ms. ___ presented on ___ with dyspnea, cough,
chest tightness and low-grade fever. She also had worsening leg
edema and increased weight concerning for HF exacerbation (EF
dropped from 55 to 47%, type 2 NSTEMI, and acute complicated
cystitis. More recently on ___ Ms. ___ received a right
heart catheterization for which she received conscious sedation
with fentanyl.
Prior to this Ms. ___ was hospitalized for ischemic colitis
thought to be ___ hypoperfusion from HF. Following discharge,
she
stayed with her sister who noticed that Ms. ___ was much
more
confused than usual, not oriented to place, had trouble
administering her insulin as well as taking her blood sugar
regularly. She remained disoriented and requiring assistance for
1 week before starting to improve; in her second week at home
she
was able to start taking her insulin by herself, monitor her
blood sugar regularly, was speaking coherently and was fully
oriented. This improvement occurred over a week until Labor Day
when she developed fever, SOB, CP prompting family to take her
to
___.
Ms. ___ sister notes that while admitted here in the CCU,
starting 48 hours ago, Ms. ___ began develop instances of
pausing mid activity. She has a video that documents Ms. ___
eating soup; she is shown to pause mid bite with the spoon held
in the air for ~6 seconds before returning to a conversation she
was having, speaking fluently. This happened twice in the span
of
a ~30 second video. Her sister reports that Ms. ___ had no
memory of these event at the time, was not frustrated by them,
and that the video well documents their frequency and duration.
Nothing similar to this has happened in the past. In the past 24
hours Ms. ___ has begun to experience myoclonic jerks which
occur ___ times each minute in both the arms and legs. These
have
not changed in frequency since onset. At this same time, Ms.
___ has become less articulate with her speech eventually
becoming non-fluent and halted with large pauses when responding
to questions.
Past Medical History:
-CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA
___ DES to LAD and Cx/OM ___ DES to LAD ___
PCI of Cx and OM with ___
-___ renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
-Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
-Hypertension
-Dyslipidemia
-Scleroderma w/ CREST syndrome
-Gastroparesis/GERD/Hiatal hernia
-Gout diagnosed ___ years ago
-OSA
-Pancreatic cyst
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
Admission Physical Exam:
VS: T102.9 HR105 RR25 SPO2 99% 6LNC
GEN: uncomfortable, thin cachectic female. older than stated
age.
mild distress.
HEENT: PERRLA, EOMI. No erythema or exudate in posterior
pharynx;
dry mucous membranes.
Neck: +JVD 10cm at 45 deg. +AJR.
Resp: No increased WOB, Lungs CTAB, No wheezes or rhonchi.
Crackles in bilateral bases.
CV: Normal S1/S2. no murmurs rubs or gallops.
Abd: Soft, mild suprapubic tenderness Nondistended with no
organomegaly; no guarding. bulging flanks.
MSK: ___ warm, with 1+ pitting edema to the knees bilaterally
Skin: No rash, Warm and dry, No petechiae. 1+ ___ pulses in ___
b/l.
Neuro: AOx3, speech fluent, no obvious facial asymmetry, moves
all 4 ext to command.
===================================================
Discharge Physical Exam:
24 HR Data (last updated ___ @ 1217)
Temp: 98.6 (Tm 98.6), BP: 138/72 (130-172/71-83), HR: 83
(80-90), RR: 16 (___), O2 sat: 96% (94-99), Wt: 122.3 lb/55.48
kg
General: Awake, NAD
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx or on tongue
Pulmonary: Breathing comfortably on RA
Cardiac: WWP, no pallor nor cyanosis
Abdomen: soft, NT/ND
Extremities: No ___ edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to name, day, month, year, and
___. Able to perform DOWB and MOYB without errors, with serial
subtraction of threes from 20, she makes one error and completes
the task slowly. Language
more spontaneous speech output today. Naming intact.
Comprehension intact to simple two step commands.
-Cranial Nerves:
II, III, IV, VI: Bilateral pupils 5mm -> 4.5mm minimally
reactive. EOMI intact. Frequent eye blinking. Left field of
vision reduced to movement nasally, temporally, superiorly,
inferiorly, right visual field also diffusely impaired and
unable to count fingers in all visual fields.
V: Sensation intact to light touch in all three distributions
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to instructions and finger rub
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. Occasional asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 4+ ___- 4 3 4 5
R 5 ___- 4 4+ 5 5
-Sensory: Sensation absent to light touch below b/l ankles,
decreased temperature throughout.
-DTRs: 2+ throughout
-Coordination: Mild dysmetria with FNF bilaterally, in
proportion to weakness/sensory loss.
-Gait: Deferred
Pertinent Results:
ADMISSION LABS:
================
___ 07:47PM BLOOD WBC-4.6 RBC-2.59* Hgb-8.2* Hct-26.7*
MCV-103* MCH-31.7 MCHC-30.7* RDW-15.9* RDWSD-58.7* Plt ___
___ 07:47PM BLOOD Neuts-75.5* Lymphs-5.2* Monos-16.7*
Eos-1.1 Baso-0.4 Im ___ AbsNeut-3.49 AbsLymp-0.24*
AbsMono-0.77 AbsEos-0.05 AbsBaso-0.02
___ 07:47PM BLOOD ___ PTT-36.9* ___
___ 07:47PM BLOOD Glucose-102* UreaN-60* Creat-2.7* Na-145
K-5.0 Cl-107 HCO3-23 AnGap-15
___ 07:47PM BLOOD ALT-16 AST-25 CK(CPK)-129 AlkPhos-74
TotBili-0.2
___ 07:47PM BLOOD Albumin-2.4* Calcium-8.5 Phos-3.6 Mg-1.7
Important Interval Labs
=======================
___ 06:51AM BLOOD TSH-2.0
___ 06:30AM BLOOD %HbA1c-6.5* eAG-140*
___ 06:30AM BLOOD Triglyc-92 HDL-69 CHOL/HD-2.7 LDLcalc-102
___ 08:54AM BLOOD Cyclspr-64*
Important Discharge labs
=========================
___ 07:30AM BLOOD Valproa-31*
___ 07:30AM BLOOD WBC-6.6 RBC-2.77* Hgb-8.8* Hct-28.5*
MCV-103* MCH-31.8 MCHC-30.9* RDW-15.1 RDWSD-57.0* Plt ___
___ 06:45AM BLOOD ___ PTT-26.2 ___
___ 07:30AM BLOOD Glucose-221* UreaN-63* Creat-3.0* Na-146
K-4.4 Cl-109* HCO3-27 AnGap-10
___ 06:45AM BLOOD ALT-11 AST-9 AlkPhos-74 TotBili-<0.2
___ 07:24AM BLOOD cTropnT-0.44*
___ 07:30AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.9
___ 06:30AM BLOOD %HbA1c-6.5* eAG-140*
___ 06:30AM BLOOD Triglyc-92 HDL-69 CHOL/HD-2.7 LDLcalc-102
___ 08:54AM BLOOD Ammonia-18
___ 06:51AM BLOOD TSH-2.0
___ 06:51AM BLOOD Vanco-13.3
___ 07:30AM BLOOD Cyclspr-PND
___ 08:54AM BLOOD Cyclspr-64*
Imaging
========
___ TTE
The estimated right atrial pressure is ___ mmHg. There is mild
global left ventricular hypokinesis. The visually estimated left
ventricular ejection fraction is 35-40%. Global longitudinal
strain is depressed (-9.6 %; normal
less than -20%) Tissue Doppler suggests an increased left
ventricular filling pressure (PCWP greater than 18mmHg). There
is Grade II diastolic dysfunction. Normal right ventricular
cavity size with normal free wall
motion. The mitral valve leaflets appear structurally normal
with no mitral valve prolapse. There is mild [1+] mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is trivial tricuspid regurgitation. There is no
pericardial effusion.
IMPRESSION: 1) No structural cardiac source of embolism
(e.g.patent foramen ovale/atrial septal defect, intracardiac
thrombus, or vegetation) seen. 2) Moderate global LV systolic
dysfunction both by LVEF and
global longitudinal strain imaging with grade II LV diastolic
dysfunction and elevated LVEDP. Compared with the prior TTE
(images reviewed) of ___, visualized findings are
similar., the findings are similar.
___ MRA neck w/o
Within confines of 2D time-of-flight technique and limited
field of view
obscuring the mid to distal bilateral cervical internal carotid
arteries:
1. Unremarkable MRA of the neck without evidence of stenosis of
the cervical internal carotid arteries by NASCET criteria.
2. Additional findings as described above.
___ MRI MRA brain w/o
1. Acute/subacute on chronic thromboembolic ischemic changes in
the right
frontal and right parietal lobes as described detail above.
2. No acute intracranial hemorrhage.
3. Unchanged left SCA focal stenosis. Otherwise, patent circle
___ with
no evidence of aneurysm formation.
___ RUQ us
1. Coarsened liver echotexture. This can be seen in the setting
of early
cirrhosis.
2. Surgically absent gallbladder.
3. At least 2 hypoechoic pancreatic cystic lesions (within the
body and
uncinate process) for which non emergent outpatient MRCP further
characterization may be performed if not previously evaluated.
4. Trace left pleural effusion.
5. No ascites.
___ CT Head
1. No acute intracranial abnormality.
2. Re-demonstration of chronic findings, as above.
___ Cardiac R cath
Elevated right heart filling pressure.
Preserved cardiac function.
Moderate pulmonary hypertension.
elevated filling pressures, pulmonary htn, PROMINENT v WAVES
ON WEDGE TRACINGS
___ CT abd pelvis
1. Small bilateral pleural effusions with overlying atelectasis.
Partially imaged lingula/inferior left upper lobe contains
scattered ground-glass opacities which could be due to
infection, but are not fully imaged.
2. Equivocal subtle perinephric stranding/haziness involving the
left iliac fossa transplant kidney. Correlate with urinalysis
to assess for infection. No hydronephrosis.
3. No bowel obstruction or bowel wall thickening.
4. Cardiac ventricular blood pool is hypodense in relation to
the myocardium, suggesting underlying anemia.
Brief Hospital Course:
BRIEF SUMMARY
=====================
___ yo F with sig PMHx of Type 1DM, ESRD s/p LURT in ___ on
cyclosporine/MMF, transfusion dependent anemia, CAD s/p ___
recently in ___, HFpEF with EF of 55% in ___, IPMN, HTN,
scleroderma/crest, and multiple recurrent MDR UTI who presented
with acute decompensated heart failure ___ inadequate PO
diuresis, acute complicated cystitis further complicated by a
likely type 2 NSTEMI. Ms. ___ was initially treated by the
cardiology service where she was diuresed and underwent right
heart cath on ___. Details of her cardiology course are below.
She was transferred to Neurology on ___ after had acute mental
status changes and twitching which were non-convulsive status.
She was started on AEDs including keppra and valproic acid,
monitored on EEG (___) and her seizures became well
controlled. She had an MRI which showed multiple acute and
subacute infarcts. She underwent stroke work-up which included
risk factor screening (Alc 6.5, LDL elevated, echo normal
without PFO).
ACUTE ISSUES:
======================
#Acute Decompensated HFpEF:
Last ECHO prior to admission was in ___ with EF 55%. BNP
elevated to ___ at OS___ prior to transfer, previous admissions
BNP elevated to ___. Likely etiology of this exacerbation was
inadequate PO diuretic dosing. She was diuresed, requiring Lasix
IV up to 100mg IV. Diuresis was complicated by a worsening ___.
She was taken for a on ___ RHC which revealed Elevated right
heart filling pressure, Preserved cardiac function, moderate
pulmonary hypertension, elevated filling pressures, pulmonary
htn and prominent V waves on wedge tracings. She continued to
diurese and was transitioned back to her home regimen.
# NSTEMI type II, & CAD s/p DES:
Mrs. ___ is s/p multiple stents, most recently ___,
anti-platelet therapy stopped in ___ per cardiology in
advance of EUS/biopsy for pancreatic mass. ECG on admission with
new lateral precordial TWI from prior, troponins elevated 0.21
-> 0.45. Received nitro and started on heparin gtt in ED. Not on
ACE-I given CKD. A heparin gtt was discontinued after hospital
day 1 and she was without further episodes of chest pain. She
was continued on her home regimen of ranolazine, aspirin 81 mg,
metop 6.25mg q6hr
#Hypertension:
History of labile, difficult to control BP. BPs frequently in
180s-190s during this admission. We uptitrated Hydral/isosorbide
dinitrate to Hydral 75 q8 and isosorbide dinitrate 40mg TID.
Given her chronic orthostatic hypotension, goal SBP was 140-160.
#Acute Complicated Cystitis:
Patient with a history of MDR E. Coli sensitive to cefepime. She
had suprapubic tenderness and CT evidence of perinephric
stranding. No leukocytosis, but patient febrile to 100.5F in ED.
CT A/P in ED showed no bowel obstruction or bowel wall
thickening. Also showed partially imaged lingula/inferior left
upper lobe which contained scattered ground-glass opacitie,
possibly ___ infection. Received Vanc/Flagyl in ED. Transplant
nephrology following and recommended based on lung exam to add
on atypical coverage and treat for a pneumonia. We sent a broad
infectious workup including stool cultures, serum/stool CMV, C.
diff, pjp smear and Urine culture negative. We treated for a
presumed pnuemonia given her lung exam and fevers. Treatment
included Cefepime (___) which was discontinued in the
setting of seizures, vanc d/ced ___ after MRSA nares negative
and Azithromycin 250mg daily (End date ___. She was afebrile
during her time on the Neurology service.
# ___ with ESRD s/p LURT ___, CKD 4:
Renal transplant followed throughout the hospitalization.
Pre-admission baseline Cr around 3.0, ISO chronic allograft
dysfunction from diabetic nephropathy and grade 2 IFTA. During
her time on cardiology her creatinine was elevated above
baseline and slightly uptrending during hospitalization. Some of
this was likely related to diueresis. FeUrea was 40 which was
suggestive of intrinsic renal disease, has muddy brown casts and
acanthocytes on urine microscopy c/w component of ATN on top of
diabetic GN. She continued on cyclosporine, MMF and prednisone.
Cyclosporine levels were trended daily. Goal cyclosporine level
50-100 per transplant nephrology.
#Seizure and stroke:
She triggered for acute mental status changes on HD#4 and HD#5.
She was minimally responsive with diffuse myoclonic jerks. Her
presentation initially appeared to wax and wane, then on ___
she became more persistently altered. CT head was negative.
Neurology was consulted who recommended EEG to assess for
subclinical status epilepticus which was confirmed. She received
Valium (Ativan allergy) twice over that first 24 hours and was
loaded/started on Keppra and Valproic Acid for seizure control
which was obtained around ___. Her EEG had initially shown
generalized 5 hz spike and wave complexes. She had an MRI which
showed two subacute infarcts in the right periventricular
pericollosal artery territory and punctate infarct in pons.
Given distribution, highest suspicion was for small vessel
etiology, though pericallosal infarct could also possibly be
embolic. Given this and timing related to right heart cath, TTE
with bubble was performed, which showed no e/o PFO. It was
therefore felt that the infarcts are unlikely related to the
right heart catheterization. MRA head/neck without severe
stenosis. A1c 6.5, LDL 102, TSH 2.0. Telemetry without
arrhythmia. Given LDL above goal, pravastatin was uptitrated to
30mg qhs in discussion with her outpatient neurologist. Higher
intensity statin contraindicated given interaction with
cyclosporine. She was continued on ASA 81mg daily. Cardiac
embolus related to decreased EF cannot be ruled out, though is
felt less likely.
She was continued on valproate and keppra for seizures. She was
discharged on keppra 500mg BID and Divalproex (DELayed Release)
750mg BID.
#DM1
Her blood sugars were quite brittle throughout this
hospitalization with frequent episodes of symptomatic
hypoglycemia at BS readings of 80+. ___ was consulted for
assistance with management of her insulin.
# Chronic Anemia: Secondary to ESRD. Receiving weekly Epo
infusions.
#Gout: initially held allopurinol ___ given asymptomatic and
possible UTI, but this was restarted on discharge.
#Hypothyroidism: she continued on her levothyroxine 125 mcg
#Scleroderma/CREST: continued on her home prednisone 5mg daily
#GERD/Gastroparesis: Continued pantoprazole (esomeprazole NF)
and promethazine
# PAD: Initially held home cilastazol 50mg qAM and 25mg qPM,
this was restarted on discharge.
Transitional Issues
=====================
Kidney transplant
-------------------
[] Please check cyclosporine level(12 hrs after pm dose), BUN,
Cr on ___
[] Goal cyclosporine trough 50-100 do not hold AM dose while
waiting for trough.
[] monitor urine output, patient has history of urinary
retention. If retaining consider straight cath.
Neuro (stroke and seizures)
[] check valproate trough in 1 week (___), get LFTs and ammonia
with this trough. Goal valproate 50-70, if LFTs or Ammonia are
elevated please call neurology at ___.
[] monitor for muscle aches. If develops would check CK.
Pravastatin interaction with cyclosporine increases risk of
rhabdomyolysis
[] Seizure semiology: behavioral arrest.
HFrEF
-------
[] Continue to hold furosemide on discharge, please monitor
daily weights and volume status.
[] discharge weight: 55.48kg, 122.3lb
[] please check orthostatics before making further changes to BP
regimen, as has historically had significant orthostatic
hypotension. ___ not tolerate significantly more BP medication
[] If Cr worsens consider reducing insulin to avoid hypoglycemia
d/t reduced clearance of insulin
========================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 102) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[x] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist--
interaction with cyclosporine
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Calcitriol 0.25 mcg PO DAILY
5. Cilostazol 50 mg PO BID
6. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
7. esomeprazole magnesium 40 mg oral BID
8. Furosemide 20 mg PO DAILY
9. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL SC Prior
to meals
10. ___ Solostar U-300 26 Units Breakfast
11. Levothyroxine Sodium 125 mcg PO DAILY
12. Lidocaine 5% Patch ___ PTCH TD QAM
13. Metoprolol Succinate XL 25 mg PO DAILY
14. Mycophenolate Mofetil 500 mg PO BID
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
16. Pravastatin 10 mg PO QPM
17. Promethazine 25 mg PO Q6 HR-Q8HR
18. Promethazine ___ID:PRN nause
19. Ranolazine ER 500 mg PO BID
20. trimethobenzamide 300 mg oral Q6H:PRN
21. Aspirin 81 mg PO DAILY
22. Vitamin D ___ UNIT PO DAILY
23. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
24. Ferrous Sulfate 325 mg PO DAILY
25. melatonin 10 mg oral QHS
26. pen needle, diabetic 32 gauge x ___ miscellaneous Other
27. Sodium Bicarbonate 1300 mg PO BID
Discharge Medications:
1. Divalproex (DELayed Release) 750 mg PO BID
2. HydrALAZINE 75 mg PO Q8H
3. Isosorbide Dinitrate 40 mg PO TID
4. LevETIRAcetam 500 mg PO BID
5. ___ Solostar U-300 26 Units Breakfast
6. Pravastatin 30 mg PO QPM
7. Allopurinol ___ mg PO DAILY
8. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
9. Aspirin 81 mg PO DAILY
10. Calcitriol 0.25 mcg PO DAILY
11. Calcium Carbonate 500 mg PO DAILY
12. Cilostazol 50 mg PO BID
13. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
14. Esomeprazole Magnesium 40 mg oral BID
15. Ferrous Sulfate 325 mg PO DAILY
16. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL SC
Prior to meals
17. Levothyroxine Sodium 125 mcg PO DAILY
18. Lidocaine 5% Patch ___ PTCH TD QAM
19. melatonin 10 mg oral QHS
20. Metoprolol Succinate XL 25 mg PO DAILY
21. Mycophenolate Mofetil 500 mg PO BID
22. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
23. pen needle, diabetic 32 gauge x ___ miscellaneous Other
24. PredniSONE 5 mg PO DAILY
25. Promethazine 25 mg PO Q6 HR-Q8HR
26. Ranolazine ER 500 mg PO BID
27. Sodium Bicarbonate 1300 mg PO BID
28. trimethobenzamide 300 mg oral Q6H:PRN
29. Vitamin D ___ UNIT PO DAILY
30. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until directed by your MD
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
acute ischemic stroke
type 2 NSTEMI
Congestive heart failure exacerbation
non-convulsive status epilepticus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
You were admitted with trouble breathing. You had too much fluid
in your body and it lead to shortness of breath and some stress
on your heart. You had a right heart catheterization.
You then developed continuous seizures without shaking, called
non-convulsive status epilepticus. While figuring out why this
happened, we discovered that you had two small areas of stroke
in your brain. We cannot be 100% sure why the strokes happened.
the possibilities are that it is either from the long term
changes from diabetes, high blood pressure and high cholesterol,
or it is related to the reduced function of your heart. We do
not think it is from the right heart catheterization.
Please follow up with Neurology and your primary care physician
as listed below.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
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:
___
|
10030753-DS-55 | 10,030,753 | 22,300,700 | DS | 55 | 2200-12-23 00:00:00 | 2200-12-23 17:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___.
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with complex medical history notable for ESRD
s/p LURT ___ on immunosuppression, CAD s/p ___ 4 (most recent
___, HFrEF (EF 35-40% ___, T1DM, severe poorly
controlled
HTN, scleroderma/CREST, who was brought to the ED by EMS after
an
episode of hypoglycemia and is now admitted for altered mental
status and weakness iso a UTI.
The patient had a recent admission at ___ ___ for
decompensated heart failure. Her hospital course was complicated
by NSTEMI, ___, and non-convulsive status epilepticus with
workup that revealed acute and subacute strokes in the right
periventricular pericollosal artery territory and punctate
infarct in pons. She was discharged on Keppra and valproate and
has not had any witnessed seizures since discharge. She also
underwent RHC iso newly reduced EF to 37% and difficult volume
management. RHC showed elevated filling pressures and pHTN and
she was aggressively diuresed.
Since her discharge on ___ she has felt generally weak and has
had periods of confusion where she does not know the date or
know
where she is. The night before presentation her FSBGs were noted
to be in the 400s. She received 10u SC insulin and in the AM she
was noted to be hypoglycemic to the ___. The patient received
2mg
IM glucagon and juice with improvement in her FSBG to 170s. She
was taken by EMS to ___ for further management.
In the ED, she was afebrile, HRs ___, BPs 200/90s but decreased
to 160s/70s after home anti-HTN meds, and SpO2 98% RA. On
initial
exam she was somnolent, grade III systolic murmur, normal lung
sounds, mild abdominal tenderness of LUQ, 1+ edema of b/l LEs,
and she was AOx4 with no focal neurologic findings. Her EKG
showed new lateral ST depressions. MB 6->4, and Trop 0.28 ->
0.16, asymptomatic. WBC 20 (normal at b/l), Hgb 11, Cr 2.5
(baseline 3.0), an otherwise normal chem-10, and lactate 1.6. UA
was notable for Lg leuks, 178 WBCs, and many bact. Imaging
included a CXR without e/o pna and a renal transplant US that
showed improved intrarenal arterial flow, no hydronephrosis, and
patent main renal vein.
Renal transplant was consulted and recommended BP control with
home medications, cyclosporine trough daily, and admission to
medicine for further management of her confusion and AMS. ___
was also consulted for assistance with management of her DMI iso
recent episode of hypoglycemia.
In addition to her home antihypertensives and insulin per
___,
she was started on ceftriaxone for a UTI (previous culture data
from ___ w/ ecoli, sensitive to CTX).
Transfer VS were: 97.6 121 169/93 21 95% RA
On arrival to the floor, patient reports marked fatigue. She
denies dysuria but endorses mild lower abdominal discomfort. She
denies diarrhea or constipation. She has had nausea and poor
appetite for the past week and had one episode of non-bloody,
non-bilious vomiting the day prior to admission. She denies any
recent chest pain, palpitations, or dyspnea. She has had no
cough, rhinorrhea, fevers, or chills. She reports a mild
headache
without neck stiffness, vision changes, or photophobia.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
-CAD s/p PCI x4: LAD PTCA ___ DES to LAD and Cx/OM ___ DES
to LAD ___ DES to Cx and OM ___
-Heart failure with reduced EF (35-40% ___
-L-sided living kidney transplant in ___ complicated by
transplant nephropathy
-Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
-Autonomic dysfunction with orthostatic hypotension and supine
hypertension
-CVA ___
-Seizure disorder
-Scleroderma w/ CREST syndrome
-Gastroparesis/GERD/Hiatal hernia
-Chronic Nausea
-Gout
-OSA
-Pancreatic cyst c/w IPMN
-Dyslipidemia
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION PHYSICAL EXAM:
___ 0417 Temp: 98.1 PO BP: 168/78 R Lying HR: 118 RR: 22 O2
sat: 98% O2 delivery: Ra
GENERAL: NAD, AOx3
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: tachycardic, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, mild TTP of lower abdomen, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert/oriented x4, non-focal exam
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Temp: 98.4 PO BP: 180/77 HR: 81 RR: 16 O2 sat: 94% O2 delivery:
Ra FSBG: 187
Constitutional: NAD
HEENT: eyes anicteric, R sided pterygium, normal hearing, nose
unremarkable, MMM without exudate
CV: RRR ___ SEM, JVP 8cm
Resp: CTAB
GI: sntnd, NABS
GU: no foley
MSK: no obvious synovitis
Ext: wwp, trace ___: mild skin tightening
Neuro: A&O grossly, speech intact and fluent, CN grossly intact
___ LUE/LLE, 4+/5 RUE/RLE, SILT BUE/BLE,
Psych: normal affect, pleasant
Pertinent Results:
ADMISSION LABS:
===========
___ 11:34AM BLOOD WBC-20.8* RBC-3.47* Hgb-11.1* Hct-34.6
MCV-100* MCH-32.0 MCHC-32.1 RDW-14.7 RDWSD-53.4* Plt ___
___ 11:34AM BLOOD Neuts-92.0* Lymphs-1.3* Monos-5.8
Eos-0.1* Baso-0.1 Im ___ AbsNeut-19.13* AbsLymp-0.27*
AbsMono-1.21* AbsEos-0.02* AbsBaso-0.03
___ 11:34AM BLOOD Glucose-178* UreaN-57* Creat-2.5* Na-141
K-4.9 Cl-101 HCO3-27 AnGap-13
___ 11:34AM BLOOD Glucose-178* UreaN-57* Creat-2.5* Na-141
K-4.9 Cl-101 HCO3-27 AnGap-13
___ 11:34AM BLOOD ALT-11 AST-33 CK(CPK)-110 AlkPhos-72
TotBili-0.2
___ 11:34AM BLOOD CK-MB-6
___ 11:34AM BLOOD cTropnT-0.28*
___ 04:20PM BLOOD CK-MB-4 cTropnT-0.16*
___ 11:34AM BLOOD Albumin-3.5 Calcium-9.5 Phos-3.2 Mg-2.1
___ 04:20PM BLOOD PTH-64
___:02PM BLOOD Lactate-1.6
___ 04:10PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 04:10PM URINE Blood-SM* Nitrite-NEG Protein-300*
Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5
Leuks-LG*
___ 04:10PM URINE RBC-5* WBC-178* Bacteri-MANY* Yeast-NONE
Epi-3
INTERIM LABS:
==========
___ 06:30AM BLOOD Valproa-14*
___ 09:00AM BLOOD Cyclspr-<30*
___ 04:36PM BLOOD ___ pO2-196* pCO2-42 pH-7.43
calTCO2-29 Base XS-3 Comment-GREEN TOP
___ 08:02AM BLOOD Cyclspr-92*
___ 08:02AM BLOOD Valproa-54
DISCHARGE LABS:
============
___ 05:25AM BLOOD WBC-6.3 RBC-2.95* Hgb-9.0* Hct-29.3*
MCV-99* MCH-30.5 MCHC-30.7* RDW-19.3* RDWSD-70.7* Plt ___
___ 07:26AM BLOOD Glucose-123* UreaN-51* Creat-3.2* Na-141
K-4.6 Cl-101 HCO3-32 AnGap-8*
MICROBIOLOGY:
==============
___ URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ Culture, Routine-FINAL
IMAGING:
=========
___ CXR
No focal consolidation to suggest pneumonia. Mild pulmonary
vascular congestion, improved from the prior exam.
___ RENAL U/S
1. Improved intrarenal arterial flow with continuous diastolic
flow now seen in the upper and lower pole intrarenal arteries,
but questionable lack of diastolic flow in the interpolar
region, as seen previously. Resistive indices in the upper and
lower poles are mildly elevated.
2. No hydronephrosis. Patent main renal vein.
___ EEG
This is an abnormal continuous EEG monitoring study because of
mild slowing of the background activity, indicative of mild
diffuse encephalopathy without specific etiology. Common causes
are medication effect, infections or toxic/metabolic
disturbances. There was intermittent focal attenuation and very
mild slowing over the right hemisphere, indicative of
subcortical dysfunction in that region. There were no
epileptiform discharges or electrographic seizures. Compared to
the prior day's recording, there is no significant change.
___ CT HEAD W/O CONTRAST
1. No new acute intracranial process.
2. Chronic findings, as above.
___ MRI
1. Interval evolution of subacute on chronic thromboembolic
ischemic changes in the right cerebral hemisphere and right
pons.
2. No new infarct or acute intracranial hemorrhage. No evidence
for PRES.
3. Additional findings as described above.
___ CHEST XR
In comparison with the study of ___, the there are lower
lung volumes. Moderate enlargement of the cardiac silhouette is
again seen with moderate pulmonary vascular congestion.
Opacification at the right base silhouetting hemidiaphragm is
consistent with pleural fluid and atelectatic changes at the
base. Retrocardiac opacification suggests volume loss in the
left lower lobe.
No evidence of acute focal consolidation, though this would be
difficult to unequivocally exclude in the appropriate clinical
setting, especially in the absence of a lateral view.
There is a spiculated opacification in the right upper quadrant
of the
abdomen, raising the possibility of a gallstone.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with complex
medical history notable for renal transplant in ___ on
immunosuppression, CAD s/p ___ 4 (most recent ___, HFrEF
(EF 35-40% ___, brittle T1DM, autonomic dysfunction with
poorly controlled HTN and orthostatic hypotension,
scleroderma/CREST, recent admission for acute on chronic HFrEF,
course complicated by CVA and seizures, brought to the ED ___
from rehab after an episode of hypoglycemia, admitted for
altered mental status and weakness presumed secondary to UTI.
ACUTE ISSUES:
===================
# Toxic Metabolic Encephalopathy
# Generalized Weakness / Fatigue
Since her discharge on ___ patient generally weak and reported
periods of confusion where she did not know the date or know
where she was. Sister/HCP reported she was somnolent since prior
to discharge, sleeping all the time, not herself. Worsened after
an episode of hypoglycemia, improved with treatment of UTI
below. Suspected a multifactorial process, in part related to
delirium from UTI, poor glycemic control, recent
hospitalizations superimposed on numerous chronic medical
problems and neurologic injury including seizure and strokes.
Initially also concerned for post-ictal state vs seizure I/s/o
hypoglycemia. Neurology was consulted, recommended EEG, which
from ___ was w/o any evidence of seizure. Valproate was
initially low likely i/s/o missing a dose in the ED, s/p one
load remained in normal range. Keppra level was 48, but per
neurology, this was okay and patient should continue keppra
500mg BID. CT head and MRI w/o any new acute strokes. Mental
status returned to baseline by discharge.
#DM type 1 c/b episode of hypoglycemia
Blood sugar 400 at rehab, was given 10u SC insulin, then
decreased to 50 and had AMS. Endorsed poor appetite, so was
likely receiving inappropriate amount of insulin for how much
she was taking in. Per sister, she has very brittle diabetes for
a long time. ___ was consulted. BG were very labile, swings
from low to high with minimal change to insulin regimen. Patient
had continuous glucose monitor, sensor was lost in the hospital,
replaced on ___. Discharged on lower amount of Levemir than
previously (see below for full regimen).
#E. coli UTI in transplanted kidney
UA positive, w/ lower abdominal pain, leukocytosis to 20
(previously normal). Urine culture grew E. coli sensitive to
ceftriaxone, resistant to cipro. Started IV ceftriaxone,
transitioned to cefpodoxime ___ to complete a 10 day
course.
#Hypertensive Urgency
Per outpatient nephrologist, goal SBP<180. Increased isosorbide
dinitrate to 60 mg tid, Hydralazine to 100mg q8h and increased
metoprolol XL to 50mg. SBPs remained elevated as high as 180s
but further increases in BP meds limited by orthostasis. Follow
up arranged with Cardiology and Neurology.
#Orthostatic hypotension
#Acute on chronic systolic heart failure
#Acute kidney injury
Initially had orthostasis, held diuretics, then developed
edema/pulmonary edema. Edema improved with diuretics but then
renal function worsened. Now appears dry to euvolemic, allowing
for autoregulation for now, decreased lasix to twice weekly on
discharge. Per discussion with transplant nephrology, given that
Cr has peaked, safe for discharge with close follow up.
Discontinued cilastozol (increased mortality in HF).
#Autonomic Dysfunction
Labile BPs and volume status as above. Followed by Neurology as
outpatient. Etiology thought to be due to diabetes. Prior workup
for other etiologies negative.
#CAD ___ 4 (most recent ___
#Chest Pain
Having intermittent chest pain, sometimes intermittent in
nature. Troponin have been stable. From ___ cath, still have
70% lesion in D1, but EKG have been stable.
Continued home statin, metop, asa, ranolazine. Of note, patient
had DES placed ___ but was directed to stop taking ticagrelor
in ___, which she had stopped for a procedure. Confirmed
with outpatient cardiologist that ticagrelor is not necessary to
continue.
#Akathisia / Hyperactivity
Patient noted to be moving her extremities continually after
somnolence improved, had a hard time extinguishing the movement
with volition. Likely medication effect (Phenergan most
trimethobenzamide). Valproate level within normal limits.
Symptoms improved since discontinuing phenergan and
trimethobenzamide. Phenergan restarted on ___ w/o any adverse
effects.
#Chronic nausea
Has has difficult to control nausea of unclear etiology on
phenergan and trimethobenzamide, followed by GI as outpatient.
Nausea appeared to correlate with episodes of hyperglycemia.
Nausea was controlled with initially PRN Zofran, but became
ineffective. Phenergan restarted on ___ w/o any adverse
effects. Trimethobenzamide discontinued due to akithisia.
#Blurry vision
Has known cataract, diabetic retinopathy, followed by ___.
Last seen by opthaomlogy on ___. Discussed with on-call
opthalmology, no indication to be seen inpatient, but should
have follow up with opthalmology in ___ weeks. No evidence of
new strokes on head imaging this admission.
#Anemia
Has chronic anemia and receives epogen as outpatient and
occasional blood transfusion. Hgb downtrending inpatient, likely
in setting of iatrogenic blood draw and not receiving epogen. No
melena/hematochezia or symptom to suspect acute drop. Iron
studies c/w ACD likely iso of CKD. Received 1u PRBC on ___ for
hgb of 6.6, with exaggerated response and hgb was stable. Epogen
was restarted. Goal hgb >8
#BPPV
Had vertigo on ___ with exam consistent with BPPV as diagnosed
with ___. Improved with epley maneuver and meclizine. No
concern for posterior stroke.
CHRONIC ISSUES:
============
#Seizure Disorder
Recent nonconvulsive status diagnosed on last hospitalization.
Started Divalproate and Keppra during that hospitalization. EEG
w/o any seizures as above, continued home AEDs. s/p 1 valproate
load.
#ESRD ___ T1DM and HTN s/p LURT (___)
Has known chronic allograft dysfunction. Renal US in ED w/
improved intrarenal arterial flow and patent vasculature. Renal
transplant was consulted. Continued immunosuppression as below.
# Immunosuppression
Continued Cyclosporine (25 mg q12h), MMF 500 mg bid and
prednisone 5 mg daily.
# Bone mineral ds
Per Renal, continued Vitamin D, no indication for phos binders
# Anemia
Previously receiving weekly EPO injections but did not have the
week before admission due to concern of seizure as a side
effect. No inpatient indication for ESA.
# Recent CVA
MRI showed two subacute infarcts in the right periventricular
pericollosal artery territory and punctate infarct in pons.
Given distribution, highest suspicion was for small vessel
etiology. Given this and timing related to right heart cath, TTE
with bubble was performed, which showed no e/o PFO. It was
therefore felt that the infarcts are unlikely related to the
right heart catheterization. Continued home Asa.
#Scleroderma w/ CREST syndrome. On immunosuppression as above
#Gastroparesis/GERD/Hiatal hernia. Continued Omeprazole.
#Gout. Continued allopurinol.
#IPMN. Seen on recent EUS, needs outpatient followup.
TRANSITIONAL ISSUES:
=====================
[] recheck BMP on ___ or ___ to ensure stability of Cr
[] Lasix restarted at 20mg twice weekly. Has bibasilar crackles
on discharge, but did not aggressively diurese given Cr and
predisposition to orthostasis
[] discharge weight: 130.4kg
[] Pt with brittle diabetes. Would only make small changes at a
time to insulin regimen. Discharge insulin regimen: 12u glargine
qam, Humalog ___ with meals
[] please check orthostatics before making further changes to BP
regimen, as has historically had significant orthostatic
hypotension. ___ not tolerate significantly more BP medication
[] Needs close follow up with ophthalmology and ___.
[] If having repeated episodes of vertigo, likely peripheral and
would benefit from vestibular ___
New medications:
Meclizine PRN vertigo
Changed medications:
Hydralazine 75mg TID to ___ TID
Isosorbide Dinitrate 40mg TID to 60mg TID
Metoprolol XL 25mg to 50mg
Held medications:
___
Stopped medications:
Cilastozol
#CODE: Full (presumed)
#CONTACT: ___
___: SISTER
Phone number: ___
Cell phone: ___
More than 30 minutes were spent preparing this discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
4. Ferrous Sulfate 325 mg PO DAILY
5. Levothyroxine Sodium 125 mcg PO DAILY
6. Lidocaine 5% Patch ___ PTCH TD QAM
7. Mycophenolate Mofetil 500 mg PO BID
8. Pravastatin 30 mg PO QPM
9. PredniSONE 5 mg PO DAILY
10. Promethazine 25 mg PO Q6 HR-Q8HR
11. Ranolazine ER 500 mg PO BID
12. Vitamin D ___ UNIT PO DAILY
13. Divalproex (DELayed Release) 750 mg PO BID
14. Metoprolol Succinate XL 25 mg PO DAILY
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
16. pen needle, diabetic 32 gauge x ___ miscellaneous Other
17. Sodium Bicarbonate 1300 mg PO BID
18. trimethobenzamide 300 mg oral Q6H:PRN
19. Allopurinol ___ mg PO DAILY
20. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
21. Calcium Carbonate 500 mg PO DAILY
22. Cilostazol 50 mg PO BID
23. Esomeprazole Magnesium 40 mg oral BID
24. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL SC
Prior to meals
25. melatonin 10 mg oral QHS
26. LevETIRAcetam 500 mg PO BID
27. HydrALAZINE 75 mg PO Q8H
28. Isosorbide Dinitrate 40 mg PO TID
29. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Meclizine 12.5 mg PO Q8H:PRN vertigo, nausea
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Polyethylene Glycol 17 g PO DAILY
4. Senna 8.6 mg PO BID
5. Furosemide 20 mg PO 2X/WEEK (MO,TH)
6. HydrALAZINE 100 mg PO Q8H
7. Glargine 12 Units Breakfast
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. Isosorbide Dinitrate 60 mg PO TID
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Promethazine 25 mg PO Q8H:PRN nausea
12. Allopurinol ___ mg PO DAILY
13. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
14. Aspirin 81 mg PO DAILY
15. Calcitriol 0.25 mcg PO DAILY
16. Calcium Carbonate 500 mg PO DAILY
17. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
18. Divalproex (DELayed Release) 750 mg PO BID
19. Esomeprazole Magnesium 40 mg oral BID
20. Ferrous Sulfate 325 mg PO DAILY
21. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL SC
Prior to meals
22. LevETIRAcetam 500 mg PO BID
23. Levothyroxine Sodium 125 mcg PO DAILY
24. melatonin 10 mg oral QHS
25. Mycophenolate Mofetil 500 mg PO BID
26. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
27. pen needle, diabetic 32 gauge x ___ miscellaneous Other
28. Pravastatin 30 mg PO QPM
29. PredniSONE 5 mg PO DAILY
30. Ranolazine ER 500 mg PO BID
31. Sodium Bicarbonate 1300 mg PO BID
32. Vitamin D ___ UNIT PO DAILY
33. HELD- trimethobenzamide 300 mg oral Q6H:PRN This medication
was held. Do not restart trimethobenzamide until told by your
doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Complicated UTI
Toxic Metabolic Encephalopathy
Akathisia ___ Phenergan
Diabetes mellitus type 1 with hyperglycemia
Autonomic dysfunction with supine hypertension and orthostatic
hypotension
Acute on chronic systolic heart failure
Acute on chronic renal failure
Renal transplant on chronic immunosuppression
Secondary:
Nausea
Benign positional vertigo
Seizure disorder
Recent stroke
Coronary artery disease status post percutaneous coronary
interventions
Chronic multifactorial anemia
Chronic urinary retention
Diabetic retinopathy and cataracts
CREST syndrome
GERD
Hiatal hernia
Gastroparesis
History of gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital because your blood sugar was very low
after receiving some insulin and you were hard to wake up.
You received antibiotics for a urinary tract infection and
became more alert.
You had more imaging of your brain including CT scan and MRI
that showed no new strokes.
The diabetes doctors worked with ___ to keep your blood sugar in
a safe range. You received a new continuous glucose monitoring.
You received a unit of blood, but became fluid overloaded and
required Lasix.
Your blood pressure medications were uptitrated.
When you return to rehab, please:
- we changed some of your medicines - see below
- see below for your followup appontments
It was a pleasure caring for you and we wish you the best,
Your ___ Team
Followup Instructions:
___
|
10030753-DS-56 | 10,030,753 | 23,017,050 | DS | 56 | 2201-03-04 00:00:00 | 2201-03-04 18:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___.
Chief Complaint:
Dyspnea, Pedal Edema, Transfer
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ y/o female with a history of ESRD (s/p LURT
___, anemia, CAD s/p ___ 4 (most recently ___, HFrEF (EF
~40%), IPMN (___), HTN, T1DM, and h/o multiple MDR UTIs
(Klebsiella, E.coli, Enterococcus), cryptogenic stroke,
scleroderma/CREST who presents with worsening lower extremity
edema, at the request of her primary cardiologist. The patient
was recently here in ___, where she was managed for
hypoglycemia. Baseline creatinine is ~3mg/dL; was biopsies in
___ which elucidated diabetic kidney disease, with Grade II
IFTA, and moderate arteriosclerosis.
In the setting of worsening lower extremity edema, the patient's
Lasix was up-titrated to daily from, twice weekly dosing on
___. The patient notes she has gained about 10 pounds
over the past month. She has remained volume overloaded, but
barring any lower extremity edema, the patient denies symptoms
suggestive of CHF such as SOB, cough, orthopnea, or PND.
Notably, labile blood pressures have been difficult to manage,
given diabetic dysautonomia; this has hindered diuresis in the
past per documentation. An implantable loop recorder was placed
given her history of cryptogenic stroke, with aim of detecting
possible occult atrial dysrhythmia. Last underwent cardiac cath
in ___, revealing elevated filling pressures, but as
aforementioned, more aggressive diuresis has been hindered by
labile BP's. Last echocardiogram revealed a depressed EF of
35-40, when prior TTE's had always suggested preserved systolic
function. Repeat catheterization has been deferred given
patient's advanced kidney disease. Various titrations of the
home
BP regimen have been undertaken in recent months.
Past Medical History:
-CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA
___ DES to LAD and Cx/OM ___ DES to LAD ___
PCI of Cx and OM with ___
-___ renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
-Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
-Hypertension
-Dyslipidemia
-Scleroderma w/ CREST syndrome
-Gastroparesis/GERD/Hiatal hernia
-Gout diagnosed ___ years ago
-OSA
-Pancreatic cyst
-Non convulsive status epilepticus
-stroke
-BPPV
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: reviewed in OMR
GENERAL: Caucasian female in NAD, alert and interactive. Appears
older than her stated age.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally with bibasilar crackles
noted. No wheezes. No increased work of breathing on RA.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: +BS, soft, slightly distended, but non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: 1+ edema bilaterally to mid-shins. No clubbing or
cyanosis. Pulses DP/Radial 2+ bilaterally.
SKIN: Warm. No rash.
NEUROLOGIC: A&Ox3, no focal neurologic deficits. CN2-12 grossly
intact. ___ strength throughout.
DISCHARGE PHYSICAL EXAM:
GENERAL: Ill appearing woman laying in bed, NAD
HEENT: NCAT.
NECK: JVP of ~10cm
CARDIAC: Normal rate and rhythm. Loud S2. Grade ___ blowing
systolic murmur.
LUNGS: Crackles bilaterally at the bases. No wheezes or rhonchi.
ABDOMEN: Soft, non-tender to deep palpation in all four
quadrants. Distended.
EXTREMITIES: Warm and well perfused. 1+ pitting edema
bilaterally
to mid shin. No clubbing or cyanosis. Pulses DP/Radial 2+
bilaterally.
NEUROLOGIC: Alert. Oriented to self, place, and time. Sensation
to light touch intact throughout. Motor function symmetric
throughout.
Pertinent Results:
ADMISSION LABS:
=================
___ 07:44PM WBC-4.9 RBC-2.98* HGB-10.4* HCT-32.4*
MCV-109* MCH-34.9* MCHC-32.1 RDW-14.7 RDWSD-58.2*
___ 07:44PM PLT COUNT-180
___ 07:44PM NEUTS-76.7* LYMPHS-12.0* MONOS-8.7 EOS-1.6
BASOS-0.4 IM ___ AbsNeut-3.72 AbsLymp-0.58* AbsMono-0.42
AbsEos-0.08 AbsBaso-0.02
___ 07:44PM GLUCOSE-86 UREA N-57* CREAT-2.8* SODIUM-145
POTASSIUM-5.3 CHLORIDE-107 TOTAL CO2-28 ANION GAP-10
___ 07:44PM cTropnT-0.28*
___ 07:44PM CK-MB-7 proBNP->70000*
DISCHARGE LABS:
==================
___ 07:50AM BLOOD WBC-6.0 RBC-2.19* Hgb-7.6* Hct-24.4*
MCV-111* MCH-34.7* MCHC-31.1* RDW-12.8 RDWSD-51.3* Plt ___
___ 10:03AM BLOOD Neuts-82.9* Lymphs-8.1* Monos-8.1
Eos-0.3* Baso-0.3 Im ___ AbsNeut-5.75 AbsLymp-0.56*
AbsMono-0.56 AbsEos-0.02* AbsBaso-0.02
___ 07:50AM BLOOD Plt ___
___ 08:12AM BLOOD Glucose-137* UreaN-60* Creat-3.3* Na-145
K-4.6 Cl-107 HCO3-30 AnGap-8*
___ 08:12AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.1
MICROBIOLOGY:
================
__________________________________________________________
___ 12:56 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 10:05 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:25 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:30 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 11:50 am BLOOD CULTURE #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:44 pm BLOOD CULTURE #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
=========
CHEST (PA & LAT)Study Date of ___
IMPRESSION:
Mild basilar atelectasis without definite focal consolidation.
Difficult to
exclude trace pleural effusion, but no large pleural effusion is
seen. No
overt pulmonary edema.
RENAL TRANSPLANT U.S. RIGHTStudy Date of ___
IMPRESSION:
1. Unremarkable appearance of the transplant kidney in the left
lower quadrant
with no hydronephrosis.
2. Patent renal transplant vasculature. The RIs remain
elevated. The main
renal artery demonstrates mild parvus tardus waveform and absent
diastolic
flow.
3. Bladder wall thickening suggesting hypertrophy or neuropathic
bladder
changes.
Transthoracic Echocardiogram Report Date: ___
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
normal cavity size and mild to moderate global systolic
dysfunction. Increased PCWP. Mild mitral regurgitation. Mild
aortic regurgitation. Mild tricuspid regurgitation.
CT HEAD W/O CONTRASTStudy Date of ___
IMPRESSION:
1. No evidence for acute hemorrhage or acute major vascular
territorial
infarct.
2. Multiple chronic infarcts are again demonstrated.
3. Paranasal sinus disease.
CHEST (PORTABLE AP)Study Date of ___
IMPRESSION:
Compared to chest radiographs ___ through ___.
Moderate cardiomegaly is larger and pulmonary vasculature is
more engorged but
there is probably no pulmonary edema. Elevation right lung base
could be due
to subpulmonic pleural effusion or right basal atelectasis.
Skin fold should
not be mistaken for left pneumothorax.
MRA BRAIN W/O CONTRASTStudy Date of ___
IMPRESSION:
1. Multiple small acute or early subacute infarcts, in the right
thalamus,
right external capsule, right parietal cortex, and possibly in
the right
insular cortex.
2. 2 mm laterally projecting outpouching, right cavernous
intracranial ICA,
small infundibulum versus tiny aneurysm.
3. Areas of mild to severe luminal narrowing, bilateral
posterior cerebral
arteries, presumably due to underlying atheromatous disease,
most severely
affecting the left P4 PCA. There is nonetheless preserved
distal PCA runoff
bilaterally.
4. Otherwise, patent circle of ___ vasculature. No
additional stenosis,
aneurysm, or occlusion.
5. Multiple foci of supratentorial and infratentorial
encephalomalacia,
compatible sequelae of remote infarction.
6. Small chronic right periventricular white matter infarcts.
7. Multiple foci of chronic microhemorrhage; although there are
a few
supratentorial foci, these are most conspicuous in the
brainstem, raising the
possibility of hypertensive angiopathy.
Brief Hospital Course:
TO OUTSIDE PROVIDERS:
======================
___ woman with PMHx significant for ESRD s/p LURT in
___, CAD s/p ___ 4 (most recent ___, HFrEF (EF 35-40%
___, T1DM, poorly controlled HTN, scleroderma/CREST, who was
transferred from OSH for lower extremity edema with evidence of
HFrEF exacerbation, and UTI in setting of h/o MDR UTIs, hospital
course complicated by poorly controlled blood glucose, labile
blood pressure, and new CVA.
TRANSITIONAL ISSUES FOR PCP:
============================
[] MEDICATION CHANGES:
ADDITIONS:
-----------
clonidine 0.1 mg/24 hour
torsemide 20 mg QD
CHANGES (below is current regimen & stated reason for change):
allopurinol ___ mg Q48H (based on renal function)
cyclosporine 25 mg QAM + 50 mg QPM (per Renal based on levels
and renal function)
hydralazine 50 mg TID (for better BP control)
isosorbide mononitrate 120 mg QD (for better BP control)
levetiracetam 250 mg PO BID (based on renal function)
sodium bicarbonate 650 mg BID (based on HCO3- levels, per Renal)
HELD (all held to reduce pill burden, restart as necessary and
tolerated):
calcium carbonate 500 mg PO QD
esomeprazole magnesium 40 mg PO BID
ferrous sulfate 325 mg PO QD
furosemide 20 mg PO QD
meclizine 12.5 mg PO Q8H: PRN
ranolazine ER 500 mg PO BID
vitamin D ___ U PO QD
melatonin 10 mg PO QHS
[] Fluid status:
On discharge, we think she is still slightly volume overloaded.
We will start torsemide 20 mg daily, and we instructed her to
take daily weights. Please re-evaluate her edema and creatinine
and alter as necessary, eventually may need only Q48H dosing.
[] HTN:
Significant issue during hospitalization complicated by CVA.
Discharge regimen is:
clonidine 0.1 mg/24 hour
torsemide 20 mg QAM
hydralazine 50 mg TID
isosorbide mononitrate 120 mg QAM
metoprolol succinate 100 mg QHS
Please adjust as necessary, may need increase in clonidine patch
to 0.2 mg if continued hypertension. Consider ambulatory BP
monitor to assess control throughout the day.
ACUTE ISSUES:
=============
# Volume overload:
# ___ edema:
# c/f HFrEF Exacerbation (EF 35-40% on TTE in ___:
Patient with history of lower extremity edema but with labile
BPs that often prevent adequate diuresis. Presented to
cardiologist clinic with worsening ___ edema, found to have BNP
>70000 on
presentation to ___ ED. Also noted to be hypertensive as below
in the ED, but unclear if this was precipitating factor of HFrEF
exacerbation. Patient was diuresed with furosemide. Repeat TTE
generally unchanged, estimated elevated PCWP. Volume overload
also complicated by nephrotic syndrome.
#Acute and subacute thalamic and external capsule infarcts:
#Hypertensive angiopathy:
Patient received MRI/MRA head which revealed new infarcts in
deeper brain structures, concerning for hypertension as cause of
infarcts. Pt was seen by neurology who recommended daily
Aspirin and BP control for ongoing stroke prevention.
#Hypertensive urgency:
Patient presented with BP 201/110. Improved with
anti-hypertensives and diuresis in ED. Patient reports
compliance with medications and was normotensive at recent
outpatient appointment, so unclear what precipitated high BP in
ED. Pt has very labile BPs likely related to DM autonomic
neuropathy that was difficult to manage even while inpt.
Nephrotic syndrome may be contributing to HTN. Renal (time of
flight) MRI was performed to evaluate for RAS and there was not
evidence of arterial stenosis in vessels perfusing the
transplanted kidney. Medications were titrated to improve
pressures as listed in discharge medications.
#Acute complicated cystitis, treated:
Dysuria on admission, UA positive. UCx positive for
Enterococcus. Given PCN allergy, decision was made to treat with
vancomycin for 10 day course (given history of transplant) and
this course was completed.
___:
#ESRD ___ T1DM and HTN s/p LURT (___):
#Nephrotic syndrome:
Patient has chronic allograft dysfunction due to diabetic
nephropathy, partial rejection with baseline Cr reportedly 3.0
though slightly lower on chart review. Patient has long history
of nephrotic syndrome, biopsy proven ___ T1DM. Likely
contributing to her edema. Cr increased above baseline, likely
pre-renal ___ due to overdiuresis. Renal transplant was
consulted for management. She was continued on her home
immunosuppressants. SPEP/UPEP were negative. Renal assisted with
fluid management, Cr returned to near baseline at d/c.
#Type 1 DM:
Very labile blood sugar with episodes of hypo- and hyperglycemia
throughout hospitalization. ___ was consulted for assistance
with management of blood sugars. Regimen as noted on d/c
medications.
CHRONIC ISSUES:
===============
#Chronic nausea:
Continue home anti-emetics, standing promethazine PRN and
multiple medications held as they were contributing to pill
burden and daily vomiting.
#Scleroderma w/ CREST syndrome:
On immunosuppression as above.
#Gastroparesis/GERD/hiatal hernia:
Continued home esomeprazole.
#Seizure disorder:
Nonconvulsive status diagnosed during previous admission and
started on divalproate and levetiracetam at that time. Continued
home divalproex ___ BID, levetiracetam 250mg BID (dose-reduced
for renal function).
#Macrocytic anemia:
Chronic, secondary to ESRD, immunosuppression. Possibly a
dilutional component from fluids. Was initially maintained on
EPO, but was discontinued given new onset stroke.
#Gout:
-Continue home allopurinol.
#Hypothyroidism:
-Continue home levothyroxine.
#Hyperlipidemia:
-Continued home pravastatin.
#BPPV:
-Continued home meclizine PRN.
GOC: We held many discussions with patient and her sister
___ about her many medical issues contributing to her
declining quality of life with > 10 admissions during ___. Pt
endorsed poor tolerance of having to take so many pills and
waxing/waning confusion even at home. Pt often expressed
wanting to be DNAR/DNI and would NEVER want a feeding tube. She
was undecided about ever wanting dialysis. However, her sister
___ did not feel that these choices accurately represented the
patient's perspective as they had a different conversation weeks
before admission when they first filled out a MOLST.
Palliative care followed and will continue to see her as an
outpatient. I have reached out to her PCP to encourage ongoing
conversations about her goals as she is very likely to get
readmitted given her many medical problems that are difficult to
manage.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Calcium Carbonate 500 mg PO DAILY
5. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
6. Divalproex (DELayed Release) 750 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. LevETIRAcetam 500 mg PO BID
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Mycophenolate Mofetil 500 mg PO BID
11. Pravastatin 30 mg PO QPM
12. PredniSONE 5 mg PO DAILY
13. Ranolazine ER 500 mg PO BID
14. Sodium Bicarbonate 1300 mg PO BID
15. Senna 8.6 mg PO BID
16. melatonin 10 mg oral QHS
17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
18. Esomeprazole Magnesium 40 mg oral BID
19. Promethazine 25 mg PO Q8H:PRN nausea
20. Meclizine 12.5 mg PO Q8H:PRN vertigo, nausea
21. Lidocaine 5% Patch 1 PTCH TD QAM
22. Fluticasone Propionate NASAL 2 SPRY NU QHS
23. Furosemide 20 mg PO DAILY
24. HydrALAZINE 50 mg PO BID
25. Isosorbide Mononitrate (Extended Release) 60 mg PO QHS
26. Metoprolol Succinate XL 100 mg PO DAILY
27. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
28. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QSAT
RX *clonidine 0.1 ___ on skin. once a day Disp #*10
Patch Refills:*0
2. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
3. Allopurinol ___ mg PO EVERY OTHER DAY
4. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM
5. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM
6. HydrALAZINE 50 mg PO TID
7. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
8. LevETIRAcetam 250 mg PO BID
9. Metoprolol Succinate XL 100 mg PO QHS
10. Sodium Bicarbonate 650 mg PO BID
11. Aspirin 81 mg PO DAILY
12. Calcitriol 0.25 mcg PO DAILY
13. Divalproex (DELayed Release) 750 mg PO BID
14. Fluticasone Propionate NASAL 2 SPRY NU QHS
15. Levothyroxine Sodium 125 mcg PO DAILY
16. Lidocaine 5% Patch 1 PTCH TD QAM
17. Mycophenolate Mofetil 500 mg PO BID
18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
19. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
20. Pravastatin 30 mg PO QPM
21. PredniSONE 5 mg PO DAILY
22. Promethazine 25 mg PO Q8H:PRN nausea
23. Senna 8.6 mg PO BID
24. HELD- Calcium Carbonate 500 mg PO DAILY This medication was
held. Do not restart Calcium Carbonate until told to restart by
a doctor.
25. HELD- Esomeprazole Magnesium 40 mg oral BID This medication
was held. Do not restart Esomeprazole Magnesium until told to
restart by a doctor.
26. HELD- Ferrous Sulfate 325 mg PO DAILY This medication was
held. Do not restart Ferrous Sulfate until told to restart by a
doctor.
27. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until told to restart by a doctor.
28. HELD- Meclizine 12.5 mg PO Q8H:PRN vertigo, nausea This
medication was held. Do not restart Meclizine until told to
restart by a doctor.
29. HELD- melatonin 10 mg oral QHS This medication was held. Do
not restart melatonin until told to restart by a doctor.
30. HELD- Ranolazine ER 500 mg PO BID This medication was held.
Do not restart Ranolazine ER until told to restart by a doctor.
31. HELD- Vitamin D ___ UNIT PO DAILY This medication was
held. Do not restart Vitamin D until told to restart by a
doctor.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
heart failure
stroke
hypertensive emergency
___
ESRD
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
WHY WERE YOU ADMITTED?
-You had lower extremity edema.
WHAT HAPPENED WHEN YOU WERE HERE?
-We thought you had fluid overload from heart failure so we
worked on getting fluid out of your body.
-Your blood pressure was very high we worked on controlling it.
-We noted that you had what looked like strokes on your head
imaging.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
-Continue to take all of your medications as described in your
discharge packet.
-Please followup with all of your doctors, especially your
primary care provider this week. Bring this handout.
-Your primary care doctor should help you with your diuretics
and blood pressure.
-Weight yourself daily and write the values down. If your
weight changes by a few pounds in 1 day, call your doctor for
assistance.
-Continue to check you blood pressure at home, making sure you
are seated for 5 minutes before checking it, resting your arm on
a table. Write down these values and bring them to your
doctor's appointments.
We wish you the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10031358-DS-9 | 10,031,358 | 29,498,981 | DS | 9 | 2158-09-07 00:00:00 | 2158-09-07 17:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
ACE Inhibitors / ___ Receptor Antagonist
Attending: ___.
Chief Complaint:
slurred speech, facial droop
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old male with history of DM, HTN, HLD,
and noncompliance to meds for financial reasons, who developed
right facial droop and slurred speech yesterday afternoon around
3pm. He says that he was feeling like himself yesterday, and he
is not missing any part of the day. Around 3pm, he called his
sister, and she could not understand any words that he was
saying. He noticed that his speech was slurred, but he did not
have any difficulty understanding others or getting words out.
He
then looked in the mirror, and he noted that the right side of
his face was droopy. He thought that it was due to his diabetes
because he has not taken his diabetes medications in over a
year.
His wife came home, and she noted that his speech was slurred
and
that his face was asymmetric. This morning, his wife woke up and
realized that her friend had had a TIA where people could not
understand what they were saying. She called his PCP who
recommended an urgent visit in the clinic, but she decided to
bring him to the ED.
In ___, he had amputation of his toes on the right foot,
and he was in rehab in ___. He tried to get up and
get
a cup of coffee, but he was connected to a wound vacuum on his
heel. He tripped and fell, and his wife says that he hit the
back
of his head. She did not witness the fall, and she is not sure
if
he lost consciousness. He was transported to ___, where he was
found to have a 4mm right parafalcine subdural hemorrhage. The
next day at ___, he was reported to have a seizure. His wife
was not present, and there is no description over the episode
other than a "generalized tonic-clonic seizure". He was started
on levetiracetam, but he has not been taking it for the past two
months.
He currently denies headache, loss of vision, diplopia,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, parasthesiae. No bowel
or bladder incontinence or retention. Otherwise, his general
review of systems is negative.
Past Medical History:
Hypothyroidism
DM (diabetes mellitus), type 2 with renal complications,
retinopathy
Diabetic retinopathy
CKD (baseline 1.1-1.3)
Hypertension
B12 deficiency
Bipolar disorder
Depression
Tremor, ?parkinsonism
Colonic adenoma
___ esophagus
Social History:
___
Family History:
mGM with DM and CAD. Sister with breast cancer and bipolar
disorder. Father with stomach cancer, peptic ulcer disease,
bipolar disorder, kidney disease, died of PNA. Mother with
bipolar disorder, died of bone cancer (per records report of
breast cancer, but patient notes it was bone cancer).
Physical Exam:
Admission Physical Exam:
Vitals: 97.3 69 151/64 18 99% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM
Neck: Supple
Pulmonary: No increased WOB
Cardiac: RRR
Abdomen: Soft, non-distended
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name days of the week
backward without difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. He was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk.
EOMI
without nystagmus. Normal saccades. VFF to confrontation. V:
Facial sensation intact to light touch. VII: Right facial droop,
symmetric strength in upper face VIII: Hearing intact to
finger-rub bilaterally.
IX, X: Palate elevates symmetrically. XI: ___ strength in
trapezii and SCM bilaterally. XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Pronation and mild drift
on
the right, orbiting of the right arm
Delt Bic Tri WrE IO IP Quad Ham TA
L 5 ___ ___ 5 5
R 5 ___ ___ 5 5
-Sensory: No deficits to light touch
-DTRs:
Bi Tri ___ Pat
L 2 2 2 2
R 2 2 2 2
-Coordination: No intention tremor. No dysmetria on FNF or HKS
bilaterally. Slightly slower finger tapping on the right.
-Gait: non-ambulatory
=========================================
DISCHARGE PHYSICAL EXAMINATION:
Vitals: 98.4 97.7 99-123/40-60 ___ 18 98%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM
Pulmonary: No increased WOB
Abdomen: Soft, non-distended
Neurologic:
-Mental Status: Alert, oriented x 3. Language is fluent with
intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Speech was dysarthric. Able to follow both
midline and appendicular commands. There was no evidence of
apraxia or neglect.
-Cranial Nerves: II, III, IV, VI: PERRL 5 to 4mm and brisk.
EOMI
without nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: Right NLFF, symmetric strength in upper face
IX, X: Palate elevates symmetrically. XI: ___ strength in
trapezii and SCM bilaterally. XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Pronation and mild drift
on
the right, orbiting of the right arm
Delt Bic Tri WrE IO IP Quad Ham TA
L 5 ___ ___ 5 5
R 5 ___ ___ 5 5
-Sensory: No deficits to light touch
-Coordination: No intention tremor. No dysmetria on FNF or HKS
bilaterally. Slightly slower finger tapping on the right.
-Gait: not tested
Pertinent Results:
___ 05:20AM BLOOD WBC-9.2 RBC-4.15* Hgb-11.9* Hct-35.9*
MCV-87 MCH-28.7 MCHC-33.1 RDW-13.0 RDWSD-40.4 Plt ___
___ 02:30AM BLOOD WBC-11.4* RBC-3.96* Hgb-11.5* Hct-34.1*
MCV-86 MCH-29.0 MCHC-33.7 RDW-12.9 RDWSD-39.8 Plt ___
___ 06:15AM BLOOD WBC-11.0* RBC-4.41* Hgb-12.6* Hct-38.5*
MCV-87 MCH-28.6 MCHC-32.7 RDW-13.3 RDWSD-41.4 Plt ___
___ 05:20AM BLOOD Neuts-53.5 ___ Monos-13.2*
Eos-4.0 Baso-1.0 Im ___ AbsNeut-4.92 AbsLymp-2.53
AbsMono-1.21* AbsEos-0.37 AbsBaso-0.09*
___ 06:15AM BLOOD Neuts-58.2 ___ Monos-11.4 Eos-4.0
Baso-0.9 Im ___ AbsNeut-6.40*# AbsLymp-2.72 AbsMono-1.26*
AbsEos-0.44 AbsBaso-0.10*
___ 05:20AM BLOOD Plt ___
___ 05:20AM BLOOD ___ PTT-29.5 ___
___ 02:30AM BLOOD Plt ___
___ 02:30AM BLOOD ___ PTT-29.5 ___
___ 05:20AM BLOOD Glucose-233* UreaN-27* Creat-1.3* Na-134
K-4.1 Cl-99 HCO3-24 AnGap-15
___ 02:30AM BLOOD Glucose-156* UreaN-23* Creat-1.4* Na-135
K-4.2 Cl-100 HCO3-22 AnGap-17
___ 06:15AM BLOOD Glucose-304* UreaN-20 Creat-1.6* Na-134
K-5.8* Cl-99 HCO3-21* AnGap-20
___ 06:15AM BLOOD ALT-16 AST-33 AlkPhos-74 TotBili-0.4
___ 06:15AM BLOOD Lipase-50
___ 06:15AM BLOOD cTropnT-<0.01
___ 05:20AM BLOOD Calcium-9.8 Phos-3.6 Mg-1.8
___ 02:30AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.7 Cholest-203*
___ 06:15AM BLOOD Albumin-3.7
___ 02:30AM BLOOD %HbA1c-8.5* eAG-197*
___ 02:30AM BLOOD Triglyc-396* HDL-38 CHOL/HD-5.3
LDLcalc-86
___ 06:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ CT HEAD W/O CONTRAST
1. 13 mm hemorrhage in the left putamen, compatible with
hypertensive
hemorrhage.
2. Paranasal sinus inflammatory disease.
___ CXR
No acute cardiopulmonary process.
___ MR HEAD W/O CONTRAST
1. Stable left putaminal hematoma with mild surrounding edema
and no
significant effect or midline shift. No acute infarct.
2. No visualization of the right distal V3 or V4 segments of the
vertebral
artery with a diminutive distal right V4 segment seen. This may
represent a diminutive vessel versus occlusion. A MRA can be
acquired for further
evaluation if clinically indicated.
3. Paranasal sinus disease.
4. Prominence of the posterior nasopharyngeal soft tissues,
which may
represent prominent adenoids. Recommend correlation with direct
visualization.
Brief Hospital Course:
Mr. ___ is a ___ year old male with history of DM,
HTN, HLD, and noncompliance to medications for financial reasons
who is admitted to the Neurology stroke service with right
facial droop and slurred speech the day prior to admission
secondary to an acute intraparenchymal hemorrhage in the Left
basal ganglia. Aspirin was held initially. His stroke was most
likely secondary to medication noncompliance for the 2 months
prior to admission due to financial difficulties. ASA 81 daily
will be restarted upon hospital discharge. He should continue
his home metoprolol and HCTZ for blood pressure control. His
deficits improved prior to discharge and the only notable
weakness was in the right nasolabial fold. He was seen by ___,
OT, and speech and swallow therapy. He will be discharged home
with outpatient speech therapy. His intraparenchmal hemorrhage
risk factors include the following:
1) DM: A1c 8.5%
2) Poorly controlled hypertension
3) Obesity
Since he has not taken his meds for the two months prior to
hospital admission, his Seroquel was restarted at the much lower
dose of 100mg qhs. The Seroquel may be uptitrated as an
outpatient as per his PCP or psychiatrist. The Seroquel was not
restarted at his prior dose of 600mg qhs because this may have
resulted in a dangerous possibility of getting a prolonged Qtc
syndrome and somnolence, among other possible side effects.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Glargine 60 Units Bedtime
aspart 8 Units Breakfast
aspart 8 Units Lunch
aspart 8 Units Dinner
5. Levothyroxine Sodium 125 mcg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. QUEtiapine extended-release 600 mg PO QHS
8. Sertraline 50 mg PO DAILY
9. Simvastatin 40 mg PO QPM
10. Aspirin 81 mg PO DAILY
11. Cyanocobalamin 50 mcg PO DAILY
12. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Simvastatin 40 mg PO QPM
RX *simvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Sertraline 50 mg PO DAILY
RX *sertraline 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
6. FoLIC Acid 1 mg PO DAILY
7. Cyanocobalamin 50 mcg PO DAILY
8. Levothyroxine Sodium 125 mcg PO DAILY
RX *levothyroxine 125 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
10.
RX *quetiapine 100 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
11. Vitamin D ___ UNIT PO DAILY
12. LeVETiracetam 750 mg PO BID
RX *levetiracetam 750 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
13. Outpatient Speech/Swallowing Therapy
1. PO diet: thin liquids, regular solids, Pills: whole in thin
liquids
2. Standard aspiration precautions, including: Small bites, chew
thoroughly
3. Speech tx upon discharge
14. 70/30 16 Units Breakfast
70/30 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin NPH and regular human [Humulin 70/30 KwikPen] 100
unit/mL (70-30) AS DIR 16 Units before BKFT; 10 Units before
DINR; Disp #*30 Syringe Refills:*0
15. KwikPen Needles
KwikPen Needles
30
Discharge Disposition:
Home
Discharge Diagnosis:
Intraparenchymal hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of facial droop and
slurred speech resulting from an acute bleed in your brain
(intraparenchymal hemorrhage). The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Bleeding in the brain can have many different causes, so we
assessed you for medical conditions that might raise your risk.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Diabetes
High blood pressure
High cholesterol
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10031575-DS-20 | 10,031,575 | 27,796,946 | DS | 20 | 2171-03-29 00:00:00 | 2171-03-29 20:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea, chest pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ woman with HTN, IDDM, HLD with heart failure (unknown EF)
diagnosed ___ at ___ here with worsening dyspnea on exertion,
lower extremity edema.
She was initially presented to ___ ___ and was diagnosed with
heart failure. She was diuresed in the hospital and improved.
She had poor adherence on follow up, stopped taking 60mg po
Lasix when she was discharged. She did continue to take on
metoprolol and lisinopril. She does not weigh herself.
Presents with gradually worsening dyspnea on exertion, lower
extremity edema, PND, orthopnea for two months, but most
noticeably over the last 2 weeks. She cannot walk up a flight of
stairs without stopping several times due to dyspnea, she cannot
walk >1city block at a time due to dyspnea, which resolves with
rest. Her lower extremities have become progressively swollen
over the last few months, but now feel "tight" and heavy.
She also reported an isolated episode of sharp chest pain
awakening her from sleep last night which lasted seconds and
resolved without intervention. Location L anterior chest with
radiation to her left arm. No association with palpation,
position. She denies current chest pain/pressure, or chest
pressure that increases with predictable activity or resolves
with rest. She was given sublingual nitro x1 in ambulance.
Of note, she is a longstanding diabetic, diagnosed ___ years
ago. Over the last ___ years has gotten better control. Knows she
has retinopathy, severe neuropathy. Has never been told had
kidney problems before. She has an opthalomologist but never has
seen podiatry.
She notes history of foot wound that was "cut" by PCP in
___. She describes being prescribed a 14 day course of
augmentin for this wound. She does not remember being told it
was related to diabetes.
In the ED initial vitals were:
97.6 90 138/83 20 100% Nasal Cannula
BP notable for 170-190's/70's-100's
Labs/studies notable for:
___: 10773, Trop-T 0.04, CK 426, MB 5
Cr 1.6 (unknown baseline), Chem 10 otherwise unremarkable
Hg 10.9, WBC, PLT wnl
UA 300 prtn RBC 163, Blood Mod
LUE Ultrasound ___:
No evidence of deep vein thrombosis in the left upper extremity.
CXR ___:
No definite focal consolidation is seen. There is no large
pleural effusion or pneumothorax. The cardiac and mediastinal
silhouettes are stable. No pulmonary edema is seen.
No acute cardiopulmonary process.
BEDSIDE TTE by cards fellow ___: some LVH, mild MR, AI, TR,
trivial effusion, unable to clearly assess wall motion.
Patient was given:
IV Furosemide 80 mg
Vitals on transfer:
VS: T98 BP194/101, 168/86 HR 73 RR 20 O2 SAT 97% RA
On the floor the patient reports fatigue but denies dyspnea,
chest pressure, nausea, vomiting.
Past Medical History:
- Diabetes mellitus, A1C 7.2% on admission (___), complicated
by neuropathy
- Hypertension
- Hyperlipidemia
- HF pEF, diagnosed during hospitalization at ___ (___)
- R foot ulcer
Social History:
___
Family History:
Cousin with ICD placement, ___
No family history of early MI, cardiomyopathies, or sudden
cardiac death.
Physical Exam:
== ADMISSION PHYSICAL EXAMINATION ==
VS: T98 BP194/101, 168/86 HR 73 RR 20 O2 SAT 97% RA
I/O: -/540in ED +NR
Weight: 126.2kg, unknown dry weight
GENERAL: Well developed, well nourished female 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 13cm with head of bed at 30 degrees
CARDIAC: laterally displaced PMI. Regular rate and rhythm.
Normal S1, S2. diastolic murmur. No rubs, or gallops. No thrills
or lifts.
LUNGS: Respiration is unlabored with no accessory muscle use.
Breath sounds limited by habitus. Crackles to bases, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly.
EXTREMITIES: 4+ pitting edema to thighs B/L, 1+ extending to
umbilicus. Warm, well perfused. No clubbing, cyanosis. L>R arm
swelling.
SKIN: R foot with 1cm punched out, ~3mm deep ulcer with foul
smell emanating, but no overt. No rashes.
NEURO: decreased sensation to light touch to feet B/L.
== DISCHARGE PHYSICAL EXAMINATION ==
VITALS: T 97.2, BP 135-145/79-88, HR 72-85, RR 18, SpO2 98/RA
WEIGHT: 106.1 kg -> 107 kg
I/O: 24hr 1100/2175, 8h 100/800
GENERAL: well-appearing obese female, NAD
HEENT: moist membranes, PERRL
NECK: JVP elevated to 7-8cm at 45 degrees, thyromegaly R>L
CARDIAC: RRR, ___ high pitched SEM at RUSB, heard throughout
rest of precordium
LUNGS: distant breath sounds, CTAB
ABDOMEN: Normoactive BS throughout, non tender
EXTREMITIES: WWP, 2+ pitting edema to knees b/l. R heel -
wrapped in guaze, dressing is clean/dry
Pertinent Results:
== ADMISSION LABS ==
___ 11:45AM BLOOD WBC-6.1 RBC-3.96 Hgb-10.9* Hct-34.2
MCV-86 MCH-27.5 MCHC-31.9* RDW-13.9 RDWSD-43.5 Plt ___
___ 11:45AM BLOOD Neuts-63.8 ___ Monos-6.4 Eos-1.3
Baso-0.5 Im ___ AbsNeut-3.88 AbsLymp-1.69 AbsMono-0.39
AbsEos-0.08 AbsBaso-0.03
___ 11:45AM BLOOD ___ PTT-31.8 ___
___ 11:45AM BLOOD Glucose-83 UreaN-16 Creat-1.6* Na-141
K-3.4 Cl-107 HCO3-28 AnGap-9
___ 11:45AM BLOOD CK(CPK)-426*
___ 11:45AM BLOOD CK-MB-5 ___
___ 11:45AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.6 Iron-58
== NOTABLE INTERVAL LABS ==
___ 05:55PM BLOOD ALT-12 AST-18 LD(LDH)-303* CK(CPK)-559*
AlkPhos-91 TotBili-0.2
___ 06:29AM BLOOD CK(CPK)-328*
___ 11:45AM BLOOD calTIBC-233* Ferritn-27 TRF-179*
___ 11:45AM BLOOD %HbA1c-7.2* eAG-160*
___ 11:45AM BLOOD TSH-6.1*
___ 03:00PM BLOOD T4-7.4
___ 11:45AM BLOOD RheuFac-14 ___ CRP-4.9
___ 03:00PM BLOOD PEP-AWAITING F FreeKap-86.8*
FreeLam-52.2* Fr K/L-1.66* IFE-PND
== IMAGING ==
-- ___ CXR
No acute cardiopulmonary process.
-- ___ UNILAT UPPER EXTR ULTRASOUND
No evidence of deep vein thrombosis in the left upper extremity.
-- ___ TTE
The left atrium is moderately dilated. The estimated right
atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 55%). The estimated
cardiac index is depressed (<2.0L/min/m2). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. There is abnormal systolic septal motion/position
consistent with right ventricular pressure overload. 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. Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. There is absent transmitral A wave
c/w impaired left atrial mechanical function. Mild to moderate
(___) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is a trivial pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and low normal global left ventricular
systolic function. Moderate pulmonary artery systolic
hypertension. Mild-moderate mitral regurgitation. Mildly dilated
thoracic aorta. Increased PCWP. Absent transmitral A wave.
The symmetric left ventricular hypertrophy with increased PCWP
and absent transmitral A wave and multivalvular regurgitation
are suggestive of an infiltrative process (e.g., amyloid).
-- ___ CARDIAC MRI
The left atrial AP dimension is mildly increased with moderate
left atrial elongation. The right atrium is
moderately dilated. There is normal left ventricular wall
thickness with normal mass. Normal left ventricular
end-diastolic dimension with SEVERELY increased left ventricular
end-diastolic volume and
moderately increased end-diastolic volume index. There is mild
global left ventricular hypokinesis with
relative preservation of apical function. The left ventricular
cardiac index is normal. There is uniformity
in regional T2. Early gadolinium enhancement images showed no
enhancement. There is no late
gadolinium enhancement (absence of scar/fibrosis). Mildly
increased right ventricular end-diastolic volume
index with mild global free wall hypokinesis and low normal
ejection fraction. Normal origin of the
right and left main coronary arteries. Mildly increased
ascending aorta diameter (normal BSA indexed
ascending aorta diameter) with normal aortic arch diameter and
mIldly dilated descending thoracic aorta
(normal BSA indexed descending aorta diameter). Mildly increased
abdominal aorta diameter (normal
BSA indexed abdominal aorta diameter). Moderately increased
pulmonary artery diameter with mildly
increased BSA indexed PA diameter. The # of aortic valve
leaflets could not be determined. There is no
aortic valve stenosis. Mild aortic regurgitation is seen. There
is moderate mitral regurgitation. There is
moderate tricuspid regurgitation. There is a small
circumferential pericardial effusion. Pericardial thickness
is normal. There is a small right pleural effusion.
IMPRESSION: Normal left ventricular wall thickness and global
mass. Moderately dilated left ventricular
cavity with mild global hypokinesis. No evidence of myocardial
edema, inflammation, infiltration
or scar/fibrosis. Mildly dilated right ventricular cavity with
low normal free wall motion. Moderate mitral
regurgitation. Moderate tricuspid regurgitation.
These findings are most c/w a non-ischemic dilated
cardiomyopathy.
___ Imaging THYROID U.S.
Heterogeneous hypervascular thyroid gland compatible with
thyroiditis. No
discrete nodules identified.
== DISCHARGE LABS ==
___ 04:25AM BLOOD WBC-6.6 RBC-4.20 Hgb-11.4 Hct-36.1 MCV-86
MCH-27.1 MCHC-31.6* RDW-14.1 RDWSD-43.8 Plt ___
___ 04:25AM BLOOD Plt ___
___ 04:25AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.0
Brief Hospital Course:
This is a ___ year old woman with a PMH notable for hypertension,
hyperlipidemia, history of heart failure (NOS) and type II
diabetes mellitus (on insulin), who presented with massive ___
edema, concerning for heart failure, found to have signs
suggestive of infiltrative cardiac disease on TTE.
# Acute on chronic heart failure with preserved ejection
fraction: diagnosed ___ at ___ [records obtained, in paper
chart -- notable for EF 56%, grade II diastolic dysfunction, dry
weight 110 kg]. TTE concerning for restrictive physiology and
possible infiltrative process, such as amyloidosis. Cardiac MRI
obtained, which demonstrated what is almost certainly dilated
cardiomyopathy due to hypertension. No evidence of infiltrative
disease on cardiac MRI. Presented massively overloaded on
examination. Aggresively diuresed with furosemide gtt, then
furosemide boluses, and finally oral torsemide. Initially held
lisinopril given elevated Cr, but appears baseline. Slowly
restarted & uptitrated, given degree of hypertension &
proteinuria. Metoprolol was stopped, given preserved EF and
possible constrictive physiology.
- Discharge weight: 106.5 kg, 234.8 lbs
- Discharge Cr: 2.1
- Discharge diuretic regimen: torsemide 100mg BID
# Type II NSTEMI: perhaps demand in setting of volume overload
and CHF, as above. Started on aspirin 81 mg daily and
atorvastatin 40 mg HS. Once euvolemic, stress test showed no
focal ischemia or perfusion defects.
# Hypertension: quite elevated on admission (180s+). Lisinopril
40mg used, as above. Started on amlodipine and isosorbide
mononitrate, which she tolerated well with satisfactory
improvement of BP.
# Renal failure: likely chronic, with possible acute component.
Significant proteinuria, with Pr/Cr 11.1. Possible etiologies
include diabetic nephropathy, cardiorenal syndrome and
hypertensive nephropathy. Creatinine 2.1 at discharge; it was
stable at this level for ~1 week prior to discharge.
# NEUROPATHIC HEEL ULCER: not infected. Likely diabetic. Dressed
per wound care recs. Debrided at bedside on ___ by podiatry.
Will follow-up with podiatry as outpatient.
# TYPE II DIABETES: FSG generally under good control. Glargine
decreased to 28U at bedtime with Humalog sliding scale at meals
and bedtime.
# ELEVATED CK: unclear etiology, resolved.
# THYROMEGALY: TSH>6, T4 normal. Thyroid US with vascular
congestion. Discussed case with endocrine, who recommends
outpatient endocrine follow-up. Follow-up appointment is
scheduled.
# IRON DEFICIENCY: Given history of CHF and iron studies
indicative of deficiency, she was given IV iron while in house,
and should have iron studies rechecked as an outpatient.
TRANSITIONAL ISSUES:
====================
[ ] f/u with podiatry for neuropathic ulcer
[ ] f/u with endocrine for radiographic thyroiditis
[ ] Chem ___ at ___ NP appointment next week
[ ] f/u with Dr ___ in ___ office after seeing ___ NP
[ ] Daily weights, call ___ office if increase >3 pounds in one
day
[ ] recheck iron studies as an outpatient to ensure proper
repletion with IV Iron while in house
- Discharge weight: 106.5 kg = 234.8 lbs
- Discharge Cr: 2.1
- Discharge diuretic regimen: torsemide 100mg BID
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Glargine 41 Units Bedtime
4. Gabapentin 100 mg PO TID
5. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
6. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg One tablet(s) by mouth Once a day Disp #*30
Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg One tablet(s) by mouth Once a day Disp #*30
Tablet Refills:*0
3. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg One tablet(s) by mouth Once a day Disp
#*30 Tablet Refills:*0
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg Once tablet(s) by mouth Once a
day Disp #*30 Tablet Refills:*0
5. Torsemide 80 mg PO BID
RX *torsemide 20 mg Four tablet(s) by mouth Once in the morning
and once in the evening Disp #*240 Tablet Refills:*0
6. Glargine 28 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Ferrous Sulfate 325 mg PO DAILY
8. Gabapentin 100 mg PO TID
9. Lisinopril 40 mg PO DAILY
10.straight cane
DX: diabetic ulcer and chronic foot pain
PX: good
___: 12 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses: acute on chronic diastolic heart failure, R
foot ulcer, diabetes mellitus (type II, on insulin)
Secondary diagnoses: elevated CK
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with too much fluid in your
body. You received a medicine called "Lasix" or furosemide, to
help remove the extra fluid from your body.
You also had extensive testing of your heart to find out why you
have "heart failure." This showed that your heart failure is
likely related to your high blood pressure.
You also were seen by the podiatrists ("foot doctors") because
of the wound on the bottom of your right foot. They cleaned it,
and recommended that you follow-up with them in their ___
urgent ___ center one week after discharge (___).
We noticed that your thyroid gland in your neck is bigger than
usual. We did some testing of the thyroid, which showed that it
is working normally. Our endocrine doctors ___ for the
thyroid gland) will see you in the office in a few weeks to
check in on your thyroid. If you notice any difficulty in
swallowing, changes in your voice, racing heart or heart
fluttering, please call their office to tell them your symptoms.
Be sure to take ALL of your medicines as prescribed. Follow up
with your doctors, as scheduled below.
Be sure to weigh yourself every day! Weigh yourself first thing
in the morning, after you have gone to the bathroom. When you
were discharged, your weight was 234.8 lbs. If your weight goes
up by more than 3 lbs in one day, or 5 lbs in one week, call
___ to speak with our cardiology team about your weight
change.
It was a pleasure taking care of you! We wish you the very best.
Your ___ Cardiology Team
Followup Instructions:
___
|
10031575-DS-25 | 10,031,575 | 21,330,901 | DS | 25 | 2173-03-12 00:00:00 | 2173-03-15 15:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ pmhx of HFpEF (EF 55% ___, HTN, DMII c/b peripheral
neuropathy, retinopathy, R toe osteo s/p amp, CKD (b/l 1.9-2.3),
HLD presenting with chest pain.
Pt awoke from sleep at 3:30am on ___ with chest pain described
as sharp substernal, non-pleuritic, radiating to R arm. + nausea
and diaphoresis initially, not recurrent. Has been constant
since then with some mild improvement by the time of arrival to
the floor.
Patient has never had this chest pain before. No increased leg
swelling. Weight stable on torsemide 80/40, no report of dietary
indiscretion.
Patient does have three pillow orthopnea at baseline. No
abdominal pain, no diarrhea or dysuria, no blood in stool or
urine, no severe headache, no double vision, no sore throat. No
cough, no congestion.
Past Medical History:
- Diastolic CHF, LVEF 55% ___, possibly related to HTN.
Diagnosed ___ at ___.
- History of CVA - treated at ___, left sided hemiparesis, ___,
no residual deficits
- Diabetes mellitus, A1C 7.2% (___), complicated by
neuropathy
- Hypertension
- Hyperlipidemia
- R foot ulcer, followed by podiatry
- S/p tubal ligation ___ years ago
- CKDIII (baseline Cr 1.7-2.0)
- R toe osteomyelitis s/p amputation
- iron deficiency anemia
Social History:
___
Family History:
Mother with T2DM and ESRD on HD. Mother has been on HD since
about age ___. Maternal uncle also with T2DM and ESRD on HD.
Children healthy, 1 son with autism.
Physical Exam:
ADMISSION EXAM:
VITALS: 98.7, 154/85, 73, 18, 100% RA
GEN: tired, NAD
HEENT: MM tacky to mildly dry
CV: RRR nl s1/s2 no mrg, no reproduction of CP on palpation
PULM: CTA b/l no wrc
GI: S/ND/NT
EXT: Non-edematous, warm
DISCHARGE EXAM:
Temp: 99 PO BP: 140-150s/90s HR: 90s RR: 18 O2 sat: 96% O2
delivery: RA
GEN: cooperative, NAD
HEENT: dry mucous membranes, mild gum inflammation on left side
of mouth, no pharyngeal erythema
NECK: JVP ~8cm at 30 degrees.
CV: RRR nl s1/s2 no mrg
PULM: CTA b/l, no crackles or wheezing
ABD: S/ND/NT
EXT: No ___ edema bilaterally, warm
Pertinent Results:
ADMISSION LABS:
___ 09:38PM BLOOD WBC-11.1* RBC-4.22 Hgb-11.9 Hct-38.3
MCV-91 MCH-28.2 MCHC-31.1* RDW-13.2 RDWSD-43.6 Plt ___
___ 09:38PM BLOOD Neuts-74.6* ___ Monos-4.6*
Eos-0.3* Baso-0.3 Im ___ AbsNeut-8.30* AbsLymp-2.19
AbsMono-0.51 AbsEos-0.03* AbsBaso-0.03
___ 09:38PM BLOOD Glucose-95 UreaN-62* Creat-2.8* Na-142
K-5.0 Cl-108 HCO3-21* AnGap-13
___ 09:38PM BLOOD CK(CPK)-81
___:38PM BLOOD CK-MB-2 proBNP-237*
___ 09:38PM BLOOD cTropnT-0.02*
___ 03:00AM BLOOD CK-MB-1 cTropnT-<0.01
___ 03:00AM BLOOD TotProt-6.7 Calcium-9.5 Phos-3.4 Mg-2.0
___ 03:00AM BLOOD PEP-NO SPECIFI FreeKap-110.0*
FreeLam-34.7* Fr K/L-3.17*
DISCHARGE LABS:
___ 09:30AM BLOOD WBC-10.5* RBC-3.63* Hgb-10.2* Hct-32.9*
MCV-91 MCH-28.1 MCHC-31.0* RDW-13.3 RDWSD-44.5 Plt ___
___ 07:51AM BLOOD Glucose-91 UreaN-39* Creat-2.4* Na-140
K-5.0 Cl-109* HCO3-17* AnGap-14
___ 07:51AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.6
PERTINENT IMAGING:
CT NECK W/O CONTRAST ___:
1. Lucency around the roots of previously treated ___ 14, with
associated left facial cellulitis. No drainable fluid
collection. Reactive lymphadenopathy.
2. Mildly enlarged and heterogeneous thyroid gland. No focal
nodule identified.
3. Likely dental disease related left maxillary and ethmoid
sinus
opacification.
CHEST XRAY ___:
In comparison with the study of ___, there are lower lung
volumes.
Cardiomediastinal silhouette is stable and there is no vascular
congestion, pleural effusion, or acute focal pneumonia.
CARDIAC PERFUSION STUDY ___:
1. Normal myocardial perfusion.
2. Normal left ventricular cavity size and systolic function.
Compared to the prior study of ___, cavity size and
systolic function have normalized.
CHEST XRAY ___:
No acute cardiopulmonary process.
Brief Hospital Course:
TRANSITIONAL ISSUES
======================
[ ] Discharge weight: 251 lbs
[ ] Discharge Creatinine: 2.4
[ ] Restart home lisinopril as Cr returns to baseline and K
within normal limits
[ ] Consider pyrophosphate scan
[ ] Discharged on oral Augmentin
[ ] Patient discharged to follow up with OMFS at ___ on ___
for tooth extraction.
PATIENT SUMMARY AND HOSPITAL COURSE:
======================================
___ pmhx of HFpEF (EF 55% ___, HTN, DMII c/b peripheral
neuropathy, retinopathy, R toe osteo s/p amp, CKD (b/l 1.9-2.3),
HLD presenting with chest pain and ___ on CKD.
# Sepsis secondary to dental abscess/tooth infection:
Patient was noted to have worsening L sided maxillary tooth pain
with associated facial swelling. Panorex imaging was obtained
and evaluated by dental team. Findings showed extensive caries
in left upper single molar with concern for acute exacerbation
of chronic apical abscess for which she was started on oral
penicillin on ___. Later that day, patient spiked a fever to
102.9F with associated rigors, sinus tachycardia to the 130s.
She was started on IV vancomycin/ceftazidime/metronidazole that
was narrowed to vanc/ceftriaxone/metronidazole later. ID and
OMFS were consulted. OMFS recommended extraction for source
control at close outpatient follow up in dental clinic. At
discharge, patient was narrowed to PO Augmentin DS 875-125mg per
ID recs for 10 days.
# Chest pain
Patient initially admitted to the ___ service for chest pain
with several cardiac risk factors (HTN, DM, HLD). Chest pain was
substernal, sharp, nonradiating, nonexertional, ___ on
admission; chest pain stopped ___ evening. Trop 0.02 on
admission, <0.01 subsequently. No ecg changes. Given cardiac
risk factors, patient underwent perfusion stress study which
showed normal myocardial perfusion. Given aspirin 325mg, then
continued on aspirin 81mg daily. Home atorvastatin increased to
80mg QHS. Chest pain resolved spontaneously without
intervention.
# Chronic HFpEF (EF 55% ___:
Patient was admitted with chest pain, felt to be euvolemic to
slightly overloaded on exam. On hospital day 1, she received
Torsemide 80mg x1 with bump in creatinine. Given her ___ and
positive orthostatic hypotension, her diuretics were
subsequently held during admission with improvement in
creatinine. Of note, home Torsemide was most recently 80mg QAM
and 40mg QPM. Given ___ on admission, this was concerning for
over-diuresis. Will be discharged on home diuretic dose given
improvement in Cr at time of discharge.
- Patient continued on home hydralazine, spironolactone,
amlodipine, imdur at discharge. Lisinopril held at time of
discharge. Discharge weight 251 lbs. Discharge Creatinine 2.4.
# Concern for amyloidosis
TTE in ___ showed LVH with increased PCWP. Concern for
infiltrative process (eg, amyloid). Serum free light chains,
SPEP, UPEP negative. Consider pyrophosphate spect as outpatient
if suspicion high enough for cardiac amyloidosis.
# ___ on CKD (b/l 1.9-2.3):
Cr 2.8 on admission. ___ felt likely to be pre-renal secondary
to over-diuresis and infection ___ dental abscess. Held home
torsemide and gave gentle IVF with improvement. Cr on discharge
2.4. Plan to restart home torsemide on discharge.
# HTN
Initially held home lisinopril, spironolactone in the setting of
___. Continued home amlodipine, imdur, and hydralazine.
Restarted all home meds except lisinopril on discharge.
Lisinopril should be restarted as outpatient as Cr improves and
K is confirmed within normal limits (K 5.0 on discharge).
Patient refused further lab draws prior to discharge.
# DMII
## peripheral neuropathy
## retinopathy
Continued home long acting 60 HS, home humalog 15 with dinner,
and SSI. Also continued home gabapentin.
# CODE: Full
# CONTACT/HCP: ___ Relationship: Husband Phone
number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Ferrous Sulfate 325 mg PO DAILY
6. Gabapentin 100 mg PO BID
7. HydrALAZINE 25 mg PO TID
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Lisinopril 10 mg PO DAILY
10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
11. Spironolactone 25 mg PO DAILY
12. Torsemide 40 mg PO QPM
13. TraZODone 25 mg PO QHS:PRN insomnia
14. Humalog 15 Units Dinner
tresiba 60 Units Bedtime
15. Torsemide 80 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth
once a day Disp #*10 Tablet Refills:*0
2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 0.5 - 1 tablet(s) by mouth Every 6 hours as
needed Disp #*6 Tablet Refills:*0
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
4. amLODIPine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Ferrous Sulfate 325 mg PO DAILY
8. Gabapentin 100 mg PO BID
9. HydrALAZINE 25 mg PO TID
10. Humalog 15 Units Dinner
Tresiba 60 Units Bedtime
11. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
13. Spironolactone 25 mg PO DAILY
14. Torsemide 80 mg PO DAILY
15. Torsemide 40 mg PO QPM
16. TraZODone 25 mg PO QHS:PRN insomnia
17. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until your creatinine improves
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Sepsis due to dental abscess
SECONDARY DIAGNOSIS:
======================
Acute on chronic kidney Disease
Orthostatic hypotension
Chronic Diastolic Heart Failure
Chest Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had chest pain
and some kidney damage.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You underwent a stress test which showed normal blood flow to
your heart.
- You had tooth pain due to an infection around your tooth and
needed IV antibiotics.
- The dentist saw you and you will need an extraction of your
tooth.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Weigh yourself every morning, call your doctor if your weight
goes up more than 3 lbs in one day.
- 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.
- Your discharge weight: 251 lbs. You should use this as your
baseline after you leave the hospital.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10031687-DS-10 | 10,031,687 | 25,653,917 | DS | 10 | 2141-05-02 00:00:00 | 2141-05-03 13:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
R foot swelling/pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with DM2, HTN, HLD, CKD, CAD s/p PCI, and chronic sCHF with
acute onset of atraumatic R foot swelling and pain x 1 day.
Completely asymptomatic otherwise, denies chest pain, shortness
of breath. Not a smoker, no cancer history, ambulates at
baseline though he was recently admitted ___ to ___ for
EGD/colonoscopy and acute on chronic kidney disease.
In the ED, initial vital signs were 99.0 82 122/58 16 98%. LENIs
were positive for right lower extremity thrombus extending from
the right femoral vein, into the popliteal vein, and into one of
the posterior tibial veins. Patient was given heparin and
acetaminophen. Transfer vital signs were 97.7 70 167/74 14 100%.
On the floor, patient reports reasonable pain control in his
foot.
Past Medical History:
# HTN
# DM2
# Hypercholesterolemia
# CKD Stage III (baseline creatinine 1.5-1.9)
# Hypothyroidism
# CAD s/p PCI
- LCx stent (___)
- Instent restenosis, LCx and OM rotational atherectomy
(___)
- RCA stent (___)
- LHC/RHC (___): Coronary arteries are normal. Mod
biventricular diastolic dysfunction. Mod pulmonary hypertension.
# chronic sCHF:
- Echo (___): EF 50%, mild AI/MR, regional HK basal inferior
and inferoseptal hypokinesis
- EF ___, LV hypokinesis, MR, AR (___)
# mod chronic dCHF (RV and LV)
# Pulm HTN: Pulm BP ___
# s/p Dual chamber pacemaker (___)
# Appendectomy
# Hernia repair
# Questionable GIB (unable to find details in chart), s/p normal
EGD and colonoscopy ___
# BPH
Social History:
___
Family History:
-DM II, HTN
-No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 145/77, 81, 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rhythm, normal S1/S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, trace b/l edema R>L especially in
foot, tender to palpation in R foot
Skin: no lesions
Neuro: A&Ox3, CNs ___ intact, strength and sensation grossly
intact
Psych: pleasant, appropriate
DISCHARGE PHYSICAL EXAM:
Vitals: 98.3 - 169/94 - 58 - 16 - 99% ra
General: Alert, NAD
HEENT: Sclera anicteric, MMM
Neck: supple
Lungs: CTAB, no w/r/r
CV: Regular rhythm, ___ systolic murmur heard throughout
precordium
Abdomen: soft, non tender, non-distended
Ext: Warm, well perfused, no CCE. L thigh very tender to
palpation. Apppears minimally swollen, but not erythematous or
warm. Femoral pulses and DPs are ___
Neuro: sensation intact bilateral ___
___ Results:
ADMISSION LABS:
___ 03:19PM BLOOD WBC-8.0# RBC-4.48* Hgb-11.5* Hct-34.9*
MCV-78* MCH-25.6* MCHC-32.8 RDW-14.3 Plt ___
___ 03:19PM BLOOD Glucose-226* UreaN-33* Creat-1.9* Na-140
K-3.5 Cl-97 HCO3-29 AnGap-18
___ 03:19PM BLOOD UricAcd-12.0*
___ 07:40AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.9
DISCHARGE LABS:
___ 06:59AM BLOOD WBC-12.9* RBC-3.79* Hgb-10.2* Hct-31.5*
MCV-83 MCH-26.9* MCHC-32.3 RDW-15.6* Plt ___
___ 06:59AM BLOOD Glucose-64* UreaN-25* Creat-1.3* Na-140
K-4.6 Cl-105 HCO3-25 AnGap-15
___ 06:59AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.4
Joint Fluid
___ 03:05PM JOINT FLUID WBC-73 RBC-20* Polys-31* Lymphs-32
___ Macro-37
___ 03:05PM JOINT FLUID Crystal-NONE
Culture- No growth to date
MICRO:
Urine
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 16 I
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING:
LENIs ___: Right lower extremity DVT starting in the mid
femoral vein, extending into the popliteal vein and into one of
the posterior tibial veins. Peroneal veins are not visualized
in either leg. There is no DVT in left leg.
CT Ab/Pelvis ___
IMPRESSION:
Large left-sided retroperitoneal hematoma with blood insinuating
throughout the left iliopsoas muscle and anteriorly in the
retroperitoneum/left anterior pararenal space to the level of
thigh.
ABIs
FINDINGS: Doppler waveform analysis reveals triphasic waveforms
at the common femoral, superficial femoral, popliteal arteries
bilaterally and monophasic waveforms at the DP and ___
bilaterally. ABIs are 0.7 bilaterally.
Pulse volume recordings show normal waveforms in the thigh and
calf
bilaterally. There is dampening at the ankle level bilaterally.
IMPRESSION: Bilateral tibial arterial disease.
CT Lower extremity
IMPRESSION:
No CT evidence of osteomyelitis. No joint effusion. No
enlarged bursal
collection in the region of the pes anserine tendons.
In the setting of high clinical concern for osteomyelitis,
consider bone scan as it is more sensitive.
Brief Hospital Course:
___ with DM2, HTN, HLD, CKD, CAD s/p PCI, and chronic sCHF with
acute onset of atraumatic R foot swelling and pain x 1 day,
found to have RLE DVT.
# DVT: appears unprovoked, no risk factors besides recent
hospitalization and age. Lovenox contraindicated given CKD. He
was started on heparin on ___, and when found to have a stable
Hct (given questionable history of GI bleed in the past), he was
started on Coumadin 2mg daily on ___. Unfortunately, INR was
very resistant, so dose uptitrated all the way to 25 mg with the
help of a hematology consult. Alternative anticoagulants were
deferred given renal failure. Patient then developed a
retroperitoneal bleed (see below), and all anticoagulation was
stopped and IVC filter was placed. Per hematology, he would
benefit from being started on warfarin again given DVT was
unprovoked. This will be discussed as an outpatient.
#RP Bleed- patient developed acute groin pain and was
light-headed and dizzy while being bridged to warfarin. BPs at
the time dropped to ___. CT abdomen/pelvis showed large
left retroperitoneal bleed. All anticoagulation was held. He
was given a total of 3 units pRBCs and Hct stabilized and
patient was asymptomatic.
# Oligoarticular Arthritis: Patient developed severe L knee pain
shortly after the RP bleed, and also was experiencing bilateral
ankle pain. We first ruled out vascular compression from
hematoma with ultrasound which was negative for fluid
collection. ABIs were obtained which showed bilateral tibial
disease but nothing acute. Rheumatology was consulted for
concern of gout who tapped the L knee joint which was
unremarkable, but thought the clinical likelihood was high given
hospital course and high uric acid level. Hence empirically
treated him with a steroid course. His pain was persistent on
30 mg steroids, so CT Lower extremity was obtained which showed
no evidence of other acute processes.
# UTI x 2: reportedly with dark foul-smelling urine on ___ but
otherwise asymptomatic. UCx grew pan-sensitive Proteus >100k
despite negative UA. Because this may be at least partially
responsible for uncontrollable sugars, he was started on cipro
500mg bid x 7 days (___). He was then found to have another
+ urine culture in the setting of uncontrolled sugars with
E.coli. He was treated for a 10 day course of ceftriaxone IV,
later transitioned to PO cefpodoxime upon discharge.
# DM2: requiring >30U insulin per day for several days while
home sitagliptin and glipizide were held. Lantus was started in
addition to humalog insulin sliding scale, and his home oral
hypoglycemics were restarted. Patient periodically required
higher doses of insulin during RP bleed and then was started on
prednisone which required ISS and NPH insulin.
# CKD with ___. Patient's home diuretic was held which improved
creatinine. This was restarted upon discharge at half the
preadmission dose of 40 mg (from 80 mg)
# HTN: normotensive, was continued on carvedilol, isosorbide,
and ramipril.
# sCHF: torsemide managed as above
# Hypothyroidism: chronic, continued on levothyroxine 25 daily
# CAD: chronic, continued on plavix 75 daily
# HLD: chronic, continued on pravastatin 40 daily
# ? mild dementia: chronic, continued on donepezil 10 qhs
# GERD: chronic, continued on ranitidine 300 daily
TRANSITIONAL ISSUES:
****Patient was hyperglycemic in the setting of medical issues
and steroid burst. Please taper off all insulin after steroid
taper ends on ___. He is already on his PO antidiabetics****
# Patient should be taking cefpodoxime THROUGH ___
# Code: Full (discussed with patient)
# Contact: daughter ___ and wife ___,
___-
# PCP to arrange IVC filter removal in ___ weeks after
placement.
# Torsemide held for most of admission, restarted on day of
discharge at half of preadmission dose for 40 mg (from 80mg)
# Patient to discuss risks/benefits of anticoagulation after IVC
filter removed.
# Pt discharged on prednisone taper for gout
# Pt started on ISS and glargine this admission for
hyperglycemia associated with steroids. Blood sugars should be
followed by PCP and also at rehab
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 25 mg PO BID
2. Donepezil 10 mg PO HS
3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Pravastatin 40 mg PO DAILY
6. Ranitidine 300 mg PO HS
7. Ramipril 10 mg PO DAILY
8. Torsemide 80 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. GlipiZIDE 5 mg PO BID
11. Nitroglycerin SL 0.3 mg SL PRN cp
12. sitaGLIPtin *NF* 25 mg Oral daily
Discharge Medications:
1. Carvedilol 25 mg PO BID
2. Clopidogrel 75 mg PO DAILY
3. Donepezil 10 mg PO HS
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Pravastatin 40 mg PO DAILY
7. Ramipril 10 mg PO DAILY
8. Ranitidine 300 mg PO HS
9. Torsemide 40 mg PO DAILY
10. GlipiZIDE 5 mg PO BID
11. sitaGLIPtin *NF* 25 mg Oral daily
12. Nitroglycerin SL 0.3 mg SL PRN cp
13. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth q 12 hrs Disp #*8
Tablet Refills:*0
14. Senna 1 TAB PO BID constipation
15. Humalog 0 Units Bedtime
NPH 8 Units Breakfast
NPH 0 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
16. PredniSONE 10 mg PO DAILY
Take on ___ then stop.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
Deep vein thrombosis
Gout
Retroperitoneal Bleed
SECONDARY:
diabetes mellitus
hypertension
hyperlipidemia
chronic kidney disease
coronary artery disease
chronic systolic congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
diagnosed with a blood clot in your right leg (deep vein
thrombosis, or DVT) that was causing your right foot pain.
Because this can be very dangerous if untreated, you were
treated with blood thinners. Unfortunately, you had some
internal bleeding and the blood thinners needed to be stopped.
Instead, we placed an IVC (inferior vena cava) filter in you to
prevent the clot from moving to your lungs.
You also suffered from gout during this admission, for which
prednisone was started. We also treated you for a urinary tract
infection.
Please continue to take the prednisone- you will need to take 1
dose of 10 mg on ___ and then off.
Please take cefpodoxime for THROUGH ___
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Followup Instructions:
___
|
10031687-DS-11 | 10,031,687 | 23,811,052 | DS | 11 | 2141-06-05 00:00:00 | 2141-06-06 23:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
new LLE DVT
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ yo male with a prior h/o HTN, DM2, CAD, CHF, and anemia
who was admitted on ___ with acute onset of atraumatic R foot
swelling and pain x1 day. He was found to have no evidence of
PE, but ___ of RLE demonstrated a thrombus extending from the
right femoral vein into the popliteal ___ and into one of the
posterior tibial veins. There was no evidence of thrombosis in
the LLE. The thrombus was though to be unprovoked. He was
initially managed on heparin with intended bridge to coumadin.
He began coumadin at 2.5 mg, uptitrated to 10mg x11 days which
brought his INR to 1.3. Hematology was consulted for resistant
INR and he was uptitrated to 25 mg with the help of hematology.
The patient then developed a retroperitoneal bleed for which he
required 3 units pRBCs. Anticoagulation was stopped, and a
retrievable IVC filter was placed with plans to remove it in ___
weeks. He was discharged to ___ in
___.
On ___ he presented to ___ clinic with severe left
upper thigh pain. This had been present since his left sided RP
bleed, but had not improved and had worsened over the past few
days. The pain had been waking him at night. His left knee pain,
attributed to gout on his last admission, continues to be very
painful. His right leg was feeling better, but on exam he had
bilateral edema and fatigue. He denied SOB, chest pain at that
time. Hematology was concerned for new thrombosis given that he
is at high risk for clot since he was off anticoagulation and
placement of IVC filter is inherently prothrombotic event and
can instigate severe ___ clotting. Bilateral ___ showed RLE
DVT extending from the common femoral vein down to the popliteal
vein, and 2 new RLE thrombi, one extending from the proximal
superficial femoral vein down to the mid portion of the vein,
and a second in the left popliteal vein. The patient was
subsequently referred to the ___ ED.
Past Medical History:
# HTN
# DM2
# Hypercholesterolemia
# CKD Stage III (baseline creatinine 1.5-1.9)
# Hypothyroidism
# CAD s/p PCI
- LCx stent (___)
- Instent restenosis, LCx and OM rotational atherectomy
(___)
- RCA stent (___)
- LHC/RHC (___): Coronary arteries are normal. Mod
biventricular diastolic dysfunction. Mod pulmonary hypertension.
# chronic sCHF:
- Echo (___): EF 50%, mild AI/MR, regional HK basal inferior
and inferoseptal hypokinesis
- EF ___, LV hypokinesis, MR, AR (___)
# mod chronic dCHF (RV and LV)
# Pulm HTN: Pulm BP ___
# s/p Dual chamber pacemaker (___)
# Appendectomy
# Hernia repair
# Questionable GIB (unable to find details in chart), s/p normal
EGD and colonoscopy ___
# BPH
Social History:
___
Family History:
-DM II, HTN
-No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.8 168/60 65 16 99RA
General: pleasant well appearing elderly gentleman lying in bed,
interactive, comfortable, no resp distress
HEENT: nc/at, sclera anicteric
Neck: supple
CV: regular rate and rhythm no m/r/g
Lungs: clear to ausc bilaterally no crackles no wheezes
Abdomen: no tenderness to palp, bowel sounds present
GU: deferred
Ext: thin, RLE 2+ pitting edema and visibly larger than LLE,
tenderness to alpation on anterior and lateral L proximal thigh
w/o overlying lesions
Neuro: alert, oriented x3 though at first said year ___, speech
fluent, linear, appropriate, moving all 4 extremities
Skin: no rashes
DISCHARGE PHYSICAL EXAM:
Vitals: 98.6 140/64 63 20 99RA
General: Chronically ill appearing elderly gentleman laying
awake in bed. A&Ox3. In NAD
HEENT: o/p somewhat dry
Neck: Radiation of murmur heard bilaterally
Cardiac: III/IV systolic murmur heard diffusely. No rubs or
gallops. Consistent with prior cardiology note from ___ clinic.
Lungs: CTAB
Abd: Soft, NT, ND, no r/g
Ext: 2+ pitting edema of the RLE to the mid calf, trace edema of
the LLE at the foot. Single flaky non-erythematous, non tender
lesion of the left anterior shin. ___ and DP pulses were
non-palpable but heard on doppler. Now only slightly stronger on
the right.
Pertinent Results:
ADMISSION LABS:
___ 06:45PM BLOOD WBC-6.5 RBC-3.96* Hgb-10.6* Hct-33.3*
MCV-84 MCH-26.9* MCHC-31.9 RDW-15.3 Plt ___
___ 06:45PM BLOOD Neuts-58.3 ___ Monos-9.5 Eos-2.8
Baso-0.5
___ 06:45PM BLOOD ___ PTT-30.4 ___
___ 06:45PM BLOOD Plt ___
___ 06:45PM BLOOD Glucose-151* UreaN-27* Creat-1.6* Na-142
K-4.0 Cl-101 HCO3-29 AnGap-16
PERTINENT LABS:
___ 08:00AM BLOOD WBC-8.1 RBC-4.40* Hgb-11.7* Hct-36.6*
MCV-83 MCH-26.5* MCHC-31.9 RDW-15.3 Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD ___ PTT-34.2 ___
DISCHARGE LABS:
___ 08:00AM BLOOD WBC-8.1 RBC-4.40* Hgb-11.7* Hct-36.6*
MCV-83 MCH-26.5* MCHC-31.9 RDW-15.3 Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-105* UreaN-24* Creat-1.4* Na-141
K-4.1 Cl-102 HCO3-29 AnGap-14
___ 08:00AM BLOOD Calcium-9.4 Phos-2.5* Mg-2.1
MICROBIOLOGY: None
IMAGING:
Bilateral lower extremity venous doppler study (___):
IMPRESSION:
Bilateral lower extremity DVT. On the right, it extends from
the common
femoral vein down to the popliteal vein. On the left, the DVT
extends from
the proximal superficial femoral vein down to the mid portion of
the vein.
The distal portion of the left superficial femoral vein is
patent but
echogenic thrombus is noted in the left popliteal vein.
These findings were discussed with the nurse ___ Dr. ___
on the phoneat 2 p.m. on ___.
Brief Hospital Course:
Mr. ___ is a ___ w/ Hx of DM2 c/b CKD stage 3, CAD s/p PCI,
CHF, HTN, anemia, and recent diagnosis of RLE DVT (s/p RP bleed
on coumadin, IVC filter placement) who presented to ___
clinic on ___ with new ___ pain, found to be new ___ DVT, and was
admitted.
ACTIVE DIAGNOSES:
# New LLE DVT
- Risk factors include relative immobility, age, and Hx of DVT
on the R. Pt presented with L thigh pain, was found to have new
LLE on ___ duplex. Pt remained hemodynamically stable and had no
objective findings of PE.
- Given that IVC filter had been placed on ___ for RLE DVT and
pt had no Si/Sx suggestive of PE, CT chest was not pursued. In
addition, this would not have altered management, as patient was
already being anticoagulated.
- On admission, patient was started on a heparin drip. Given
history of RP bleed on Coumadin and Hx of CKD, Rivaroxiban was
chosen in consultation with Hematology as a suitable oral
anticoagulant for this patient.
- He was switched from heparin gtt to rivaroxiban during this
admission and tolerated the medication well.
- Pt to follow with Dr. ___ in clinic after discharge. Plan
is to have filter removed as an outpatient, which will be
arranged during ___ f/u appointment with heme (see transitional
issues below).
- Patient to undergo outpatient work-up for coumadin
resistance, follow-up scheduled with Hematology.
# CHRONIC DIAGNOSES
# Prior RLE DVT
- Anticoagulation with Rivaroxiban as above
- IVC filter placed on last admission, see transitional issues
below
# Oligarticular arthritis
- Not an active issue during this hospitalization
- pt developed L knee pain shortly after RP bleed during last
hospitalization. Had extensive w/u that ruled out vascular
compression from hematoma.
- Rheum tapped knee and felt that gout was most likely etiology
despite unrevealing tap. Was treated empirically with steroids,
CT demonstrated no other cause.
# DM2
- The patient's blood sugar was well-managed with insulin
during this admission
- During his previous admission, persistent hyperglycemia
requiring >30 U insulin per day was an issue ___ pt not being
able to continue non-formulary medication (Januvia).
- This problem was not significant on this admission; the pts
blood sugar was only occasionally as high as low 200s.
# CKD
- Not an active issue on this hospitalization, stable on home
medications
# HTN
- Not an active issue on this hospitalization, stable on home
medications
# Congestive heart failure
- Not an active issue on this hospitalization, stable on home
medications
# Hypothyroidism
- Not an active issue on this hospitalization, stable on home
medications
# CAD
- Not an active issue on this hospitalization, stable on home
medications
- Per discussion with cardiology, pt's Plavix was discontinued,
as his stents had been placed in the remote past and was no
longer indicated, particularly in the setting of Hx of RP bleed.
- Started on ASA 81 mg
# HL
- Not an active issue on this hospitalization, stable on home
medications
# Mild dementia
- Not an active issue on this hospitalization, stable on home
medications
# GERD
- Not an active issue on this hospitalization, stable on home
medications
TRANSITIONAL ISSUES
# Plan for IVC filter removal was discussed with ___ fellow
and ___ attending and is as follows:
- To be done in outpatient setting. This will be arranged on
___ heme f/u appointment.
- He has an Eclipse IVC filter placed ___ per ___ attending
who put this in, ___ months is a reasonable timeframe to remove
this type of IVC filter.
# Medication changes
- Plavix was stopped, ASA 81 was started
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 12.5 mg PO BID
2. Clopidogrel 75 mg PO DAILY
3. Donepezil 10 mg PO HS
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Pravastatin 40 mg PO DAILY
6. Ramipril 10 mg PO DAILY
7. Ranitidine 300 mg PO HS
8. Torsemide 80 mg PO DAILY
9. GlipiZIDE 5 mg PO BID
10. sitaGLIPtin *NF* 25 mg Oral daily
11. Senna 1 TAB PO BID constipation
12. Nitroglycerin SL 0.3 mg SL PRN cp
13. Isosorbide Mononitrate (Extended Release) 90 mg PO QHS
14. Terazosin 2 mg PO HS
Discharge Medications:
1. Carvedilol 12.5 mg PO BID
2. Donepezil 10 mg PO HS
3. GlipiZIDE 5 mg PO BID
4. Isosorbide Mononitrate (Extended Release) 90 mg PO QHS
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Pravastatin 40 mg PO DAILY
7. Ramipril 10 mg PO DAILY
8. Ranitidine 300 mg PO HS
9. Senna 1 TAB PO BID constipation
10. Torsemide 80 mg PO DAILY
11. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet,delayed
release (___) by mouth daily Disp #*90 Tablet Refills:*0
12. Rivaroxaban 15 mg PO DAILY
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
13. Nitroglycerin SL 0.3 mg SL PRN cp
14. sitaGLIPtin *NF* 25 mg Oral daily
15. Terazosin 2 mg PO HS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- LLE DVT
Secondary diagnoses:
- preexisting RLE DVT s/p IVC filter
- RP bleed on coumadin
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 our pleasure caring for you at ___. You were admitted
to the hospital because you developed a new blood clot in your
left leg. Because you developed a bleeding complication on
blood thinners during your previous hospitalization, we treated
you with a different blood thinner that is less likely to cause
bleeding problems. You tolerated this new blood thinner without
any problems and were discharged home.
Please weigh yourself every morning, and call your physician if
your weight goes up more than 3 lbs in one day.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
10031687-DS-12 | 10,031,687 | 21,674,234 | DS | 12 | 2141-06-15 00:00:00 | 2141-06-15 11:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
Mechanical Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old male with a prior h/o HTN, DM2,
CAD (s/p PCI ___ and ___, CHF (s/p BiV Pacemaker in ___,
CKD Stage III (secondary to hypertensive nephrosclerosis), and
anemia who presented to the ED s/p a fall. He was recently
admitted from ___ for RLE DVT (transitioned from heparin
to coumadin and course was c/b RP bleed). He was discharged with
an IVC filter off anticoagulation. He was admitted again from
___ for LLE DVT and he was started on rivaroxiban. He now
presents after having sustained a fall at home.
Per the patient, he "slid" down last night and spent the evening
trying to get off the ground back into his chair. He lives at
home with his wife and daughter but said he did not want to ask
them for help. He ultimately was able to get himself back into
his chair after considerable effort.
In the ED, his VS were 98.4 62 135/53 16 97% ra. He was
evaluated for fall with negative NCHCT, and pelvic/c-spine XR.
His CXR and UA were normal. His labs were significant for acute
on chronic renal insufficiency with a Cr of 2 (baseline Cr 1.3).
On the floor, the patient complained of left knee and thigh
pain, which he says was evaluated in previous admissions and was
found NOT to be gout.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
# Bilateral ___ DVTs (___) - RB bleed on Coumadin. On
Rivaroxiban. S/P IVC Filter.
# HTN
# DM2
# Hypercholesterolemia
# CKD Stage III (baseline creatinine 1.5-1.9) - secondary to HTN
# Hypothyroidism
# CAD s/p PCI
- LCx stent (___)
- Instent restenosis, LCx and OM rotational atherectomy
(___)
- RCA stent (___)
- RHC (___): Coronary arteries are normal. Mod biventricular
diastolic dysfunction. Mod pulmonary hypertension.
# chronic sCHF (s/p BiV Pacemaker in ___:
- Echo (___): EF 50%, mild AR/MR, moderate TR, regional HK
basal inferior
and inferoseptal hypokinesis
# mod chronic dCHF (RV and LV) per ___ cath
# Pulm HTN: Pulm BP ___
# Appendectomy
# Hernia repair
# Questionable GIB (unable to find details in chart), s/p normal
EGD and colonoscopy ___
# BPH
Social History:
___
Family History:
-DM II, HTN
-No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.8, 154/72, 68, 18, 98%
General: NAD, lying comfortably in bed
HEENT: dry mucous membranes, EOMI
Neck: JVP non-elevated
CV: Pacemaker pocket c/d/i. RRR. ___ LLSB systolic murmer, ___
holosystolic murmur at apex radiating to axilla
Lungs: CTAB
Abdomen: soft, nt, nd
Ext: mild erythema and warmth over medial aspect of left knee.
no palpable effusion. TTP over that area and also over
posterolateral left thigh. no palpable cord decreased ROM in
left knee.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.1 HR 77 BP 146/72 R 18 97% on RA
General: NAD, lying comfortably in bed
HEENT: MMM, EOMI
Neck: JVP non-elevated
CV: Pacemaker pocket c/d/i. RRR. ___ LLSB systolic murmer, ___
holosystolic murmur at apex radiating to axilla
Lungs: CTAB
Abdomen: soft, nt, nd
Ext: left knee without erythema or tenderness. no palpable
effusion. Improved ROM.
Pertinent Results:
Admission Labs:
___ 01:10PM GLUCOSE-259* UREA N-41* CREAT-2.0* SODIUM-143
POTASSIUM-5.6* CHLORIDE-95* TOTAL CO2-29 ANION GAP-25*
___ 01:10PM WBC-10.2 RBC-4.23* HGB-11.0* HCT-34.2*
MCV-81* MCH-26.0* MCHC-32.1 RDW-14.6
___ 01:10PM NEUTS-65 BANDS-0 ___ MONOS-11 EOS-1
BASOS-1 ___ MYELOS-0
___ 01:10PM PLT SMR-NORMAL PLT COUNT-176
___ 01:10PM CK(CPK)-226
Discharge Labs:
___ 05:45AM BLOOD WBC-8.4 RBC-3.81* Hgb-10.1* Hct-30.9*
MCV-81* MCH-26.5* MCHC-32.7 RDW-14.5 Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD Glucose-159* UreaN-26* Creat-1.6* Na-139
K-4.2 Cl-99 HCO3-32 AnGap-12
___ 05:45AM BLOOD CRP-73.4*
___ 05:45AM BLOOD ESR-58*
___ 05:45AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.9 UricAcd-13.3*
LEFT KNEE RADIOGRAPHS, THREE VIEWS:
There is no fracture or malalignment.
Mild narrowing of the medial compartment is similar to prior
examination.
Small osteophytes along the superior aspect of the patella are
unchanged.
Dense vascular calcifications are noted. No joint effusion is
seen on the
cross-table lateral view. IMPRESSION: Mild degenerative changes
without acute traumatic injury.
CT C-SPINE:
1. No evidence of fracture or traumatic malalignment.
2. Finding suggesting paralysis of the left vocal cord,
correlate with
symptoms or direct visualization.
3. Heterogeneous left lobe of thyroid with 4 mm nodule for
which a nonurgent
ultrasound evaluation could be performed if clinically
indicated.
LENIs:
Bilateral lower extremity DVT with minimal improvement since the
prior study.
1. On the right the thrombus extends from the proximal
superficial femoral
vein down to popliteal vein, slightly improved on the prior exam
when thrombus
was also seen in the common femoral vein.
2. On the left, the thrombus extends from the distal superficial
femoral vein
into the popliteal vein. The previously seen thrombus within
the proximal and
mid superficial femoral vein is not visualized.
Brief Hospital Course:
This patient is a ___ year old male with a prior h/o HTN, DM2,
CAD (s/p PCI), CHF (BiV pacing, EF 50%), B/L ___ DVT (on
rivaroxiban), Stage III CKD who presented to the ED s/p a fall
with left knee and thigh pain. On admission, his vital signs
were stable and his exam was benign. His labs were significant
for acute on chronic renal insufficiency with a Cr of 2
(baseline Cr 1.3).
ACTIVE DIAGNOSES:
#Mechanical Fall - The patient denies having "fell" but instead
reports that he "slid" down to the ground, never losing
consciousness, nor injuring any part of his body. His physical
exam was benign, except for chronic L knee and thigh pain. Knee
radiagraphs were obtained and were negative for acute fracture.
Imaging was significant for a negative NCHCT and negative
pelvic/c-spine XR. ___ evaluated the patient and felt that he
presented below his baseline and required mod/max assist for
sit<>stand transfers and contact guard assist for all mobility
and would benefit from rehab following discharge.
#Acute on Chronic Kidney Injury - Admission labs significant for
Cr 2 (baseline 1.3) His physical exam was consistent with
dehydration. Given his fall, we checked a CK, which was normal
to rule out rhabdo. We held Ramipril and Torsemide and treaded
him with gentle IVF. He responded well and we restarted his
medication at discharge.
#Left knee and thigh pain - This patient reported tenderness on
the medial aspect of his left knee, which is apparently
consistent with prior admissions (see ___ discharge summary,
when he had a negative Rheum work-up for Gout). It is not
entirely clear what is causing this pain as prior aspiration was
negative for cyrstals, though rheum still felt it was most
consistent with gout last admission. We decided to empirically
institute another short course of steroids, and his knee pain
seemed to improve (though it was always quite mild). Notably,
his labs on this admission were significant for elevations in
Uric Acid (13.3), CRP (73) and ESR (58). Given his kidney
function, we did not treat with NSAIDS, but instead used
Acetaminophen, a Lidoderm Patch, and Prednisone 30 mg daily x 2
doses which provided relief. He is discharged to take 20 mg for
2 days, 10 mg for 1 day, and 5 mg for 2 days of Prednisone. More
concerning to him was his thigh pain, which extended from his
inguinal area down the lateral aspect of his thigh. On review of
his CT from ___, it seems very likely that this pain is
sciatica from compression of the nerve by a very large RP
hematoma, clearly demonstrated on CT in ___. We reassured him
that this pain should improve with time.
#DM2/Hyperglycemia - Pt had a fingerstick in mid ___ while
after being treated with steroids. Treated with ISS. Restarted
on Home DM meds (Glipizide, Sitagliptin) at discharge with an
ISS to be used while he he continues a steroid taper.
CHRONIC DIAGNOSES
#Bilateral DVTs s/p IVC filter (___) - ___ with RLE DVT in ___
and was started on Coumadin complicated by an RP bleed so an IVC
filter was placed and he was discharged off anticoagulation.
Readmitted in ___ with LLE DVT so patient was started on
Rivaroxiban. On this admission, LENIs were repeated which
demonstrated slight improvement in both ___ DVTs. Rivaroxaban was
continued.
#CHF (systolic and diastolic, EF 50% in ___, mild AI/MR,
moderate TR, s/p BiV Pacemaker in ___ - We initially held
Ramipril and Torsemide in setting of acute on chronic kidney
injury. These were restarted at discharge. We continued the
patient's Carvedilol and Isordil for HTN.
#CAD - s/p PCI in ___ and ___
Not an active issue on this admission. Continued patient on
Aspirin
#HL
Not an active issue on this admission. Continued patient on home
dose of Pravastatin
#Hypothyroidism
Not an active issue on this admission. Continued on
levothyroxine.
#Dementia
Not an active issue on this admission. Continued on Donepezil
#GERD
Not an active issue on this admission. Continued on Ranitidine
#Constipation
Not an active issue on this admission. Continued on Senna
#BPH
Not an active issue on this admission. Continued on Terazosin
TRANSITIONAL ISSUES
# Plan for IVC filter removal as follows:
- To be done in outpatient setting. This will be arranged on
___ heme f/u appointment.
- He has an Eclipse IVC filter placed ___ per ___ attending
who put this in, ___ months is a reasonable timeframe to remove
this type of IVC filter.
# Medication changes
- Isosorbide Mononitrate decreased back to 60 mg QHS
- Started Acetaminophen 650 mg TID and Lidoderm Patch
- Prednisone taper 20 mg for 2 days, 10 mg for 1 day, 5 mg for
2 days
- Use Insulin Sliding Scale while patient takes steroid
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 12.5 mg PO BID
2. Donepezil 10 mg PO HS
3. GlipiZIDE 5 mg PO BID
4. Isosorbide Mononitrate (Extended Release) 90 mg PO QHS
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Pravastatin 40 mg PO DAILY
7. Ramipril 10 mg PO DAILY
8. Ranitidine 300 mg PO HS
9. Senna 1 TAB PO BID constipation
10. Torsemide 80 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Rivaroxaban 15 mg PO DAILY
13. Nitroglycerin SL 0.3 mg SL PRN cp
14. sitaGLIPtin *NF* 25 mg Oral daily
15. Terazosin 2 mg PO HS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
3. Donepezil 10 mg PO HS
4. Isosorbide Mononitrate (Extended Release) 60 mg PO QHS
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Pravastatin 40 mg PO DAILY
7. Ramipril 10 mg PO DAILY
8. Ranitidine 300 mg PO HS
9. Rivaroxaban 15 mg PO DAILY
10. Senna 1 TAB PO BID constipation
11. Terazosin 2 mg PO HS
12. Torsemide 80 mg PO DAILY
13. GlipiZIDE 5 mg PO BID
14. Nitroglycerin SL 0.3 mg SL PRN cp
15. sitaGLIPtin *NF* 25 mg Oral daily
16. Acetaminophen 650 mg PO TID
17. Lidocaine 5% Patch 1 PTCH TD DAILY pain
apply 12 hours on and 12 hours off
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute on Chronic Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair.
Discharge Instructions:
You came to the hospital because you had slipped and had trouble
getting up on your own due to pain. We evaluated you for
fracture but there was no evidence of this on your x-rays. You
were having left leg pain, which we treated with pain
medication. We believe you are having pain related to a prior
bleed in your abdomen when you were taking Coumadin in ___.
You were also admitted because of abnormal kidney function. We
temporarily stopped your medications that can affect your kidney
function (Ramipril and Torsemide). We treated you with fluids
and your kidney function improved.
You are being discharged to an extended care facility for rehab.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Followup Instructions:
___
|
10031850-DS-15 | 10,031,850 | 28,839,328 | DS | 15 | 2137-03-14 00:00:00 | 2137-03-14 16:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Buttock/Perineal Pain
Major Surgical or Invasive Procedure:
___: Exam under anesthesia, incision and drainage of
horseshoe supralevator abscess, ___ placement of posterior
anal fistula.
___: Exam under anesthesia, perineal debridement,
placement of drains, flexible sigmoidoscopy to 30 cm.
___: Laparoscopic sigmoid colectomy with end colostomy
___ procedure) and perineal debridement.
History of Present Illness:
___ presents from her rehab facility with leukocytosis and a
complaint of intermittent buttock and perineal pain. Her
daughter
believes her symptoms of pain began ___ days ago. She has waxing
and waning mental status and endorses no other clear symptoms.
REctal exam was quaiac positive, with gross purulence,
fluctuance. Opening to
left of anal verge with active extravasation of frank pus.
Perianal and perineal induration and moderate erythema. CT
showed Bilateral large subcutaneous air-fluid collections
concerning for
abscesses.
Past Medical History:
-Large right frontal and left mesial temporal masses, likely
meningiomas. Has been seen by Dr. ___ recommended
surgical resection but patient refused
-HTN
-HLD
-___
-s/p CCY
-thyroid disease
Social History:
___
FAMILY HISTORY: no history of seizures or strokes
Family History:
No known family history of brain tumors or thyroid problems
Physical Exam:
Exam at Discharge: Elderly female patient, ___ speaking
(limited ___, refusing to get out of bed today, lying in
bed, gas in ostomy appliance, foley catheter with clear yellow
urine, pain controlled
AFVSS
Neuro: Waxing and Waning mental status, alert to self, deemed
incompetent by psych
CV: RRR
Pulm: no issues
Abd: obese, lap sites well healed and closed with dermabond,
colostomy pink
Rectal area wound: large surgical wound over left and right
gluteal area deeper and up to labia on the right side with
setons, red granulating tissues with yellow slough
Ext: No edema
Pertinent Results:
___ 05:40AM BLOOD WBC-14.7* RBC-3.31* Hgb-9.8* Hct-29.6*
MCV-90 MCH-29.7 MCHC-33.1 RDW-16.2* Plt ___
___ 06:45AM BLOOD WBC-16.0* RBC-3.16* Hgb-9.3* Hct-27.8*
MCV-88 MCH-29.5 MCHC-33.5 RDW-16.2* Plt ___
___ 07:00AM BLOOD WBC-18.7* RBC-3.32*# Hgb-9.7*# Hct-29.7*
MCV-90 MCH-29.3 MCHC-32.8 RDW-15.9* Plt ___
___ 07:10AM BLOOD WBC-17.9* RBC-2.37* Hgb-7.0* Hct-21.0*
MCV-89 MCH-29.4 MCHC-33.2 RDW-15.5 Plt ___
___ 04:20AM BLOOD WBC-20.0* RBC-2.53* Hgb-7.3* Hct-22.2*
MCV-88 MCH-28.7 MCHC-32.7 RDW-15.6* Plt ___
___ 05:32AM BLOOD WBC-21.6* RBC-2.51* Hgb-7.3* Hct-22.5*
MCV-90 MCH-28.9 MCHC-32.3 RDW-14.4 Plt ___
___ 05:34AM BLOOD WBC-25.9* RBC-2.75* Hgb-8.0* Hct-24.5*
MCV-89 MCH-29.3 MCHC-32.8 RDW-14.8 Plt ___
___ 02:20PM BLOOD WBC-28.7*# RBC-3.39* Hgb-9.9* Hct-29.7*
MCV-88# MCH-29.4 MCHC-33.4 RDW-14.4 Plt ___
___ 05:40AM BLOOD Plt ___
___ 06:45AM BLOOD Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:10AM BLOOD Plt ___
___ 07:10AM BLOOD ___
___ 04:20AM BLOOD ___
___ 05:32AM BLOOD ___
___ 05:34AM BLOOD ___ PTT-28.6 ___
___ 05:50PM BLOOD ___ PTT-34.2 ___
___ 04:40AM BLOOD Glucose-167* UreaN-20 Creat-0.8 Na-134
K-5.5* Cl-101 HCO3-24 AnGap-15
___ 03:53AM BLOOD Glucose-147* UreaN-14 Creat-0.7 Na-135
K-4.0 Cl-100 HCO3-24 AnGap-15
___ 06:50AM BLOOD Glucose-173* UreaN-17 Creat-0.7 Na-132*
K-5.0 Cl-98 HCO3-24 AnGap-15
___ 04:11AM BLOOD Glucose-193* UreaN-29* Creat-0.9 Na-135
K-5.4* Cl-102 HCO3-23 AnGap-15
___ 04:37AM BLOOD Glucose-173* UreaN-29* Creat-0.8 Na-133
K-4.2 Cl-99 HCO3-24 AnGap-14
___ 04:26AM BLOOD Glucose-136* UreaN-29* Creat-0.8 Na-133
K-5.5* Cl-100 HCO3-21* AnGap-18
___ 04:45AM BLOOD Glucose-172* UreaN-31* Creat-0.7 Na-132*
K-4.8 Cl-101 HCO3-24 AnGap-12
___ 04:30AM BLOOD Glucose-183* UreaN-28* Creat-0.7 Na-131*
K-4.6 Cl-101 HCO3-24 AnGap-11
___ 06:15AM BLOOD Glucose-131* UreaN-18 Creat-0.8 Na-132*
K-4.7 Cl-101 HCO3-25 AnGap-11
___ 04:01AM BLOOD Glucose-121* UreaN-22* Creat-0.6 Na-135
K-3.7 Cl-102 HCO3-25 AnGap-12
___ 03:45AM BLOOD Glucose-192* UreaN-23* Creat-0.6 Na-134
K-3.6 Cl-102 HCO3-25 AnGap-11
___ 05:00AM BLOOD Glucose-178* UreaN-16 Creat-0.6 Na-135
K-3.4 Cl-102 HCO3-26 AnGap-10
___ 04:40AM BLOOD Calcium-9.3 Phos-3.7 Mg-1.5*
___ 03:53AM BLOOD Calcium-9.2 Phos-3.4 Mg-1.6
___ 06:50AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.4*
___ 04:11AM BLOOD Albumin-3.1* Calcium-9.1 Phos-3.9 Mg-1.8
___ 04:37AM BLOOD Calcium-9.2 Phos-4.7* Mg-1.9
___ 04:26AM BLOOD Calcium-9.0 Phos-4.0 Mg-1.9
___ 04:45AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0
___ 04:30AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.0
___ 06:15AM BLOOD Calcium-8.9 Phos-4.4 Mg-1.8
___ 04:01AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.6
___ 07:10AM BLOOD TSH-6.4*
___ 07:00AM BLOOD Vanco-11.7
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 3:33 ___
IMPRESSION:
1. Bilateral perianal fistulas with large bilateral ischioanal
fossa
abscesses and marked subcutaneous gas extending into the
perineal soft tissues and into the left gluteus, new from
___. Clinical correlation is recommended as findings are
concerning for Fournier's gangrene.
2. No acute intra-abdominal process.
3. Intraluminal aortic thrombus with approximately 50% focal
stenosis,
unchanged from the prior study.
4. Sigmoid enhancing lesion is concerning for a neoplasm,
unchanged from
___. Recommend correlation with colonoscopy.
5. 7mm left lower lobe pulmonary nodule. If there is no prior
CT already
documenting long term stability, recommend follow up CT in 6
months from the ___ study if pt has no risk factors for
malignancy. If pt has risk factors, follow up in 3 months from
the ___ study is recommended.
Brief Hospital Course:
The patient was admitted to the Acute Care Surgery Service from
the Emergency department with a large perirectal abscess which
extended from the perirectal area to the labia. The ___
white blood cell count was 28.7 and she had significant pain.
Given the appearance of the abscess on CT scan, including the
large amount of air seen in the subcutaneous tissues, the
patient was taken to the operating room with Dr. ___ on
___. The abscess was drained, ___ drain and setons were
placed, the wound was packed and the patient was given
intravenous antibiotics (Please see operative note for further
detail). The patient was transferred to the ___ inpatient
service. Antibotic therapy was continued on the inpatient unit.
The patient frequently refused intravenous narcotic pain
medications from the nursing staff. However, the patient
appeared to be in significant pain and would cry out with
repositioning. On ___, the Colorectal Surgery Service was
notified of the patient and consulted. Dr. ___ the
patient the following morning and accepted the patient to the
inpatient Colorectal Surgery Team. Dr. ___ extensively
to the ___ family on the phone regarding the possible need
for a diverting colostomy to give the patient a chance to heal
the wound and the ___ serious condition. The patients
mental status waxes and wanes at baseline. Antibiotic coverage
was broadened to Vancomycin and Zosyn. She was taken to the
operating room for exam under anesthesia, debridement, and
dressing change on ___. The wound was irrigated, two Malecot
drains were placed, and the wound was packed (Please see
operative note for details). Drainage from the wound was sent
for culture. The patient tolerated this well. Antibiotics were
continued throughout this time and the ___ WBC had come
down to 21 on the morning of hospital day four. The ___
family again were counseled on the surgical option of diverting
colostomy. On ___, the patient was brought for a laparoscopic
sigmoid colectomy with end colostomy ___ procedure) and
perineal debridement. This was tolerated without complication
(please see operative report for further details). ___ Malecot
drains which required flushing were placed in the operating room
and the wound required extensive gauze packing. Psychiatry was
asked to evaluate the patient for competency on ___
and deemed the patient competent to make her own decisions.
Throughout the weeks following, the patient intermittently
accepted medications by mouth, pain medications, and
fluids/nutrition by mouth. She removed the Malecot drains from
the wound on her own and repeatedly removed the colostomy
appliance. She was not cooperative with care. The patient was
educated by the nursing staff with use of the ___
Interpreter as well as surgical attending who speaks ___.
The antibiotic therapy was narrows to Zosyn only. On ___
psychiatry returned to evaluate the ___ competency and at
this time, deemed her incompetent. The lack of patient
cooperation was very concerning to the nursing and surgical team
as the patient had an large wound and without antibiotic therapy
and nutrition the wound would certainly get infected and this
could be devastating for the patient. A family meeting was
organized and the ___ situation was explained to the
daughter and son-in-law. With psychiatry and social work input,
the family decided to pursue guardianship in order to consent
for additional surgical , placement in a rehabilitation facility
and also if code status was to be addressed. Because of stress
in the home related to the daughters children, it was decided
with the help of the ___ legal team that guardianship would be
pursued for the daughter by the ___ legal team to expedite the
process as the patient required a G-Tube for enteral feedings.
While guardianship was being pursued a PICC line was placed at
the bedside and TPN was initiated. She continued to
intermittently refuse medications and other nursing care. The
wound was irrigated twice daily and the dressings were changed
to to best of the nursing and surgical staff's ability. Zosyn
was continued until ___ when after careful discussion, it
was decided that the patient had completed her course of
treatment.
A PICC line was placed on ___ for TPN. Patient pulled on the
PICC line on ___ and thus a CXR was ordered to evaluate the
position of the line. The PICC line was replaced however it was
discontinued prior to discharge to the rehabilitation facility.
Restraints for the ___ left arm were required as the
patient continued to pull at her PICC line and ostomy bag in a
chronic but non-agitated confusional state. Restraints were
minimized for the ___ comfort.
The patient continued on TPN and increased PO intake was
encouraged over the coming week while the patient awaited legal
guardianship. She was able to increasingly take PO and strict
calorie counts were taken to assess her need for continued TPN.
After careful discussion with nutrition, Dr. ___ the
___ family TPN was discontinued and the patient
intermittently took food. Because of the increase in PO intake a
feeding tube was not placed and the TPN was discontinued. The
___ home diabetes medications were not continued as the
patient did not have reliable PO intake. The patient was given
subcutaneous insulin.
On the afternoon of ___ the Colorectal Surgery team was
notified that guardianship was awarded to the ___ daughter
and that a rehabilitation hospital had agreed to accept the
patient. She was discharged with wound care orders as
appropriate. Dr. ___ writer, the surgical team, social
work, case management, and nursing met with the ___ family
multiple times throughout this admission. The Foley catheter was
left in place for discharge, however, a voiding trial can be
attempted at the rehabilitation facility.
Medications on Admission:
Actos 15 mg daily
Colace 50 mg twice a day
Tricor 48 mg tablet
Tylenol ___ mg tablet
levothyroxine 150 mcg daily
metformin 1,000 mg twice a day
omeprazole 40 mg daily
Flagyl 500 mg Twice Daily
Levaquin 500 mg Daily
Glipizide 5 mg Twice Daily
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
do not give more than 3000mg of tylenol daily
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC TID
4. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
5. Levothyroxine Sodium 150 mcg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. OxycoDONE Liquid 2.5-5 mg PO Q4H:PRN pain
8. Tricor *NF* (fenofibrate nanocrystallized) 48 mg Oral daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fournier's Gangrene/Extensive horseshoe perirectal abscess
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted to ___ with a
large horseshoe abscess of the perirectal area requiring
extensive debridement and placement of drains. A diversion of
your colon and a colostomy was performed in order to help your
gangrenous abscess heal. You were given antibiotics and daily
dressing changes to the affected area were performed. The
dressings will continue to be changed by the nursing staff at
the rehabilitation facility.
You had decreased drive and ability to take oral food. You
recieved TPN for a time, and as your tolerance of food increased
this was stopped. It is important you continue to eat healthy
foods and stay as hydrated as possible.
Please continue to care for the colostomy as instructed by the
nursing team.
Followup Instructions:
___
|
10032176-DS-14 | 10,032,176 | 20,464,560 | DS | 14 | 2133-08-17 00:00:00 | 2133-08-19 19:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Depakote / lisinopril / Topamax / Ultram / hydrochlorothiazide
Attending: ___.
Chief Complaint:
Dyspnea, cough, headache, diarrhea
Major Surgical or Invasive Procedure:
Colonoscopy and EGD
History of Present Illness:
___ year old lady with history of HTN, COPD, IDDM,
hypothyroidism, DVT who presented with diarrhea, SOB, and
headache x ___ days, found to
have severe Hyponatremia.
Patient presented for routine PCP check up today, but was
complaining of shortness of breath, diarrhea, pounding headache,
and ___ edema R>L x 10 days. She reported tan watery diarrhea,
___
episodes/ day, not associated with abdominal pain, nausea or
vomiting. She has not had any recent travel or dietary/water
source changes. Lives in senior housing so she thinks that maybe
half of her apartment complex has diarrhea at baseline. Her
appetite had been poor, and additionally reported minimal fluid
intake; she has continued to take HCTZ. She endorses
lightheadedness for the last several days.
In addition, she notes cough ongoing for weeks, non productive,
no fevers, no chills. She reports dyspnea with difficulty lying
flat due to shortness of breath, also with progressive ___ edema
over the last week and half with RLE>LLE. She does have history
of DVT many years ago in setting of a "tumor removal" from her
leg. Initial vitals at PCP office BP 102/58, Pulse 80, Temp 98.1
°F (36.7 °C), Resp 18, SpO2 97%, and was sent to ___ for
further evaluation.
At ___, she was noted to have SpO2 90% on RA, no focal
neurological deficits on exam, but 2+ ___ edema. Evaluation there
remarkable for: Na 115, K 5.4, BUN/Cr ___, LFTS WNL, BNP 522,
TSH 4.2 (upper limit of normal), random cortisol 13.9, negative
influenza A/B. CTH and CXR WNL (no reports available for
review).
In the ED, initial vitals were: 97.7 HR 60 BP 182/80 SpO2 99% 2L
NC
- Exam notable for: "Clinically dry, no crackles on exam,
bilateral ___ edema"
- Labs notable for:
WBC 6.5 Hgb 9.6 Plt 181
114| 80 | 13
-------------
4.8 | 22 | 0.7
Lactate 1.0
Serum osm 240
Uosm 427 Na 89 Cr 52 Pr/Cr 1.0
U/A >182 WBC, 4 RBC, few bacteria Epi 1
- Imaging was notable for: No new imaging obtained
- Patient was given: 250 mL NS bolus
Review of systems was negative except as detailed above.
Past Medical History:
Seizure disorder
Hypertension
COPD
IDDM
GERD
Hyperlipidemia
History of DVT
Social History:
___
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
GENERAL: Pleasant elderly lady breathing comfortably in no acute
distress
HEENT: MMM, no JVD at 90 degrees
CARDIAC: Normal rate, regular rhythm, no m/r/g appreciated
PULMONARY: Diffuse expiratory wheezes throughout all lung fields
ABDOMEN: Soft, nontender, distended/obese, no fluid wave
apprecaited
EXTREMITIES: 2+ tight edema in bilateral ___, RLE>LLE; cap refill
>2s
SKIN: No rashes appreciated
NEURO: AO x 4, moves all 4 extremities symmetrically and with
purpose
DISCHARGE EXAM:
General: Laying down in bed, alert and conversive
HEENT: Moist mucous membranes. No pharyngeal exudates or
erythema.
Lungs: Low lung volumes with minimal air movements.
Clear to auscultation bilaterally.
CV: Normal rate, regular rhythm, no m/r/g appreciated
ABDOMEN: Abdomen soft, nontender, nondistended
Ext: No bilateral edema appreciated in lower extremities
Neuro: A&Ox3
Pertinent Results:
___ LABS:
==============
___ 08:57PM BLOOD WBC-6.5 RBC-3.73* Hgb-9.6* Hct-27.7*
MCV-74* MCH-25.7* MCHC-34.7 RDW-15.9* RDWSD-42.7 Plt ___
___ 08:57PM BLOOD Neuts-62.2 ___ Monos-8.8 Eos-1.4
Baso-0.2 Im ___ AbsNeut-4.05 AbsLymp-1.73 AbsMono-0.57
AbsEos-0.09 AbsBaso-0.01
___ 08:57PM BLOOD Plt ___
___ 08:57PM BLOOD Glucose-101* UreaN-13 Creat-0.7 Na-114*
K-4.8 Cl-80* HCO3-22 AnGap-12
___ 08:57PM BLOOD Glucose-101* UreaN-13 Creat-0.7 Na-114*
K-4.8 Cl-80* HCO3-22 AnGap-12
___ 08:57PM BLOOD cTropnT-<0.01
___ 08:57PM BLOOD proBNP-525*
___ 08:57PM BLOOD TotProt-6.9 Calcium-9.4 Phos-3.7 Mg-1.5*
___ 09:01PM BLOOD Lactate-1.0 Na-114*
DISCHARGE LABS:
___ 04:20AM BLOOD WBC-7.5 RBC-3.61* Hgb-9.0* Hct-29.3*
MCV-81* MCH-24.9* MCHC-30.7* RDW-18.0* RDWSD-51.2* Plt ___
___ 04:20AM BLOOD Plt ___
___ 04:20AM BLOOD Glucose-161* UreaN-14 Creat-0.8 Na-141
K-3.8 Cl-98 HCO3-29 AnGap-14
___ 04:20AM BLOOD Calcium-9.3 Phos-4.9* Mg-1.9
___ 04:20AM BLOOD IgA-122
___ 04:20AM BLOOD tTG-IgA-PND
STUDIES:
=========
BILAT LOWER EXT VEINS PORT Study Date of ___
No evidence of deep venous thrombosis in the right or left lower
extremity
veins. Subcutaneous edema is noted in the calves bilaterally.
TTE ___
Mild symmetric biventricular hypertrophy with normal left
ventricular cavity size and
regional/global biventricular systolic function.
Echocardiographic evidence for diastolic
dysfunction with elevated PCWP. Moderate pulmonary artery
systolic hypertension with elevated
right atrial pressure.
EGD ___
Normal mucosa in the whole esophagus
Esophageal hiatal hernia
Erosions in the antrum (biopsy)
Normal mucosa in the whole examined duodenum
Colonoscopy ___
Normal mucosa in the whole colon (random biopsies)
Polyp (4mm) in the descending colon (polypectomy)
Diverticulosis of the whole colon
Recommend repeat colonoscopy in ___ years
Brief Hospital Course:
Ms. ___ is a ___ with history of HTN, COPD, IDDM,
hypothyroidism, DVT who originally presented with diarrhea, SOB,
and headache x ___ days, found to have severe hypervolemic
hyponatremia that improved with diuresis and discontinuation of
her hydrochlorathiazide. She was found to have iron deficiency
anemia and dysphagia for which she underwent EGD and colonoscopy
without pertinent findings.
ACTIVE ISSUES
=======================
#Hypotonic, Hypervolemic Hyponatremia
Admitted with severe hyponatremia to 111. Etiology was mostly
hypervolemia due to diastolic heart failure exacerbation and
HCTZ use. We d/c'd HCTZ and placed a fluid restriction and
initiated pharmacologic diuresis with loop diuretics until the
patient was euvolemic. Patient originally had symptomatic
headaches, confusion, and shortness of breath; these all
improved with diuresis. Renal was consulted and made
recommendations about an outpatient diuretic regimen with
torsemide 10 mg PO QD. The patient's Na normalized to 141 by
discharge and she was asymptomatic.
#Heart failure with preserved ejection fraction
Patient originally presented with severe bilateral lower
extremity edema, orthopnea, shortness of breath, and severely
elevated BNP. LENIs were negative. Responded well to diuresis as
above. Was euvolemic at discharge. Discharge weight: 110.4 kg.
Discharge Cr: 0.8.
#Anemia
Hgb remained consistently low with microcytic pattern during
admission. Ferritin was low-normal and TIBC was high-normal.
Patient also described ongoing weight loss and change in stool
patterns (alternating diarrhea/constipation + worm-like stools).
Last colonoscopy in ___ included removal of 17 polyps and
recommendation for follow-up colonoscopy in ___ year, which
patient did not get. She received both a colonoscopy and an EGD
as an inpatient. Had one colonic polyp removed and random
biopsies sent. EGD was notable for mild gastritis with antral
erosions (no stricture).
#Change in stool habits
Patient reported 10 days of watery diarrhea prior to admission.
She also described change in stool formation
("worm/pebble-like"). Diarrhea was likely viral gastroenteritis
given time course. C diff was negative. After admission patient
was constipated for 1 week. This resolved with a bowel prep that
was done in preparation of an inpatient colonoscopy to evaluate
for iron deficiency anemia (see above). IgA levels and
transglutaminase antibodies were sent, both negative.
#Dysphagia
Patient complained of discomfort while swallowing during
admission. Was evaluated by speech and swallow who found no
oropharyngeal pathology. EGD showed mild gastritis, no evidence
of esophageal stricture.
#Klebsiella UTI
Patient had UA concerning for infection upon admission,
speciated to Klebsiella. Was treated with ceftriaxone x 3 days
with good result. Subsequently denied urinary discomfort.
#Vulvovaginal candidiasis
#Urinary retention
Patient had vaginal discharge and inner groin rash consistent
with candidiasis. Responded very well to PO fluconazole and
miconazole powder. Pt originally had Foley upon admission which
was discontinued. Pt had one day of urinary retention which
later resolved. Likely was due to UTI / prolonged Foley
placement.
# Hypoxia/dyspnea
Patient had acute on chronic dyspnea during hospitalization. Has
40 pack year smoking history and COPD. Generally felt with
activity. CXR without evidence of pulmonary edema, pneumonia, or
pleural effusion. LENIs negative as above. Patient's oxygenation
improved with 2L NC, later weaned to RA. She was also given
standing Duonebs.
#Hyperglycemia
Patient was managed on an insulin sliding scale. PO
anti-hyperglycemics were held.
#Sore throat
Patient complained of sore throat that was managed with throat
lozenges and chloraseptic spray with good response. Likely a
viral pharyngitis. No erythema or exudates on exam.
#Hypomagensia
Patient had hypomagnesmia upon admission that normalized with
administration of MgSO4.
CHRONIC ISSUES
========================
# History of seizures: Continued home keppra
# Hypertension: Home losartan was increased from 25 to 50 mg PO
QD. Eventually may benefit from increasing home losartan to 100
mg but holding off currently i/s/o ongoing diuresis; continue
metoprolol
# Hyperlipidemia: Continued home pravastatin.
# Diabetes: Received insulin SSI while in house.
# Hypothyroidism: Continued home levothyroxine 175 mcg.
Transitional issues
[ ] HFpEF: patient to be discharged on PO torsemide 10 mg QD as
maintenance diuretic. Please adjust PRN to maintain weight and
euvolemic status.
Discharge dry weight 110.4 kg. Discharge Cr 0.8.
[ ] GI biopsies: F/u on pathology from colonoscopy random
biopsies and polypectomy. F/u on EGD biopsy pathology of antral
erosions.
[ ] Mild gastritis: counsel patient to avoid NSAIDS given hx of
microcytic anemia and gastritis on EGD
[ ] Weight loss, poor appetite: patient should receive
age-appropriate cancer screening and PHQ-9 screening as
outpatient for follow-up for poor appetite and weight loss.
Patient endorsed weakness, confusion, poor appetite for several
weeks prior to admission. ? if this was due to low sodium that
had been present for some time. She denied symptoms of
depression.
[ ] Patient noted to have iron deficiency anemia throughout
hospitalization. Colonoscopy and EGD revealed one polyp and mild
gastritis. Pt should have follow up for ongoing anemia with
monitoring of symptoms.
Greater than ___ hour spent on care on day of discharge.
#CODE STATUS: Full, limited trial
#CONTACT: Son ___ ___ Pt's son ___, is alternate:
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 12.5 mg PO DAILY
2. Ibuprofen 800 mg PO Q12H:PRN Pain - Mild
3. Levothyroxine Sodium 175 mcg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Losartan Potassium 25 mg PO DAILY
6. LevETIRAcetam 1000 mg PO BID
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
9. Pravastatin 40 mg PO QPM
10. Gabapentin 600 mg PO TID
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Omeprazole 40 mg PO DAILY
13. glimepiride 2 mg oral BID
14. Aspirin 81 mg PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Heparin 5000 UNIT SC BID
3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H sob
4. Miconazole Powder 2% 1 Appl TP TID:PRN Rash
5. Multivitamins 1 TAB PO DAILY
6. Nicotine Patch 14 mg/day TD DAILY
7. Losartan Potassium 50 mg PO DAILY
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
9. Aspirin 81 mg PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU BID
11. Gabapentin 600 mg PO TID
12. glimepiride 2 mg oral BID
13. LevETIRAcetam 1000 mg PO BID
14. Levothyroxine Sodium 175 mcg PO DAILY
15. MetFORMIN (Glucophage) 1000 mg PO BID
16. Metoprolol Succinate XL 25 mg PO DAILY
17. Omeprazole 40 mg PO DAILY
18. Pravastatin 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary diagnosis
Hypervolemic Hyponatremia
Secondary diagnosis
Iron deficiency anemia
Constipation
Vaginal candidiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you had a headache, shortness
of breath, and diarrhea. We found that you had very low sodium
levels in your blood. This is called hyponatremia.
- You also had anemia (low blood levels) with low iron levels.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We gave you diuretics to lower the amount of fluid in your
body.
- You got a upper endoscopy and colonoscopy that found some
irritation in the esophagus. There was one polyp in the colon.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10032409-DS-15 | 10,032,409 | 20,612,017 | DS | 15 | 2129-05-06 00:00:00 | 2129-05-07 02:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Enalapril / Ace Inhibitors / Iodine / Codeine /
Advair HFA / Combivent
Attending: ___.
Chief Complaint:
Wrist fracture
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS: ___ with history of COPD on 3L o2 at
home, diabetes, and forgetfulness suggestive of dementia,
presents 1 day s/p fall down stairs. She presented herself to
___ today where she was noted to have pain in her left wrist,
shoulder, and bilateral knees.
.
At ___ a distal ulnar fracture was identified on XR and she was
sent to the emergnency room for further evaluation. her initial
vitals were 97.7 120, 168/94, 20 100 on 4L. The patient reported
s ___ pain in left wrist, ___ pain in right shoulder, ___
pain in b/l knees.
.
Per ED records, the patient does not recall incidents
surrounding fall, but is also a poor historian. She denies loss
of consciousness, but cannot provide any details regarding
slipping or how she woke up. She denies urinary or stool
incontinence, chest pain, palpitations, confusion, headache,
dizziness, or any other symptoms. After discussion with her
daughter, the fall was clearly witnessed and occurred after the
patient missed a step while going down stairs. There was no
evidence of presyncopal period or syncopy upon fall.
.
An EKG demonstrated sinus tach at 106, normal axis, normal
intervals, no St--Twave abnormalities. X-rays showed the
fracture of the ulna, and right shoulder no fracture, b/l knees
no fracture.
.
The patient was noted to have an episode in the ED where on
pulse oximetry she was tachycardic to 147 with an O2 sat of 79.
An EKG was obtained, unchanged from admission. trop <0.01.
.
She was then put on face mask, HR came down to 100s, was given
morphine 4mg IV, and when HR remaimed stable, was taken off
oxygen and patient maintained o2 sat 95 (RA). She takes 3L home
O2 for COPD, and when put on 3L NC, satting 100%.
.
A d-dimer was elevated but the patient was unable to get a PE CT
secondary to potential dye allergy. She was guaiac negative and
started on heparin with plan for V/Q scan subsequently.
.
The patient was evaluted by orthopedics who splinted the left
wrist with volar splint; no need for reduction. Very edematous;
per ortho, should have wrist elevated on 10 pillows. A head CT
demonstrated no intracranial abnormality and a CXR demonstrate
no acute changes.
.
Vitals on transfer 140/85 84 18 97(3L).
.
.
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.
.
Past Medical History:
- Oxygen-dependent COPD (3LPM), status post respiratory arrest
in
___ for which she was intubated, had a prolonged
hospital and rehab stay, and was also treated for pneumonia
- Hypertension
- Diabetes
- Hyperlipidemia
- osteoporosis with compression fractures
- Tobacco abuse
- Schizoaffective disorder
- Tardive dyskinesia
- Chronic uritcaria
- Depression
- Colonic adenoma
- s/p tonsillectomy
- s/p prophylactic appendectomy at time of hysterectomy
- s/p total abdominal hysterectomy (pt has ovaries)
Social History:
___
Family History:
Mother: ___, heart disease, hypertension, diabetes, anemia
Sister: ___ cancer
Father: ___, TB, passed away in ___
Daughter: ___
Physical ___:
VS - Afebrile, BP 151/89, HR 94, RR 21, O2-sat 100 2L%
GENERAL - Elderly, well-appearing in NAD, comfortable,
appropriate
HEENT - NC/AT, s/p cataracts bilaterally, EOMI, sclerae
anicteric, MMM, OP clear
NECK - supple,
LUNGS - CTA bilat, poor air movement with increase I/E ratio,
resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - Slight edema and tenderness over the knees
bilaterally. No c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - patient with scattered urticaria over right arm.
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&O x 1. Gait not tested. Other than pupiles
remainder of CN II-12 appear grossly intact.
Pertinent Results:
___ 04:00PM ___ PTT-26.6 ___
___ 04:00PM PLT COUNT-283
___ 04:00PM NEUTS-87.1* LYMPHS-9.9* MONOS-1.7* EOS-1.2
BASOS-0.1
___ 04:00PM WBC-9.1# RBC-4.95 HGB-13.1 HCT-39.5 MCV-80*
MCH-26.6* MCHC-33.3 RDW-14.2
___ 04:00PM D-DIMER-1254*
___ 04:00PM CALCIUM-9.7 PHOSPHATE-2.9 MAGNESIUM-2.1
___ 04:00PM cTropnT-<0.01
___ 04:00PM estGFR-Using this
___ 04:00PM GLUCOSE-246* UREA N-9 CREAT-0.7 SODIUM-131*
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-27 ANION GAP-13
___ 06:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 06:52PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:50AM BLOOD WBC-6.7 RBC-4.76 Hgb-12.7 Hct-39.0 MCV-82
MCH-26.7* MCHC-32.6 RDW-14.4 Plt ___
___ 05:50AM BLOOD Plt ___
___ 05:50AM BLOOD Glucose-66* UreaN-14 Creat-0.8 Na-137
K-4.6 Cl-102 HCO3-26 AnGap-14
___ 04:00PM BLOOD cTropnT-<0.01
___ 05:50AM BLOOD Calcium-9.2 Phos-3.8 Mg-1.9
___ 04:00PM BLOOD D-Dimer-1254*
___ 06:52PM URINE Color-Straw Appear-Clear Sp ___
___ 06:52PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
.
Radiology studies from ___:
.
wrist 3 view xray
IMPRESSION:
1. Comminuted intra-articular distal radial fracture.
2. Mildly displaced ulnar styloid fracture.
.
Shoulder: no acute fracture or dislocation
.
Knee AP/Lat/oblique
THREE VIEWS, RIGHT KNEE: No acute fracture or dislocation. There
is a small joint effusion. No suspicious lytic or sclerotic
lesions.
THREE VIEWS, LEFT KNEE: There is no acute fracture or
dislocation. There is a small joint effusion. No suspicious
lytic or sclerotic lesions. Mild
vascular calcifications.
There is minimal lateral patellar subluxation bilaterally.
IMPRESSION: No acute fracture or dislocation.
.
Head CT: IMPRESSION: No CT evidence for acute intracranial
process
.
CXR
Frontal and lateral views of the chest are obtained. Lungs
remain
relatively hyperinflated. There is persistent mild blunting of
the right
costophrenic angle, and a trace pleural effusion cannot be
excluded. No focal consolidation is seen. There is no evidence
of pneumothorax. The cardiac silhouette remains enlarged with
left ventricular configuration, similar to prior. The aorta is
calcified and tortuous. Prominence of the right hilum is stable.
Brief Hospital Course:
___ y/o female with dementia, COPD, and wrist fracture s/p fall.
.
# Wrist fracture: Evaluted by orthopedics and splinted. xrays
show nondisplaced fracture, no surgical intervention needed at
this time. Treated pain with tylenol and oxycodone standing.
Pt is not good candidate for prn medications due to baseline
dementia making it difficult for her to communicate need for
pain meds. She was evaluated by ___ and had trouble ambulating
with walker, so it was suggested that she complete course of
rehab. In terms of pt's fall. It was purely mechanical
(witnessed by family member who is a very reliable historian).
Pt was worked up with head/neck CT, CXR, shoulder and knee
xrays, all of which were negative. Pt will follow up with
repeat xrays in ortho-clinic on ___. She was discharged with
splint.
.
# Tachcardia/Hypoxia: Was most likely secondary to acute pain
and chronic COPD. No evidence of right heart strain on exam.
Oxygenation resolves quickly with baseline O2, suggesting lack
of shut physiology. Elevated d-dimer is not specific generally
and especially not so in an elderly patient s/p fall. Nothing in
history suggests change in O2 status from baseline. Per Wells
criteria patient with value of 1.5 putting pre-test prob of PE
at 3.6%. She was maintained on tele (without significant
arrhythmias) throughout hospitalization and O2 sats were wnl on
home dose of o2.
.
# COPD: Patient at baseline. Continue combivent, fluticasone,
per home regimen.
.
# Dementia/TD: Pt was maintained on home olanzapine,
perphenazine. Her tetrabenazine was held during hospitalization
given risk for severe sedation in conjunction with opiate pain
medications.
.
# GERD: maintained on omeprazole/Ranitidine
.
# Cardiac: Pt was maintained on home medication regimen. She is
on simvastatin and diltiazem, which can potentially cause
rhabdomyolysis and myositis. We dicharged her on 20mg
pravastatin and the rest of her home medications.
.
# DM: Mantained on ISS in ___ and was discharged on home
medication regimen.
.
# Urticaria: pt has chronic hives/urticarial rash likely
secondary to MGUS. Reports that nebulizers have contributed to
urticaria but did observe exacerbation of hives with nebulizers
during hospitalization. Hives come and go along arms
bilaterally and back. Sarna cream was given with relief. She
was maintained on her home dose of fexofenadine 180mg BID.
.
Full code
Transitional:
- follow up with ortho ___, repeat xrays
Medications on Admission:
1) Albuterol
2) Clonazepam
3) Diltiazem 180 daily
4) Fexofenadine
5) Fluticaxone
6) Glargine
7) Lispro
8) Atrovent
9) Combivent
10) Losartan
11) Metformin
12) Nystatin
13) Olanzapine
14) Omperaqzole
15) pERPHENAZINE
16) rANITIDINE
17) sIMVASTATIN
18) Tetrabenazine.
Discharge Medications:
1. Dulera 100-5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
puffs Inhalation twice a day.
2. ipratropium-albuterol ___ mcg/Actuation Aerosol Sig: ___
Puffs Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
3. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
4. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
5. fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
6. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
7. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. perphenazine 8 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
11. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
12. insulin lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous three times a day.
13. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 7 days.
14. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
15. oxycodone 5 mg Tablet Sig: 0.25 Tablet PO Q8H (every 8
hours) for 7 days: hold for respiratory depression and sedation.
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheeze.
17. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheeze.
18. pravastatin 10 mg Tablet Sig: Two (2) Tablet PO once a day.
19. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Twenty
(20) units Subcutaneous at bedtime.
20. metformin 500 mg Tablet Extended Rel 24 hr Sig: Two (2)
Tablet Extended Rel 24 hr PO once a day.
21. tetrabenazine 25 mg Tablet Sig: One (1) Tablet PO at
bedtime: please hold this medication until pt stops taking
oxycodone .
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
nondisplaced distal radial fracture
ulnar styloid fracture
COPD
urticaria
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you. You were admitted to the
hospital with a wrist fracture. Orthopedics placed a splint on
your arm and we treated your pain with oxycodone and tylenol.
Pt evaluated you and think that you are unsafe to ambulate at
home and you will require rehab.
.
We have made the following changes to you medications:
1. Start oxycodone 1.25mg by mouth three times daily for pain
for seven days
2. Start tylenol ___ by mouth every 8hrs for pain
3. Start pravastatin 20mg by mouth once daily
4. Stop simvastatin
5. Hold tetrabenazine 25 mg until you stop taking oxycodone
.
We have arranged follow up appointments for you below.
Followup Instructions:
___
|
10032409-DS-18 | 10,032,409 | 25,997,537 | DS | 18 | 2129-07-29 00:00:00 | 2129-07-30 08:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Enalapril / Ace Inhibitors / Iodine / Codeine /
Advair HFA / Combivent / Losartan / Levofloxacin /
hydrochlorothiazide
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ F with history COPD on 3L oxygen, DM on
insulin, HTN, schizoaffective disorder, tardive dyskinesia
recently admitted in ___ s/p syncopal event who was sent in
by ___ from ___ for confusion and tachycardia. Per report
from PCP, ___ she had been having memory difficulty x 2 weeks
and altered mental status progressively worsening for past week.
At ___ office she was noted to be tachycardic to 110 and
hypertensive also with encephalopathy and difficulty following
commands. Sent to ED for evaluation for underlying infectious
process, urinary, respirtory or hepatic sources. Patient denies
chest pain, orthopnea or PND but reports shortness of breath,
labored breathing.
.
In discussion with granddaughter, ___, the patient has been
experiencing frequent short term memory defecits. She forgot how
to use her walker, has to be isntructed to eat, forgot how to
turn the water faucet off. These memory deficits have been
progressive for past few days.
.
In the ED, initial vitals 98.2 ___ 16 98% 2l. CT head
showed No acute intracranial process. No hemorrhage. No
fracture. Age related atrophy and chronic small vessel ischemic
disease. CXR with Stable appearance of the chest, without
evidence for acute
disease. EKG in the ED SR 88, NA/NI, c/w prior. Vitals prior to
transfer 98.4, 77, 132/45, 18, 98% RA
.
On arrival to floor, patient hypertensive but stable with O2
sats in mid-90s%. She appears to have labored breathing, using
accessory muscles but maintaining O2 sats in 92-96% range on RA.
.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- Oxygen-dependent COPD (3LPM), status post respiratory arrest
in ___ for which she was intubated, had a prolonged
hospital and rehab stay, and was also treated for pneumonia
- Hypertension
- Diabetes
- Hyperlipidemia
- Osteoporosis with compression fractures
- Dementia
- Chronic MGUS
- Tobacco abuse
- Schizoaffective disorder
- Tardive dyskinesia
- Chronic uritcaria
- Depression
- Colonic adenoma
- s/p tonsillectomy
- s/p prophylactic appendectomy at time of hysterectomy
- s/p total abdominal hysterectomy (pt has ovaries)
- mechanical fall resulting in fractured left wrist and
discharged on ___
Social History:
___
Family History:
- Family History:Mother: ___, heart disease, hypertension,
diabetes, anemia
- Sister: ___ cancer
- Father: ___, TB, passed away in ___
- Daughter: ___
Physical ___:
Admission Exam:
VS - 98.4 ___ 20 94%RA W:78.1kg
GENERAL - Chronically ill appearing ___ yo F who appears to have
labored breathing with accessory muscle use. She is not speaking
full sentences because of SOB. She is alert and oriented to
person place and time but endorses difficult short term memory,
she asked me to repeat my name multiple times.
HEENT - NCAT, tongue tremulous, numbness on right side of face.
NECK - supple, no ___, no thyromegaly, no JVD, no carotid bruits
LUNGS - Reduced air movement throughout, diminished breath sound
over left posterior lung fields, increased on right side but
still poor air movement. Lungs are clear withut wheezes, rales
or rhonchi in areas that are moving air well. No egophany,
resonant to percussion
HEART - S1 S2 clear and of good quality, RRR, no MRG
ABDOMEN - Obese, NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - Awake, A&Ox3, CN V sensory defecits on right, tremulous
with intention tremor and tongue tremor. Dysmetria on finger to
nose but moving all extremities. Inattentive with inability to
complete days of week backwards. Tearful and self-aware of
confusion
Pertinent Results:
Admission Exam:
___ 12:30PM BLOOD WBC-7.7 RBC-4.86 Hgb-12.8 Hct-41.0 MCV-84
MCH-26.2* MCHC-31.2 RDW-15.0 Plt ___
___ 12:30PM BLOOD Neuts-78.6* Lymphs-16.6* Monos-2.6
Eos-1.7 Baso-0.4
___ 12:30PM BLOOD ___ PTT-26.5 ___
___ 12:30PM BLOOD Glucose-202* UreaN-8 Creat-0.6 Na-137
K-4.2 Cl-100 HCO3-28 AnGap-13
___ 12:30PM BLOOD Albumin-4.5 Calcium-9.9 Phos-2.7 Mg-2.0
___ 12:30PM BLOOD ALT-23 AST-17 AlkPhos-110* TotBili-0.3
___ 12:30PM BLOOD cTropnT-<0.01
___ 12:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Discharge Labs:
___ 06:00AM BLOOD WBC-6.3 RBC-4.47 Hgb-11.7* Hct-37.8
MCV-85 MCH-26.1* MCHC-30.9* RDW-15.1 Plt ___
___ 06:00AM BLOOD ___ PTT-27.7 ___
___ 06:00AM BLOOD Glucose-105* UreaN-15 Creat-0.7 Na-140
K-3.9 Cl-101 HCO3-29 AnGap-14
___ 06:00AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.0
Microbiology:
- RPR ___ Negative
Reports:
- CT Head ___
1. No acute intracranial process.
2. Chronic small vessel ischemic disease.
3. Age-related atrophy.
4. Hypodensities in the bilateral thalami, left greater than
right, and genu of the right internal capsule that are unchanged
compared to ___ suggesting small old lacunar infarcts.
CXR PA/LAT ___
The heart is mildly enlarged. The aorta is mildly tortuous and
calcified. There is blunting of the right costophrenic sulcus
but similar to prior studies, suggesting scarring. To a lesser
degree, there is also
blunting of the left costophrenic sulcus that appears unchanged.
Hemidiaphragms are flattened suggesting mild hyperinflation.
There is no
definite pleural effusion or pneumothorax
___ Neurophysiology EEG
IMPRESSION: Abnormal EEG due to mild diffuse background slowing
and
disorganization, indicative of a mild diffuse encephalopathy
which is etiologically non specific. There were no epileptiform
features.
___ Radiology MR ___ W/O CONTRAST
IMPRESSION: No acute infarct seen. Moderate brain atrophy and
moderate small vessel disease. Chronic lacunes in the basal
ganglia. No acute infarcts.
Brief Hospital Course:
___ F with history COPD on 3L oxygen, DM on insulin, HTN,
schizoaffective disorder, tardive dyskinesia sent in to the ED
for increasing confusion and forgetfullness.
# Encephalopathy: Acute short term memory loss without obvious
preceeding event. Inattention on exam but oriented indicating
most likely delirium versus acute progression of dementia. Acute
onset and with possible stepwise decline is curious for vascular
dementia. CT head also showing some small vessel ischemic
disease which may be consistent with vascular dementia. MRI head
did not show acute process or acute stroke. In addition, chronic
psychiatric disease with dopaminergic medications may be
exacerbating her clinical status. Toxic-metabolic work up all
negative except for low TSH but FT4 is 1.0. B12, Folate and RPR
all normal/negative. After reading prior neuro notes she did not
seem far off from baseline. Neurology was consulted who
requested an EEG which showed mild diffuse background slowing
and disorganization, indicative of a mild diffuse encephalopathy
which is etiologically non specific. There were no epileptiform
features. Final diagnosis was polypharmacy induced
encephalopathy. Benadryl was discontinued, Clonazepam tapered
down and discontinued and Tetrabenzaprine dose halved. Plan to
discontinue Tetrabezaprine all together but patient requested it
continued. Neuro also felt she definatively has sleep apnea
which is likely contributing to poor morning arousability. CPAP
was started on the floor and continued as an outpatient.
# COPD: Oxygen-dependent COPD (3LPM), s/p respiratory arrest in
___ with protracted intubation course. Labored,
tachypnic breathing on admission though without oxygen
requirement. After being placed back on home O2 of 2L NC her
respiratory status improved and she maintained O2 sats in >95%.
Continued home regimen of Albuterol 0.083% Neb Soln 1 NEB IH
Q4H:PRN, Fluticasone Propionate NASAL 1 SPRY NU DAILY,
Ipratropium Bromide Neb 1 NEB IH Q6H, Dulera *NF*
(mometasone-formoterol) 100-5 mcg BID and supplemental O2 at 2L
NC. No acute exacerbation during admission. Patient is on
Azithromycin chronically as an outpatient, unclear if this can
be continued, defer to outpatient pulmonary for that decision.
# Glycosuria: 1000 Glu on UA. Serum glucose only 200 so unclear
why she is spilling so much glucose. Possibly Fanconi syndrome
though patient with normal renal function, phosphate and bicarb
slightly elevated. Elevated bicarb likely compensating for
chronic CO2 retention, no evidence of RTA to look for Fanconi's.
Dilute urine may also indicate she is not concentrating
appropriately. Repeat urine continued to show glycosuria. This
can be monitored as an outpatient.
# Hypertension: Chronic, uncontrolled, asymptomatic at this
point, not being treated as an outpatient. Allergy to ACE-I and
ARBs which would be first line given possibly renal dysfunction
with glycosuria. Consider starting Chlorthalidone as an
outpatient.
# Diabetes Mellitus: Type II, insulin dependent, complicated by
vascular disease. Continued Lantus 20 units QHS and QACHS ___ and
HISS, held Metformin while inpatient
# Schizoaffective disorder: On typical antipsychotics
complicated by movement disorders and tardive dyskinesia.
Consider changing medications as there may be contributing to
AMS deterioration. Discontinued Clonazepam 1 mg PO/NG QHS due to
lethargy but continued Perphenazine 8 mg PO/NG QHS, Olanzapine 5
mg PO HS, Tetrabenazine 25 mg Oral QHS
TRANSITIONAL ISSUES:
- Treat hypertension as an outpatient, consider starting
Chlorthalidone
- Continue to titrate down and discontinue
antipsychotics/anticholinergics as an outpatient, this is likely
contributing to encephalopathy
- Patient started on CPAP
- CODE STATUS: Full
- CONTACT: HCP is Grand___: ___ ___, Daughter
___: ___
___ on Admission:
- diltiazem HCl 240 mg Capsule, Extended Release Daily
- ipratropium-albuterol ___ mcg/actuation ___ IH Q6hours:prn
- albuterol sulfate 2.5 mg /3 mL (0.083 %)nebs Q4-6hrs:prn
for shortness of breath or wheezing.
- senna 8.6 mg Tablet PO BID as needed for constipation.
- camphor-menthol 0.5-0.5 % Lotion QID:prn
- olanzapine 5 mg Tablet PO HS
- Dulera 100-5 mcg/actuation HFA Aerosol 2 Inhalation q12h
- tetrabenazine 25 mg PO qhs
- pravastatin 20 mg Tablet PO DAILY
- fluticasone 50 mcg/actuation Spray Nasal DAILY
- insulin lispro 100 unit/mL sliding scale
- insulin glargine 100 unit/mL Twenty (20) U QHS
- metformin 1,000 mg PO twice a day.
- azithromycin 250 mg daily
- Perphenazine 8 mg PO/NG QHS
- Clonazepam 1 mg PO/NG QHS
- Ranitidine 300 mg PO/NG HS
Discharge Medications:
1. DILT-XR 240 mg Capsule,Ext Release Degradable Sig: One (1)
Capsule,Ext Release Degradable PO once a day.
2. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
3. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous
ASDIR: Use ASDIR by your sliding scale.
4. CPAP
Positive Airway Pressure for OSA: Indication Known OSA
Nasal CPAP: CPAP level: Auto setting, 5-20 cm H2O; Supp O2: 3
L/min Rate, spontaneous
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. perphenazine 8 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
8. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Dulera 100-5 mcg/actuation HFA Aerosol Inhaler Sig: One (1)
IH Inhalation BID (2 times a day).
10. ipratropium-albuterol ___ mcg/actuation Aerosol Sig: ___
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every ___ hours as needed
for SOB/Wheezing.
12. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Topical four
times a day as needed for rash.
13. olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Dulera 100-5 mcg/actuation HFA Aerosol Inhaler Sig: Two (2)
Inhalation twice a day.
15. tetrabenazine 12.5 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
16. insulin lispro 100 unit/mL Solution Sig: as directed
Subcutaneous three times a day: per sliding scale.
17. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous once a day.
18. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
19. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at
bedtime.
20. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Encephalopathy
Chronic obstructive pulmonary disease
Obstructive sleep apnea
Secondary:
Schizoaffective Disorder
Mood disorders
Tardive Dyskinesia
hypertension
Type 2 insulin dependent diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
It was a pleasure treating you during this hospitalization. You
were admitted to ___ because of
increasing confusion and forgetfullness at home. Infectious and
metabolic work up did not show any specific cause for your
encephalopathy. Neurology was consulted and you completed an
electroencephalograpm, which showed that you were not having any
seizures. Our neurologists felt that your confusion was likely
caused by a combination of excess sedating medication, which we
have stopped, and sleep apnea, a medical condition that causes
you to stop breathing briefly many times a night during sleep.
The following changes to your medications were made:
- STOP Clonazepam (Klonopin) as this may worsen your confusion
- STOP Benadryl (diphenhydramine) as this may worsen your
confusion
- REDUCE your Tetrabenazine from 25mg to 12.5 mg (one half
tablet) every night
- START using your CPAP machine every night, as much as
possible, when you sleep.
- No other changes were made to your medications, please
continue taking as previously prescribed
Followup Instructions:
___
|
10032409-DS-19 | 10,032,409 | 22,661,627 | DS | 19 | 2130-01-21 00:00:00 | 2130-01-21 14:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Enalapril / Ace Inhibitors / Iodine / Codeine /
Advair HFA / Losartan / Levofloxacin / hydrochlorothiazide
Attending: ___.
Chief Complaint:
weakness, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a h/o COPD on ___, s/p resp arrest in ___, HTN, DM,
dementia, schizoaffective d/o, tardive dyskinesia presents for
worsening ambulation, confusion, dyspnea.
Per pt's family, pt doing well until a few days ago. More
recently, she has been slower to respond, has had difficulty
walking to the bathroom and is requiring more assistance. She
has urinary incontinence at baseline, but has had increased in
voiding and incontinence. Two nights ago, pt went to bathroom,
daughter found her sitting in the bathtub. Daughter does not
believe she fell, she asked patient what was wrong, but patient
was unable to recall events. Pt had one episode of near fall
3days ago and yesterday, where she felt like her knees would
give away. She was found sitting on the ground watching TV. Pt
stated that her knees gave away, family does not think she had
LOC or hit her head. Yesterday, pt also told her daughter her
breathing was "not good," dyspnea improved w/ CPAP. At
baseline, communicates w/ simple few word sentences, but now
appears slower to respond to questions; she used to walk w/
walker but has not used it recently. She is compliant with her
CPAP at night. Daughter thinks she had subjective fevers, but
no documented fevers. No chills. Daughter cares for pt at home.
Otherwise, no cough, abdominal pain, diarrhea at home, slurred
speech, clumsiness, objective weakness.
In the ED, VS: 98.3 72 143/71 20 100% 15L. Neuro: nonfocal;
Lungs: R base ?crackles. CT head- neg for bleed; VBG: 7.41/47;
CXR: ? PNA on R. She received azithro, cftx, and asa.
Currently, denies pain or shortness of breath
ROS: 12 point review of system is also + for constipation,
chronic tardive dyskinesia, otherwise negative.
Past Medical History:
- Oxygen-dependent COPD (3LPM), status post respiratory arrest
in ___ for which she was intubated, had a prolonged
hospital and rehab stay, and was also treated for pneumonia
- Hypertension
- Diabetes
- Hyperlipidemia
- Osteoporosis with compression fractures
- Dementia
- Chronic MGUS
- Tobacco abuse
- Schizoaffective disorder
- Tardive dyskinesia
- Chronic uritcaria
- Depression
- Colonic adenoma
- s/p tonsillectomy
- s/p prophylactic appendectomy at time of hysterectomy
- s/p total abdominal hysterectomy (pt has ovaries)
- mechanical fall resulting in fractured left wrist and
discharged on ___
Social History:
___
Family History:
- Family History:Mother: ___, heart disease, hypertension,
diabetes, anemia
- Sister: ___ cancer
- Father: ___, TB, passed away in ___
- Daughter: ___
Physical ___:
On Admission:
VS: 98.8, 138/78, 80, 20 99% 2L
GEN: Responds to most questions w/ simple few word sentences,
constricted affect, repetative lip smacking
HEENT: OP clear, MMM
NECK: Supple, No JVD
CV: RR, no murmurs/rubs/gallops
RESP: Sparse scattered wheeze, no dullness, symetric expansion
of chest
ABD: Soft NT, ND
GU: No CVAT
EXTR: wwp, no edema
Neuro: CN2-12 intact, cogwheel rigidity, strength ___
throughout, sensation to LT intact, nl FNF, gait deferred, neg
babinski, no pronator drift
On Discharge:
VS: Tm 98.5 BP 169/85 HR 97 RR 20 SaO2 96%3L
GEN: Alert, Responding appropriately to questions, Oriented x 3
HEENT: OP clear, MMM
NECK: Supple
CV: RRR, no m/r/g
RESP: CTA B, diminished BS throughout, no w/r/r
ABD: S/NT/ND
NEURO: Non-focal
Pertinent Results:
Admission Labs:
___ 03:30PM BLOOD WBC-9.4 RBC-4.58 Hgb-12.5 Hct-37.8 MCV-83
MCH-27.3 MCHC-33.1 RDW-15.3 Plt ___
___ 03:30PM BLOOD Neuts-72.4* ___ Monos-3.4 Eos-1.5
Baso-0.1
___ 03:30PM BLOOD Glucose-232* UreaN-16 Creat-0.8 Na-141
K-4.0 Cl-103 HCO3-28 AnGap-14
___ 03:30PM BLOOD ALT-21 AST-26 AlkPhos-96 TotBili-0.2
Discharge Labs:
___ 06:25AM BLOOD WBC-14.5* RBC-4.55 Hgb-12.4 Hct-38.6
MCV-85 MCH-27.3 MCHC-32.1 RDW-16.7* Plt ___
___ 06:25AM BLOOD Glucose-120* UreaN-29* Creat-0.8 Na-141
K-4.0 Cl-104 HCO3-29 AnGap-12
___ 06:25AM BLOOD Calcium-9.6 Phos-3.6 Mg-2.2
___ 09:00PM BLOOD CK(CPK)-158
___ 04:00AM BLOOD CK(CPK)-150
___ 03:30PM BLOOD cTropnT-<0.01
___ 09:00PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-62
___ 04:00AM BLOOD CK-MB-3 cTropnT-<0.01
___ 07:30AM BLOOD VitB12-___ Folate-15.3
___ 07:30AM BLOOD TSH-0.43
___ 06:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:20PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 06:20PM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 06:20PM URINE Mucous-RARE
___ URINE CULTURE - negative
___ BLOOD CULTURE - negative x 2
CXR ___ - FINDINGS: AP upright and lateral views of the
chest are provided. Evaluation through the lower lung is
limited due to underpenetrated technique. Allowing for this, no
definite signs of pneumonia or CHF. No large effusions are
seen. Aorta is unfolded. The heart size is within normal
limits. The bony structures appear intact.
IMPRESSION: Limited, negative.
CT Head ___ - FINDINGS: There is no acute intracranial
hemorrhage, edema, mass effect or major vascular territorial
infarction. There is no shift of normally midline structures.
Periventricular and subcortical white matter hypodensities are
compatible with chronic small vessel ischemic disease.
Ventricular and sulci are prominent, compatible with age-related
involutional changes. Imaged paranasal sinuses and mastoid air
cells are well aerated. There is no fracture.
IMPRESSION: No acute intracranial process.
UE U/S ___ - FINDINGS:
There is normal gray scale appearance with compression, color
Doppler flow, and spectral Doppler waveforms of the right
subclavian, axillary, and brachial, basilic, and cephalic veins.
Numerous thyroid cysts in the right thyroid lobe are
incompletely assessed.
IMPRESSION: No DVT in the right upper extremity.
CXR ___ - Heart size is top normal. Mediastinum is within
normal limits. Lungs are essentially clear. No pleural
effusion or pneumothorax is seen.
IMPRESSION: No evidence of acute cardiopulmonary abnormality
demonstrated.
CTA CHEST ___ - Dense atherosclerotic mural calcifications
are present along the thoracic aorta. The aorta is of normal
caliber without aneurysm or dissection. Contrast bolus is
suboptimal for evaluation of the subsegmental pulmonary
arteries. The main, lobar, and segmental pulmonary arteries are
opacified without filling defect. A linear hypodensity through
a right lower lobe medial basal subsegmental pulmonary artery
(4:106, 502a:65), which is not expanded, may be artifactual.
Bovine arch is incidentally noted.
CHEST: The visualized portion of the thyroid is unremarkable.
No axillary, supraclavicular, mediastinal, or hilar
lymphadenopathy. Dense calcification is present in the left
anterior descending, circumflex, and right main coronary
arteries. The heart is mildly enlarged. Trace pericardial
effusion is similar to prior.
Mild to moderate upper zone predominant centrilobular emphysema
is similar to ___. 4 mm perifissural right middle lobe
nodule is stable since ___. No new pulmonary nodule.
There is bibasilar dependent atelectasis, similar to prior. No
focal consolidation, pleural effusion, pneumothorax, or
pneumomediastinum.
Airways are patent to subsegmental levels. The esophagus is
normal. This study is not tailored for evaluation of the
subdiaphragmatic organs. Within this limitation, the visualized
upper abdominal organs are unremarkable.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion
concerning for
malignancy.
IMPRESSION:
1. Quality of contrast bolus allows exclusion of pulmonary
emboli up to the segmental pulmonary arteries. Filling
heterogeneities within the pulmonary arteries beyond this level
are equivocal. Curvilinear hypodensity within a right lower
lobe medial basal subsegmental pulmonary artery may be
artifactual, but a subacute pulmonary embolism is not entirely
excluded.
2. Mild upper zone predominant centrilobular emphysema.
3. Mild cardiomegaly. Three-vessel coronary artery
calcification.
4. 4-mm right middle lobe perifissural pulmonary nodule, with
demonstrated two year stability since ___.
Brief Hospital Course:
___ with a h/o COPD on 3___, s/p resp arrest in ___, HTN, DM,
dementia, schizoaffective d/o, tardive dyskinesia presents for
worsening ambulation, confusion, dyspnea.
# Altered Mental Status: Concern for slowing of speech and
slowness to respond on admission, though it appears per
communication with PCP and family that this has been a subacute
to chronic process. UA unremarkable for UTI, and CXR limited but
w/o evidence of pna. Electrolytes were normal. CT head w/o
bleed, and neuro exam w/o focal deficits. Patient was not
delerious, but could converse really in few word responses.
Psych was consulted and they recommended continuing to hold the
Olanzapine. She seemed to tolerate the Perphenazine. While this
can cause TD, they recommended outpatient ___ with her
psychiatrist. Neuro was consulted for AMS and concern for
possible truncal weakness. They found no reason to EEG or MRI.
Per review of old psych notes, pt has had word finding and
memory difficulties. H/o schizoaffective d/o. TSH, B12 and
Folate were normal. Initially tetrabenzapine was discontinued.
However, pt's family reports that pt needs this medication for
her tardive dyskinesias. Mental status was continuing to improve
at the time of fall.
# Worsening ambulation, fall: No focal defecits on neuro exam,
head CT unremarkable. ___ & OT consults were placed. The
patient is being discharged to rehab for continued physical
therapy.
# Urinary inc, frequent voiding: UA/Ucx neg. Foley catheter
placed in ED was taken out. Could be related to underlying
cognitive impairment. Per family happened 1 month ago as well.
# Acute on chronic COPD exacerbation-Pt with severe COPD on 3L
NC at baseline. Pt appeared to be at her baseline status ___
word sentences and intermittent tachypnea that family reported
was worse in the evenings. Pt did have several episodes of acute
dyspnea/tachypnea often in the evenings during admission. EKG's
were unchanged. Cardiac enzymes were normal. CTA of the chest
did not show any large PE and there were never any clinical
signs of pneumonia. It was discovered that combivent had
erroneously been on the patient's medication allergy list. She
had been taking this medication QID at home without any
difficulities. She was therefore, started on steroids and
nebulizer therapy. With this, her respiratory status improved.
# DM 2: Pt was continued on home lantus, ISS was continued.
Metformin was held while in-house and restarted on discharge. Of
note, Lantus was uptitrated ___ hyperglycemia in the setting of
steroids. This will likely need to be readjusted after her
steroid burst is complete.
#HTN - Home diltiazem was continued. Hydralazine was
added/uptitrated for better blood pressure control. BP was still
noted to be elevated at the time of discharge. If blood pressure
remains elevated, diltiazem will likely need to be further
increased.
#Schizoaffective d/o - Olanzapine stopped
#Sleep Apnea - on CPAP
TRANSITIONAL ISSUES:
- Pt with new leukocytosis on the day of discharge.
Asymptomatic, afebrile. Likely related to steroid burst. Please
repeat CBC ___ days after discharge to ensure stability.
- Please monitor BP's and uptitrate diltiazem as needed.
- Please monitor fingersticks. Lantus has been increased for
better glucose control. However, after steroid burst is
complete, pt's Lantus dose will likely need to be decreased.
- Pt with a cognitive neuro ___ appt scheduled for ___
___. Also with an upcoming ___ appt (see
follow-up information).
- Pt will need PCP ___ appointment at the time of discharge from
rehab.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/CaregiverwebOMR.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob
2. Azithromycin 250 mg PO Q24H
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Albuterol-Ipratropium 2 PUFF IH Q4H:PRN sob
6. MetFORMIN XR (Glucophage XR) 500 mg PO BID
Do Not Crush
7. Dulera *NF* (mometasone-formoterol) 100-5 mcg/actuation
Inhalation bid
8. Nystatin Cream 1 Appl TP BID
to redness of under skin folds
9. Perphenazine 8 mg PO QHS
10. Pravastatin 20 mg PO DAILY
11. Ranitidine 300 mg PO HS
12. tetrabenazine *NF* 12.5 mg Oral daily itch
13. Senna 1 TAB PO BID:PRN constipation
14. Acidophilus Probiotic *NF* (acidophilus-pectin, citrus) 175
mg Oral bid
15. Diltiazem Extended-Release 360 mg PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob
2. Azithromycin 250 mg PO Q24H
3. Diltiazem Extended-Release 360 mg PO DAILY
4. Dulera *NF* (mometasone-formoterol) 100-5 mcg/actuation
Inhalation bid
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Perphenazine 8 mg PO QHS
7. Pravastatin 20 mg PO DAILY
8. Ranitidine 300 mg PO HS
9. Senna 1 TAB PO BID:PRN constipation
10. MetFORMIN XR (Glucophage XR) 500 mg PO BID
Do Not Crush
11. Acidophilus Probiotic *NF* (acidophilus-pectin, citrus) 175
mg Oral bid
12. Nystatin Cream 1 Appl TP BID
to redness of under skin folds
13. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
14. HydrALAzine 75 mg PO Q6H
Hold for SBP <140.
15. PredniSONE 60 mg PO DAILY Duration: 3 Days
for three more days, ending ___
16. Albuterol-Ipratropium 2 PUFF IH Q6H
17. tetrabenazine *NF* 12.5 mg HS daily
Discharge Disposition:
Extended Care
Facility:
___
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Schizoaffective disorder
Tardive dyskinesia
Physical deconditioning
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge to Rehab - Estimated length of stay > 30 days.
Discharge Instructions:
You were admitted with report of mental slowing. There was no
evidence of infection, no witnessed or suspected seizure
activity. Your Olanzapine (zyprexa) was discontinued under
recommendation of inpatient psychiatry team and you should ___
with your outpatient psychiatrist.
In addition, you developed an acute exacerbation of your COPD
and were treated with steroids and nebulizer therapy. You were
alert and oriented though deconditioned. Physical and
occupational therapy evaluated you. You are being discharged to
a rehab facility to help you build up your strength.
Please continue your Oxygen and CPAP use as per outpatient
provider ___.
Medication changes:
- Start prednisone 60 mg daily for 3 more days (ending on
___
- Start hydralazine for your blood pressure
- We increased your insulin while you are on steroids. Your
insulin requirement will likely decrease after your steroid
course is complete.
Followup Instructions:
___
|
10032725-DS-20 | 10,032,725 | 20,611,640 | DS | 20 | 2143-03-25 00:00:00 | 2143-03-25 18:48:00 |
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, hemiplegia
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
Ms. ___ is a ___ woman with a history of endometrial
cancer with recently discovered poorly differentiated lesion to
the right femur, s/p open reduction internal fixation on
___ on prophylactic lovenox therapy presented with altered
mental status and hemiplegia. ___ was found at her facility
tonight unreponsive and hemiparetic on the left with severe
weakness, was at her baseline two hours prior.
.
Of note patient was recently hospitalized from ___
with episode of chest pain. No clear source was identified,
however patient was noted to new metastatic lesions of the lung,
femur, and adrenals on imaging. She was noted to have
hypercalcemia which was managed with pamidronate. She completed
her outpt workup for RLE mass which underwent open reduction and
internal fixation. She was subsquently started on carboplatin,
received one dose, with plans to follow up as outpt for
___ tx. She subsquently underwent 5 rounds of radiation
tx to her right femur for pain control. Palliative care was
also consulted for assistance with pain management.
.
In the ___ ED, vital signs were stable. Pt was noted to be
drowsy with left sided hemiplegia, tachycardia, and RLE edema.
Exam with L sided weakness, with some resistance to gravity.
She was able to follow simple commands, alert and oriented to
self and month. Code stroke was called at 2:53A. Due to initial
concern for septic emboli from her surgical site she was treated
with 1gm Vancomycin. CT head demonstrated multiple hyperdense
lesions with surrounding edema thought to be hemorrhagic
conversion of mets. Neurology will follow. Ortho also consulted
for evaluation of RLE edema, thought to be related to recent
surgery. RLE Xray with no acute pathology. ___ showed no DVT,
CTA also ruled out PE. Compartment syndrome was thought to be
highly unlikely. Vital signs on transfer HR 116 BP163/97 O2 sat
100% RA.
.
.
On the floor, pt is very somnulant and not able to respond to
questions.
Past Medical History:
Onc:
- TAH/BSO/Lymphadenectomy on ___ that revealed FIGO stage I,
grade ___ endometrioid carcinoma.
- Imaging from ___: bilateral hilar adenopathy up to 2cm,
right adrenal nodule, multiple bilateral lesions in the kidneys,
a 1.4 cm subcutaneous soft tissue nodule in the right inguinal
region, andmultiple 1-cm right inguinal lymph nodes. 5X5X22 cm
right distal femoral mass with soft tissue extension.
- Femoral mass pathology poorly differentiated carcinoma
"compatible with" endometrial carcinoma.
-Hypertension
-Hypercholesterolemia
-DM
-Back surgery on L5/S1 in ___
Social History:
___
Family History:
The patient's father died from cancer (type unknown). She has no
family history of clotting disorders or heart disease.
Physical Exam:
ADMISSION EXAM:
Vitals: T:100.1 BP:109 P:121/86 R:21 O2:100% RA
General: obtunded, unresponsive to sternal rub, nailbed pressure
HEENT: Sclera anicteric, pupils small but reactive bilaterally,
resists passive eye opening on the right, but not on the left.
mouth open. oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses. RLE warm, nonerythemetous,
twice the size of LLE, but edema nonpitting. small well healing
incisions, at the right trochanter and right lateral femoral
head.
Neuro: pupils reactive, unable to assess other cranial nerves as
pt not responsive, left facial droop. minimal to absent gag
reflex. has tone in the RUE, protects arm when dropped, makes
some spontaneous movements of the hand and arm. LUE flaccid. no
posturing. reflexes minimal bilaterally. babinski equivocal
bilaterally.
.
DISCHARGE EXAM
General: More responsive this AM, able to follow commands
HEENT: Sclera anicteric, pupils small but reactive bilaterally,
oropharynx clear
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses. RLE warm, nonerythemetous,
twice the size of LLE, but edema nonpitting. small well healing
incisions, at the right trochanter and right lateral femoral
head.
Neuro: pupils reactive, strength is ___ on the right UE. Is not
moving RLE due to pain. Cannot move left side. Facial droop on
left.
Pertinent Results:
ADMISSION LABS:
___ 01:20AM BLOOD WBC-23.8* RBC-4.44 Hgb-11.5* Hct-33.2*
MCV-75* MCH-25.9* MCHC-34.6 RDW-16.4* Plt ___
___ 01:20AM BLOOD Neuts-86.6* Lymphs-9.4* Monos-3.4 Eos-0.3
Baso-0.3
___ 01:20AM BLOOD ___ PTT-35.0 ___
___ 07:31AM BLOOD Glucose-153* UreaN-26* Creat-1.1 Na-135
K-4.5 Cl-100 HCO3-22 AnGap-18
___ 07:31AM BLOOD ALT-3 AST-20 AlkPhos-166* TotBili-0.2
___ 07:31AM BLOOD Albumin-3.4* Calcium-8.8 Phos-2.8 Mg-2.3
___ 07:31AM BLOOD TSH-0.56
___ 01:40AM BLOOD Glucose-148* Na-136 K-4.4 Cl-97
calHCO3-24
___ 04:17AM BLOOD Lactate-1.7
.
No Labs obtained on discharge.
.
EEG:
This is an abnormal continuous ICU video EEG study because of
diffusely suppressed and slow background indicative of a
moderate to severe encephalopathy. The frontally predominant
delta frequency activity can be seen in toxic/metolic
disturbances, but may also be seen in midline or subcortical
dysfunction, including hydrocephalus. Thus, clinical correlation
is recommended. No epileptiform discharges or electrographic
seizures were present in the record. A note was made of sinus
tachycardia and occasional premature wide complex beats.
.
CT head:
IMPRESSION: Multiple hyperdense masses involving both the
superficial and
deep white matter and deep gray matter, with an area of
vasogenic edema in the left occipital lobe. Differential
diagnosis is broad, though findings are most likely secondary to
hemorrhagic metastases given the clinical history. Other
possibilities, though less likely include hemorrhagic infarcts
secondary to dural venous or cortical venous thrombosis,
spontaneous hemorrhage from complication of anticoagulation
(given the recent history of orthopedic surgery), lymphoma or
infection. Further characterization with MRI of the brain is
recommended
Brief Hospital Course:
Mrs ___ is a ___ y/o f with metastatic poorly differentiated
carcinoma who was admitted for AMS and new left hemiplegia found
to be likely d/t newly diagnosed malignant metastases to brain
(multiple lesions) with hemorrhage into right thalamic lesion.
After consultation with the oncology team and patient's family
decision was made to focus care on comfort and patient was
discharged home with hospice.
ALTERED MENTAL STATUS (AMS) patient was transientently
intubatied for airway protection to allow for disgnostic
testing. Attributed to multiple brain mets, some with
complication of bleeding, and surrounding vasogenic edema. No
clinical or EEG evidence for active seizures. Treated with oral
steroids and prophylactic anti-convulsant.
BRAIN LESIONS Not previously recognized. Likely metastatic
disease from her known poorly differentiated CA of uncertain
primary. Evidence for hemorrhage into lesions per CT. Per our
oncology team no further theraputic or palliative
chemo/radiation can be offered that would be of benefit to the
patient.
HEMIPLEGIA, LEFT likely ___ to acute bleed into brain
mets(consistent with right thalamic lesion and hemmorage seen on
CT). Repeat Head CT without significant change.
CARCINOMA metastatic poorly differentiated, unclear etiology.
Per oncology team no plans for further chemotherapy.
RIGHT LEG SWELLING recent orthopedic surgery ORIF. No further
interventions with Orthopedic service. No evidence for DVT by
___.
Goals of care: meeting was held with patient's family, ICU and
Oncology team, per patient's dire condition and family's wishes
decision to transition to comfort focused care. Patient was
followed by palliative care and is now dicharged to out patient
hospice.
DISPOSITION -- returned home with hospice services.
Discharge Medications:
1. methadone in 0.9 % sod. chlor 1 mg/mL (1 mL) Syringe Sig: 0.6
mg per hour Intravenous continuous via CADD pump: + Bolus 0.2mg
every 20 minutes PRN breakthrough pain
.
Disp:*10 100ml vials* Refills:*0*
2. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Fourteen
(14) units Subcutaneous at bedtime.
Disp:*30 ml * Refills:*0*
3. One Touch Ultra System Kit Kit Sig: One (1) kit
Miscellaneous four times a day.
Disp:*1 kit* Refills:*0*
4. Dilaudid concentrate (20mg/ml) Sig: ___ mL Sublingual
q2hr as needed for pain/respiratory distress: Please use 0.5-1mL
(___) q2 hours sublinguially PRN for pain or respiratory
distress.
Disp:*60 mL* Refills:*0*
5. Ativan liquid (2mg/ml) Sig: 0.5 ml Sublingual every six (6)
hours: Please use 1mg (0.5ml) sublingually q6hrs. ___ hold for
sedation.
Disp:*30 mL* Refills:*0*
6. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day: ___ hold for loose stools.
Disp:*30 suppositories* Refills:*0*
7. acetaminophen 650 mg Suppository Sig: One (1) suppository
Rectal every six (6) hours as needed for fever or pain.
Disp:*30 suppositories* Refills:*2*
8. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: One (1)
liter Intravenous q nightly: Please run 1 Liter nightly at
100ml/hr over 10 hours.
Disp:*7 liters* Refills:*2*
9. dexamethasone oral solution (10mg/ml) Sig: One (1) ml
Sublingual every eight (8) hours: Please place 1ml sublingual q8
hours.
Disp:*60 ml* Refills:*0*
10. supplies
Please supply with One Touch Ultra testing strips. Dispense 100
strips, no refills
11. One Touch UltraSoft Lancets Misc Sig: One (1) lancet
Miscellaneous every six (6) hours.
Disp:*100 lancets* Refills:*0*
12. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) cc Injection
five times a day as needed for IV flush: 10cc flush to IV site
PRN.
Disp:*30 syringes* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
metastatic brain cancer
Secondary:
endometrial cancer
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted because you were found
unresponsive and with trouble moving the left side of your body.
You had a head CT scan here that showed multiple areas of cancer
in the brain. You were initially intubated to support your
breathing but the breathing tube was quickly removed and you
have been breathing well on your own. With the help of your
family, we have arranged for you to be able to go home and be
comfortable.
Please take the following medications:
1. Please use a methadone pump at 0.6 mg per hour Intravenous
continuous infusion via CADD pump: + Bolus 0.2mg every 20
minutes as needed for breakthrough pain
2. Please check blood sugars daily and give glargine 14 units
for blood sugars >200. Please do not give if sugars are <200.
3. Please use Dilaudid for breakthrough pain control. Use ___
ml under the tongue as needed for pain every 2 hours.
4. Please use ativan to prevent seizures. Place 0.5ml under the
tongue every 6 hours. This may be held if Ms. ___ is too
sedated and sleepy.
5. Please use bisacodyl 10 mg Suppository daily. This should be
held for loose stools.
6. Use acetaminophen 650 mg Suppository every 6 hours as needed
for fever or pain.
7. Take dexamethasone 1mL under the tongue every 8 hours.
8. Please take 1 liter of fluid (normal saline) nightly, to be
run at 100cc/hr for 10 hours.
Followup Instructions:
___
|
10033085-DS-11 | 10,033,085 | 23,404,293 | DS | 11 | 2160-10-22 00:00:00 | 2160-10-23 12:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R foot Osteomyelitis
Major Surgical or Invasive Procedure:
___: R ___ MPJ debridement; abx spacer
History of Present Illness:
___ male patient presenting to the ED with concern for a
right toe infection. Patient with PMH of DM with history of
prior foot infections. He gets his care in ___. He states
that he has a 5 week history of a R foot/hallux infection. He
had been on IV abx converted to orals and then started on
daptomycin/ertapenem by Infectious Disease in ___. He
relates that his foot has continued to be erythematous and
swollen for the past few weeks despite abx course. He was seen
today by his podiatrist and had xrays take which revealed bony
destruction. He was then told to present to ___ for further
workup and treatment. Denies any recent fevers or chills. No
recent nausea, vomiting, chest pain, or SOB. The foot is not
painful but he has neuropathy.
Past Medical History:
DM - does not recall last HgbA1C
HTN
cataracts - surgery in the past
Social History:
___
Family History:
n/c
Physical Exam:
Admission Phyisical Exam:
PE:
Vitals: 98.1 98 189/108 17 99% RA
GEN: NAD, Aox3
RESP: CTA, breathing comfortably on room air
CV: RRR
ABD: soft, nontender, ___ FOCUSED EXAM: Dp/Pt pulses palpable b/l. crt<3sec to the
digits. normal proximal to distal cooling. Edema to the R
forefoot and ___ MPJ area. Small ulceration to the plantar
aspect of the R hallux which probes deep. Mild erythema
surrounding the R ___ MPJ. No pain with palpation.
NEURO: CNII-XII intact. light touch sensation diminished to the
___ b/l.
Discharge Physical Exam:
PE:
Vitals:
GEN: NAD, Aox3
RESP: CTA, breathing comfortably on room air
CV: RRR
ABD: soft, nontender, ___ FOCUSED EXAM: crt<3sec to the digits. Dry surgical dressing
intact
Pertinent Results:
___ 10:10PM BLOOD WBC-7.6 RBC-4.18* Hgb-11.7* Hct-37.5*
MCV-90 MCH-28.0 MCHC-31.2* RDW-15.0 RDWSD-48.4* Plt ___
___ 10:10PM BLOOD Neuts-83* Bands-2 Lymphs-7* Monos-4*
Eos-2 Baso-0 ___ Metas-2* Myelos-0 AbsNeut-6.46*
AbsLymp-0.53* AbsMono-0.30 AbsEos-0.15 AbsBaso-0.00*
___ 10:10PM BLOOD ___ PTT-34.8 ___
___ 10:10PM BLOOD Glucose-69* UreaN-19 Creat-1.0 Na-141
K-4.7 Cl-102 HCO3-23 AnGap-16
___ 07:28AM BLOOD %HbA1c-9.5* eAG-226*
___ 06:34AM BLOOD CRP-11.2*
___ 10:27PM BLOOD Lactate-1.8
___ 1:45 pm TISSUE PROXIMAL PHALYNIX 5.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 1:38 pm TISSUE IST METATARSAL.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary):
GRAM POSITIVE COCCUS(COCCI). RARE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
The patient was admitted to the podiatric surgery service from
the ED on ___ for a R foot infection. On admission, he was
started on broad spectrum antibiotics. He was taking to the OR
for Right foot debridement on ___. Pt was evaluated by
anesthesia and taken to the operating room. There were no
adverse events in the
operating room; please see the operative note for details.
Afterwards, pt was taken to the PACU in stable condition, then
transferred to the ward for observation.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled oral pain medication on a
PRN basis. The patient remained stable from both a
cardiovascular and pulmonary standpoint. He was placed on
vancomycin, ciprofloxacin, and flagyl while hospitalized and
discharged with oral antibiotics. His intake and output were
closely monitored and noted to be adequate. The patient received
subcutaneous heparin throughout admission; early and frequent
ambulation were strongly encouraged.
The patient was subsequently discharged to home on POD3 with IV
antibiotics. 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. Carvedilol 25 mg PO BID
2. MetFORMIN XR (Glucophage XR) 500 mg PO Q8H
3. amLODIPine 10 mg PO DAILY
4. SITagliptin 100 mg oral DAILY
5. Other 34 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Daptomycin 600 mg IV Q24H Duration: 6 Weeks
RX *daptomycin 500 mg 600 mg IV q24h Disp #*51 Vial Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Ertapenem Sodium 1 g IV Q24H Duration: 6 Weeks
RX *ertapenem [Invanz] 1 gram 1 gram IV q24h Disp #*42 Vial
Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth q4-6h Disp #*20 Tablet
Refills:*0
6. Other 34 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. amLODIPine 10 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Carvedilol 25 mg PO BID
10. MetFORMIN XR (Glucophage XR) 500 mg PO Q8H
11. SITagliptin 100 mg oral DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R foot Osteomyelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service after your right foot surgery.
You were given IV antibiotics while here. You are being
discharged home with the following instructions:
ACTIVITY:
There are restrictions on activity. Please remain non weight
bearing to your R foot until your follow up appointment. You
should keep this site elevated when ever possible (above the
level of the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking in a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
Followup Instructions:
___
|
10033106-DS-8 | 10,033,106 | 28,055,712 | DS | 8 | 2166-03-29 00:00:00 | 2166-03-29 15:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"abdominal pain."
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ yo M with a PMHx of alcoholic pancreatitis who p/w
abominal pain following a recent episode of drinking.
.
The patient reports that he has had several episodes of
pancreatitis in the past, most recently ___ years ago. He
started drinking after his wife died but denies problems with
alcholism. The most recent episode started ___ with
epigastric and suprapubic ___ pain that caused the patient to
assume the fetal position. The patient thinks that this may be
similar to prior episodes of pancreatitis. The above episode
was preceeded by the patient consuming 2- 12 oz drinks of rum
and coke that contained 3 oz of alcohol each. She denies
radiation of the pain to her back or other portions of her
abdomen. The pain was relieved by tylenol 3 and made worse with
po intake at home. The patient had worsening pain on the day of
admission and came to the ED.
.
In the ED, the patients VS were stable, was found to have a
lipase of 379, she was given IVF and sent to the floor.
.
The patient currently has ___ pain in the epigastric portion of
his abdomen. Denies n/v, f/c and says that he moved his bowels
in the last 24 hours that was NB. He endorses decreased ability
to sleep and decreased po intake ___ to his pain.
.
12 point ros is otherwise negative
Past Medical History:
-HCV infection, genotype 1-had been seen by Dr. ___ never
got active treatment
-PTSD likely from military action
-HTN
-ED
-h/o alcoholic pancreatitis
Social History:
___
Family History:
multiple reported cancers in mother, father, both died in ___;s
of cancer
Physical Exam:
Admission
VS:
97.9 178/88 56 18 100 RA
Gen: AAOX3, NAD
HEENT: OP clear, MMM
Endo/Lymph: no obvious thryoid masses, no lad
CV:RRR, no RMG
Lungs:CTAB, no wrr
Abdomen: mildly TTP in epigastrum, no rebound, active BS X4
Extremities: WWP, no edema, pulses 2+ and equal
Skin: no rashes
Neuro: MS and CN wnl, strength and sensation wnl
Psyc: mood and affect wnl
Pertinent Results:
CXR ___
-preliminary read by me-no pleural effusions, no CM, no focal
infiltrates
___ 08:58PM LIPASE-379*
Brief Hospital Course:
This is a ___ yo with a PMHx of alcoholic pancreatitis who p/w
epigastric abdominal pain following alcohol consumption and a
lipase of 379 and a leukocytosis with eosinophillia
.
#Acute pancreatitis: suspected alcohol related due to recent
alcohol intake and the fact that he is s/p cholecystectomy and
has unremarkable LFTs making stone related pancreatitis less
likely. He received supportive care while on bowel rest with
IVF and IV morphine PRN on admission Though his exam his
abdomen is soft and he appears quite comfortable he rated his
pain ___ on ___. His pain resolved as ___ and he was
tolerating PO fluids and toast/crackers with plans to advance
his diet. He had no abdominal pain on exam and his vitals
remained stable. At discharge he was avised to abstain from
alcohol and continue to advance his diet. For loose stool a
cdiff test was sent and was negative in addition to O+P sent for
___.
#Significant Eosinophillia with absolute eosinophil count of
7400. Hematology has been consulted to review smear and discuss
appropriate workup. Differential remains broad but the
magnitude of his eosinophillia is quite high. Hematology
evaluated the patient and reviewed his peripheral smear which
did show a high number of eo's but no other abnormalities. For
now they recommend troponin, CK-MB and EKG which were all normal
to exclude end organ damage with eosinophilic cardiac
infiltration. Heme recommended beginning an outpatient workup
with the following tests: B12 (normal), SPEP (normal), stool O+P
(pending), HIV serology, PFTs, TTE, tryptase, strongy ab.
*The following tests need to be ordered as an outpatient HIV,
strongylodes antibody, PFTs, TTE, tryptase []
*monitor CBC with diff as outpatient
*New medications should be minimized, though no allergic
medication exposures are known at this time.
*If he has persistent eosinophilia he will require more in depth
workup as 6 months is required in order to make a diagnosis of
hypereosinophillic syndrome.
## HTN: Resume lisinopril but held HCTZ on admission due to
limited PO intake. He will resume lisinopril and HCTZ on
discharge
##Alcohol abuse: We have advised cessation and have started
thiamine and folate. No signs of active withdrawal
## HCV: chronic. Has not received interferon based therapy in
the past due to diagnosis of PTSD
Medications on Admission:
trazadone 150 QHS
lisinopril/HCTZ-unsure of dose
protonix prn
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO every ___ hours
as needed for pain for 3 days.
Disp:*20 Tablet(s)* Refills:*0*
2. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed for Insomnia.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day as needed for
indigestion.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Pancreatitis
Eosinophilia
Hypertension
Chronic HCV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized for treatment of pancreatitis
(inflammation of pancreas). This may have been a result of
alcohol use and you are advised to avoid further alcohol use to
minimize the chance of this happening again. You underwent a
gallbladder operation so it is less likely that this is related
to gallstones.
Your blood work showed an abnormally high level of white blood
cells called, eosinophils. There are many possible reasons for
this and your doctors ___ need to do additional tests as well
as to monitor this blood cell level.
Medication changes:
NEW: oxycodone (pain medicine), take as needed for next 3 days
continue home blood pressure medications
Followup Instructions:
___
|
10033106-DS-9 | 10,033,106 | 20,827,120 | DS | 9 | 2169-06-11 00:00:00 | 2169-06-11 16:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right groin pain
Major Surgical or Invasive Procedure:
Aspiration of R seminal vesicle abscess
History of Present Illness:
___ yo M with a history of HCV, HTN who presents with right groin
pain since ___. He also noticed swelling in his right groin
as well associated with tenderness to palpation. He thought it
was related to when he lifted a heavy object. The pain persisted
and got worse so he presented to the ED for further evaluation.
He denies any fevers or chills. He denies any new sexual
partners and denies having unprotected sex. He denies any
burning with urination, dysuria, or hematuria. He denies a
history of STI. He has had a poor PO appetite since the pain
started and urinating less frequently during this time. He has
continued to take all his home medications.
In the ED, initial vitals were: ___ 111/68 16 100% ra
- Labs were significant for WBC 14.0 without bands, BUN/Cr
___ (baseline ___, urinalysis with positive leukocytes,
positive nitrites, large blood and many WBC and moderate
bacteria
- CT ab/p revealed a ring-enhancing mass in the area of the
right seminal vesicle and bladder wall thickening.
- He was seen in the ED who recommended broad spectrum
antibiotics with vanc and zosyn and admission to medicine
because of medical co-morbidities.
- The patient was given 5mg IV morphine x 2, 4.5 g pip-tazo, 1gm
vancomycin, and 3L IVF.
Vitals prior to transfer were: 98.7 70 117/58 18 100% RA.
Upon arrival to the floor, he reports that his pain has
significantly improved.
Social History:
___
Family History:
multiple reported cancers in mother, father, both died in ___;s
of cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1 ___ 20 98%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-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, tender 4cm x 4cm area
of induration on right groin
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. left EJ
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM:
Brief Hospital Course:
___ is a ___ year old man with a past medical history
of untreated hepatitis C and hypertension who presented with 6
days of right groin pain and swelling found to have a seminal
vesicle abscess on CT and subsequently found to have a UTI be
bacteremic. He had no fever, chills, dysuria, hematuria, or
flank pain. He was afebrile with normal vitals throughout his
hospitalization. The seminal vesicle abscess was aspirated,
resulting in significant relief of his pain and he was started
on IV Zosyn. He was initially treated with IV Zosyn but switched
to PO ciprofloxacin based on culture data and ID
recommendations. Cultures from the abscess, urine, and blood all
grew pan-sensitive E. coli so, per ID recommendations, he was
switched to PO ciprofoxacin 500 mg BID and discharged on this
regimen to complete a 14 day course from the first negative
blood culture. He developed diarrhea on the day before
discharge. Urology was consulted and recommended tamsulosin for
3 months post-discharge due to concern for urinary retention. He
had 3 PVRs not indicative of urinary retention post-aspiration.
He was instructed to f/u with urology 2 weeks after discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. lisinopril-hydrochlorothiazide ___ mg oral DAILY
2. sildenafil 100 mg oral as directed
3. TraZODone 150 mg PO QHS
4. Cyanocobalamin 1000 mcg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. TraZODone 150 mg PO QHS
3. Vitamin D 1000 UNIT PO DAILY
4. Acetaminophen 650 mg PO Q6H:PRN pain
5. Ciprofloxacin HCl 500 mg PO Q12H bacteremia
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*26 Tablet Refills:*0
6. Tamsulosin 0.4 mg PO DAILY urinary retention
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*90
Capsule Refills:*0
7. lisinopril-hydrochlorothiazide ___ mg oral DAILY
8. Sildenafil 100 mg ORAL AS DIRECTED
Discharge Disposition:
Home
Discharge Diagnosis:
Seminal vesicle abscess
Ecoli Bacteremia (blood stream infection)
Ecoli Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized at ___
from ___ because you had an abscess (a collection of
bacteria and pus) in your groin, an infection in your urine, and
an infection in your blood. The abscess in your groin was
drained and you were treated with antibiotics. Initially you
were given antibiotics by IV, but then you were switched to oral
antibiotics.
It is important that you continue to take the oral antibiotics
(ciprofloxacin 500 mg twice a day) through ___ to
ensure that you complete eliminate the infection from your
blood.
You developed diarrhea the day before discharge. We think this
was due to the stool softeners you were taking. If you continue
to have diarrhea, please follow up with your PCP. You should
also follow up with urology in 2 weeks and with your primary
care provider ___ ___ days. It was a pleasure taking care of you.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10033290-DS-7 | 10,033,290 | 22,588,582 | DS | 7 | 2163-07-08 00:00:00 | 2163-07-11 16:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
RUE pain/weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ man with afib on apixaban, CHF, and
LBBB who presents from clinic for evaluation of left hand pain
and right arm pain. History was obtained with help from a
___ in
Yesterday, he developed acute onset numbness and pain in his
right hand. Started at 2pm when he was on the bus going home
after working for a day. Did not do anything out of the ordinary
at work, did not lift heavy boxes. Pain (numbness, some tingling
with needle-like sensation) was most severe in his right thumb,
and it went up his right arm gradually. Felt like his arm was
not there, and he would have to use his left hand to move his
right arm around. At ___, sensation was returning, and he
started being able to move his arm again. He took eliquis at
8pm, then another at 10pm, and another at midnight. He felt like
this helped his weakness.
He went to work today and noticed that he was unable to do
things as quickly with his right hand. He was also having some
trouble with fine motor movements such as buttoning his pants.
Still has pain in her right thumb and thenar eminence, sometimes
his fingertips as well. Pain is worse with certain positions.
Of note, he has been taking 2 tablets of eliquis at midnight
since ___ started rather than BID.
Past Medical History:
afib, CHF, LBBB, varicose veins
Social History:
___
Family History:
mother with CAD, father with liver cancer, brother died of
cancer
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: T: 96.8F HR: 60 BP: 141/85 RR: 16 SaO2: 98% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: irregularly irregular
Pulmonary: breathing comfortably on RA
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, speech is fluent with
full sentences, intact repetition, and intact verbal
comprehension. Naming intact. No paraphasias. No dysarthria.
Normal prosody. No evidence of hemineglect. No left-right
confusion. Able to follow both midline and appendicular
commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[Delt] [Bic] [Tri] [ECR] [FEx][IO] [IP] [Quad] [Ham] [TA]
[Gas]
L 5 5 5 5 5 4+ 5 5 5 5 5
R 5 5 5 5 5 4+ 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 1+ 1+ 1+ 1+ 0
R 1+ 1+ 1+ 1+ 0
Plantar response flexor bilaterally
- Sensory: decreased sensation to pin over right thenar
eminence, thumb/index/middle/ring fingers, and just below the
pinky finger. Dorsum of hand is normal as is the pinky finger.
Decreased sensation to LT over similar areas. Intact elsewhere.
Increased pain with wrist flexion and extension on the right.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Able to tap each finger to thumb easily on L hand,
more difficult on R hand though pt says this is pain limited.
Also slower with rapid alternating movements in R hand.
- Gait: deferred
DISCHARGE EXAM
MS ___, attentive, fluent CN PERRLA, no droop, Motor: ___
throughout, sensory intact to light tough. Able to ambulate with
good balance. Reports pain with manipulation of the first
carpo-metacarpal joint
Pertinent Results:
___ 01:50PM BLOOD WBC-6.8 RBC-4.66 Hgb-14.4 Hct-41.0 MCV-88
MCH-30.9 MCHC-35.1 RDW-12.2 RDWSD-39.2 Plt ___
___ 07:35PM BLOOD WBC-7.1 RBC-4.67 Hgb-14.4 Hct-41.5 MCV-89
MCH-30.8 MCHC-34.7 RDW-12.2 RDWSD-39.5 Plt ___
___ 07:35PM BLOOD Neuts-51.1 ___ Monos-8.1 Eos-4.5
Baso-0.3 Im ___ AbsNeut-3.64 AbsLymp-2.54 AbsMono-0.58
AbsEos-0.32 AbsBaso-0.02
___ 01:50PM BLOOD ___ PTT-33.2 ___
___ 07:35PM BLOOD ___ PTT-32.9 ___
___ 01:50PM BLOOD Glucose-126* UreaN-17 Creat-0.8 Na-137
K-4.5 Cl-100 HCO3-26 AnGap-16
___ 07:35PM BLOOD Glucose-92 UreaN-15 Creat-0.7 Na-139
K-3.9 Cl-102 HCO3-29 AnGap-12
___ 07:35PM BLOOD ALT-15 AST-16 AlkPhos-51 TotBili-0.7
___ 01:50PM BLOOD CK-MB-5 cTropnT-<0.01
___ 07:35PM BLOOD Albumin-4.4 Calcium-9.4 Phos-4.0 Mg-1.9
Cholest-158
___ 07:35PM BLOOD %HbA1c-6.3* eAG-134*
___ 07:35PM BLOOD Triglyc-95 HDL-39 CHOL/HD-4.1 LDLcalc-100
___ 07:35PM BLOOD TSH-1.4
HAND (PA,LAT AND OBLIQUE) RIGHT
Severe osteoarthritis of the first CMC and triscaphe joint and
probable mild degenerative changes of the radio scaphoid joint.
Minimal degenerative change involving the DIP joints. No
fracture, dislocation, bone erosion, suspicious lytic or
sclerotic lesion, soft tissue calcification or radiopaque
foreign body identified.
IMPRESSION:
Osteoarthritis including severe osteoarthritis of the first CMC
and triscaphe joints. No fracture or bone erosion.
Brief Hospital Course:
___ man with afib on AC (but not taking it correctly at the
moment) presents with R hand pain with a report of weakness
after sleeping on the arm. He has had weakness of the arm in the
past after sleeping on it in a peculiar way. He main complaint
that brought him into the hospital is pain in the joints of the
hand. Xray confirmed severe arthritis in the first CMC and
triscaphe joint. He was prescribed ibuprofen for pain and given
a prescription for a wrist splint to stabilize his hand while
sleeping. He was also instructed to take his Eliquis BID in
order to best prevent future strokes. He should follow up with
his PCP in one week.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Furosemide 20 mg PO DAILY:PRN edema
3. Lisinopril 5 mg PO DAILY
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*15 Tablet Refills:*0
2. Apixaban 5 mg PO BID
3. Furosemide 20 mg PO DAILY:PRN edema
4. Lisinopril 5 mg PO DAILY
5. Metoprolol Succinate XL 12.5 mg PO DAILY
6. Simvastatin 40 mg PO QPM
7.Hand Splint
Please provide splint to the right hand for stabilization during
sleep
Discharge Disposition:
Home
Discharge Diagnosis:
Hand Arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were admitted with symptoms of hand pain. We performed an
xray of your hand which showed a fair amount of arthritis but no
evidence of fracture or dislocation. We are providing you with a
prescription for ibuprofen to help with the pain as well as a
hand splint to stabilize the area while you sleep.
It was a pleasure taking care of you.
___ Neurology
Followup Instructions:
___
|
10033409-DS-6 | 10,033,409 | 21,582,131 | DS | 6 | 2111-12-09 00:00:00 | 2111-12-13 17:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx uncontrolled DM2 c/b small vessel CVA ___, vascular
dementia, recent L5 nerve root injection, frequent UTI p/w one
week AMS and nonfocal weakness, superimposed on months of
chronic behavior changes.
History obtained from daughter (long term care ___), as
patient unable to remember recent history.
At baseline pt gives conflicting answers and has very poor short
term memory; however over the last week she is more confused
talking to herself and seems to be hallucinating, crying
inappropriately. Hard time mobilizing to car (?weakness). Crying
in a wheelchair -- "lost her hope she couldn't walk at all". She
usually only uses a wheelchair for longer trips outside the
house and uses the rolling walker in the house. ___ night she
could not hold herself at all, not even to transfer from
wheelchair to bed. Since ___ she hasn't been able to go to
day care, not able to bathe in tub.
Patient was treated ___ with Cipro for UTI, however abx stopped
after the cultures were negative. Has had months of intermittent
urinary incontinence. Daughter has not noted any new breathing
symptoms (has a chronic dry cough). No sputum production. Has
chronic intermittent constipation. Intermittent enemas at home.
No fevers. No chills. No clear sweats - maybe that one day it
was very hot. No N/V/D.
H/o small vessel CVA ___, vascular dementia. At baseline
attends Adult Day Care 4x/week, uses rolling walker for
ambulation, Mini-mental ___. Behavior changes noted in outpt
notes ___.
Pt has had at least 3 falls since ___. Fall ___ with head
trauma and presented to BID ED, where ___ showed "No acute
intracranial process. Chronic small vessel disease and old
lacunar infarcts, unchanged from prior."
In the ED, initial vitals: 97.1, 76, 123/67, 18, 98% RA
Labs were significant for: Plt 141, Alb 2.9
CXR ED ___: "volumes are low with bibasal opacities most
suggestive of atelectasis, though difficult to exclude a
component of pneumonia in the correct clinical setting."
EKG ED:
In the ED, pt received: IV Ceftriaxone 1g, IV Azithromycin 500mg
Vitals prior to transfer: , 83, 109/97, 16, 99% RA
Currently, patient is laying comfortably in bed, afebrile
ROS: No photophobia. No fevers/chills/HA/changes in vision/abd
pain/burning on urination/dyspnea.
Past Medical History:
- Vascular dementia without behavioral disturbance ___
- Stroke, small vessel ___: "Around ___ she was noted
to have problems with speaking, forgetfulness, and mild right
sided weakness. She was seen at ___ for
an MRI scan on ___ which showed diffuse
periventricular white matter disease. There was also a subacute
hemorrhagic infarct in the left lobe of the globus palates and
the genu of the internal capsule. MR angiography of the ___
___ and neck were normal"
- Lumbar Radiculitis (sx include low back and R leg pain since
___ MRI lumbar spine ___ showed severe L4-L5
circumferential disc bulge with right neural foraminal stenosis)
s/p R L5 lumbar transforaminal selective nerve root injection
(2.0 cc of kenalog (40 mg/ml) and 1 cc of 1% of lidocaine) on
___
- DM (diabetes mellitus), type 2, uncontrolled w/neurologic
complication (CVA, retinopathy)
- Mild nonproliferative diabetic retinopathy ___
- Nephrotic syndrome ___
- CKD stage G2/A3, GFR ___ and albumin creatinine ratio >300
mg/g ___
- Minimal change disease ___
- Hypothyroidism ___: "atrophic thyroid on us ___- prob
___'s"
- Hypertension, essential ___
- Hypercholesterolemia ___: "LDL Goal < 70"
Social History:
___
Family History:
Mother had DM2, lived to ___
No family hx of dementia
Physical Exam:
=======================
ADMISSION PHYSICAL
=======================
VS: 97.6, 164 / 89, 101, 18, 97 RA
GEN: Alert, lying in bed, no acute distress. Unable to sit up
without assistance, apparently due to truncal weakness
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor.
NECK: Supple
PULM: Bibasilar crackles, no wheezes
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended, no lower abdominal TTP
EXTREM: Warm, well-perfused, no edema, 2+ DP b/l
NEURO: A&Ox2. Symmetric smile, grimace, shoulder shrug, head
turn. Mild L ptosis. Neg pronator drift b/l. ___ strength RUE
(limited by R shoulder pain), 4+/5 strength LUE, ___ strength
b/l ___.
=======================
DISCHARGE PHYSICAL
=======================
Vitals: 98.7, 153 / 78, 73, 18, 98 Ra
General: alert, laying in bed, no acute distress
HEENT: MMM, anicteric sclera
Lungs: clear to auscultation bilaterally, no wheezes
CV: regular rate and rhythm, normal S1 + S2, no murmurs
Abdomen: soft, non-distended
Ext: warm, well perfused, no clubbing, cyanosis or edema
Neuro: Does not cooperate fully with neuro exam. Oriented to
self and "hospital", does not know year. Mild L ptosis. B/l
stiffness on passive plantarflexion and dorsiflexion. Stiff
(?Cogwheeling) at wrists b/l.
Pertinent Results:
=========================
ADMISSION LABS
=========================
___ 05:53PM BLOOD WBC-7.7 RBC-3.86* Hgb-12.6 Hct-36.8
MCV-95 MCH-32.6* MCHC-34.2 RDW-12.6 RDWSD-43.9 Plt ___
___ 05:53PM BLOOD Neuts-64.0 ___ Monos-8.8 Eos-2.0
Baso-0.5 Im ___ AbsNeut-4.92 AbsLymp-1.87 AbsMono-0.68
AbsEos-0.15 AbsBaso-0.04
___ 05:53PM BLOOD Glucose-227* UreaN-17 Creat-0.8 Na-133
K-3.4 Cl-100 HCO3-26 AnGap-10
___ 05:53PM BLOOD ALT-22 AST-19 AlkPhos-51 TotBili-0.3
___ 06:20AM BLOOD CK(CPK)-68
___ 05:53PM BLOOD cTropnT-<0.01
___ 07:20AM BLOOD CK-MB-4 cTropnT-<0.01
___ 05:53PM BLOOD Albumin-2.9* Calcium-9.2
___ 07:20AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.7
___ 06:20AM BLOOD TSH-13*
___ 06:20AM BLOOD Free T4-1.1
___ 12:24AM BLOOD Lactate-1.3
___ 05:53PM BLOOD Lipase-32
=========================
DISCHARGE LABS
=========================
___ 06:20AM BLOOD WBC-8.8 RBC-4.26 Hgb-14.0 Hct-40.3 MCV-95
MCH-32.9* MCHC-34.7 RDW-12.8 RDWSD-44.1 Plt ___
___ 06:20AM BLOOD Neuts-63.4 ___ Monos-8.9 Eos-2.0
Baso-0.7 Im ___ AbsNeut-5.59 AbsLymp-2.18 AbsMono-0.79
AbsEos-0.18 AbsBaso-0.06
___ 06:20AM BLOOD Glucose-182* UreaN-22* Creat-0.7 Na-138
K-3.5 Cl-103 HCO3-24 AnGap-15
___ 06:20AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
=========================
MICRO
=========================
___ 12:10 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:08 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:53 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
=========================
IMAGING SUMMARIES
=========================
___ Imaging MRI CERVICAL, THORACIC, LUMBAR
1. Lumbar spondylosis, similar from examination of ___ with
degenerative grade 1 anterolisthesis of L4 on L5 and L5 on S1,
severe L4-L5 spinal canal narrowing crowding the cauda equina,
severe L4-L5 right and moderate to severe neural foraminal
narrowing and bilateral L5-S1 moderate to severe bilateral
neural foraminal narrowing.
2. Cervical spondylosis results in bilateral moderate neural
foraminal
narrowing at multiple levels without high-grade spinal canal
narrowing.
3. No significant spinal canal or neural foraminal narrowing at
the thoracic spine.
4. No cord signal abnormality.
5. Additional findings as described above.
___ Imaging MR HEAD W/O CONTRAST
1. No acute infarct.
2. Confluent moderate to severe subcortical and periventricular
T2/FLAIR white
matter hyperintensities are nonspecific, but compatible with
chronic
microangiopathy in a patient of this age.
3. Moderate cerebral volume loss.
4. Additional findings as described above.
___ Imaging CT HEAD W/O CONTRAST
No intracranial hemorrhage.
Stable chronic lacunar infarct left basal ganglia, internal
capsule.
Severe chronic small vessel ischemic changes.
___ Imaging CHEST (PA & LAT)
AP upright and lateral views of the chest provided. Lung
volumes are low with bibasal opacities most suggestive of
atelectasis, though difficult to exclude a component of
pneumonia in the correct clinical setting. No large effusion,
pneumothorax. No signs of congestion or edema.
Cardiomediastinal silhouette is unchanged. Bony structures
appear intact.
___BD & PELVIS WITH CO
No acute findings to account for abdominal pain. Incidental
findings as
detailed above.
Brief Hospital Course:
Ms ___ is a ___ with poorly controlled DM2 c/b small vessel
CVA ___ and vascular dementia who presents with one week of
worse-than-usual confusion, increased frequency of urinary
incontinence, and nonfocal weakness, superimposed on months of
chronic behavior changes, likely progression of vascular
dementia. She was noted to have intermittent urinary retention
while admitted.
====================
ACUTE ISSUES
====================
# Altered Mental Status
Believed to be progression of vascular dementia. ICH/ischemic
stroke ruled out by NCHCT and MRI. Patient is afebrile, no
leukocytosis, neg UCx from ___, CXR shows most likely
atelectasis and no SOB/change in chronic dry cough. No current
medications or electrolyte abnormalities that could cause
toxic/metabolic AMS. NPH unlikely given imaging. Neuro
consulted, recommended contrast MRI of brain, and C, T, L-spine.
These spine MRIs showed no interval changes compared to prior in
___ (stable lumbar and cervical spondylosis with spinal canal
narrowing and neural foramen narrowing). MRI brain shows no
acute infarct, just confluent subcortical ___ changes c/w chronic
microangiopathy. Ortho Spine does not think surgery is indicated
in this pt because her neuro deficits do not correlate with MRI
findings, so surgery not likely to improve her function. Per
Neuro Movement Disorders, pt has Parkinsonism from either
vascular dementia vs actual ___ dz. Plan is to trial
Carbidopa-Levodopa (___) 0.5 TAB PO TID until follow up with
Dr. ___ in ___ months.
# Urinary incontinence
Subacute vs chronic. Could be related to progression vascular
dementia. Bladder scans this admission c/f retention, decided on
straight cath BID with titration of frequency as needed.
====================
CHRONIC ISSUES
====================
# Nephrotic syndrome: high protein diet (Ensure). Chronic (last
albumin also 2.9 in outpatient setting in ___
- monitor albumin
- urine protein and albumin
# HTN: continue home losartan 100mg PO QD and
hydrochlorothiazide25mg PO QD
# DM2: managed with lifestyle interventions at home. Started ISS
___ because ___
# Hypothyroidism: continue home levothyroxine 125 mcg PO QD
# Hypercholesterolemia: continue home simvastatin 40 mg tablet
PO QPM
=====================
TRANSITIONAL ISSUES
=====================
- re-check TSH in 2 weeks as outpt (was ___ here with normal free
T4)
- family education on physical assist, straight cathing (some of
daughters are ___)
- BID straight catherization, tirate frequency as needed
- submitted requet for electric bed. Will also need ___ lift
and ramp at home before returning home.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 125 mcg PO DAILY
2. losartan-hydrochlorothiazide 100-25 mg oral DAILY
3. Simvastatin 40 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. Artificial Tears 1 DROP BOTH EYES TID
6. melatonin 1 mg oral QPM:PRN
7. Aspirin 81 mg PO DAILY
8. Acetaminophen 650 mg PO BID:PRN Pain - Mild
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Medications:
1. Carbidopa-Levodopa (___) 0.5 TAB PO TID
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
3. Senna 8.6 mg PO BID:PRN constipation
4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
5. Artificial Tears 1 DROP BOTH EYES TID
6. Aspirin 81 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Levothyroxine Sodium 125 mcg PO DAILY
10. losartan-hydrochlorothiazide 100-25 mg oral DAILY
11. melatonin 1 mg oral QPM:PRN
12. Simvastatin 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
- Weakness
- Acute on chronic encephalopathy or dementia
- Urinary incontinence and urinary retention
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___ and family,
WHY WAS I ADMITTED TO THE HOSPITAL?
- you have been more confused over the past week
- you have been having weakness as well
WHAT WAS DONE FOR ME IN THE HOSPITAL?
- we ruled out other causes of your confusion and believe it is
due to progression of your vascular dementia
- A head CT and brain MRI were performed
- our Neurologist and Movement Disorder Specialists evaluated
you for your weakness and rigidity and started you on Sinemet
for ___ stiffness
- we worked with case management to apply for more equipment at
home for after rehab
WHAT SHOULD I DO WHEN I GO BACK TO HOME?
- review your medication list and take as prescribed
- follow up with the neurology movement disorder clinic as
recommended below
- work with your rehab doctors
- please work with physical therapy
- Straight cath twice a day and record the values of how much
urine comes out in a log to show your doctor.
It was a pleasure to take part in your care.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10033552-DS-6 | 10,033,552 | 21,543,627 | DS | 6 | 2132-07-02 00:00:00 | 2132-07-02 21:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Atenolol / Amlodipine / Tekturna / felodipine
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Lap appendectomy
History of Present Illness:
Mrs. ___ is a ___ yo F with a past medical history of GERD,
hypertension, and chronic kidney disease. She is presenting
with sudden onset RLQ abdominal pain that began at 9 am this
morning. She reports that the pain began in the periumbilical
area and localized to the RLQ. She has experienced nausea this
morning but no emesis, she reports being slightly hungry. She
did have some chills earlier but no subjective fevers. She
denies any urinary symptoms, as well as any back or flank pain.
WBC 11.3 in the ED, CT abdomen highly suspicious for acute
appendicitis.
Past Medical History:
PMH: GERD, HL, HTN, CKD
PSH: Hysteroscopy w/ dilation and curretage (___),
Tonsillectomy ___ for cyst), resection bilateral wrist cysts
Social History:
___
Family History:
FH: HTN in mother, CVA and prostate cancer in father
Physical ___:
On admission:
PE: 99.7 92 140/71 16 95% RA
NAD, AAO
RRR
CTA b/l
soft, nondistended abdomen, tender to palpation in RLQ with
voluntary guarding
no peripheral edema or cyanosis
On discharge:
97.8, 83, 104/75, 18, 94% RA
Gen: NAD, AAOx3
CV: RRR no m/r/g
Pulm: CTAB no w/r/r
Abd: Soft, appropriately TTP about incisions, ND, +BS.
Incisions with dermabond, c/d/i.
Ext: WWP no c/c/e
Pertinent Results:
___ 02:40PM BLOOD WBC-11.3*# RBC-5.12 Hgb-14.8 Hct-47.4
MCV-93 MCH-28.8 MCHC-31.1 RDW-12.6 Plt ___
___ 02:40PM BLOOD Neuts-79.6* Lymphs-15.7* Monos-3.3
Eos-1.1 Baso-0.2
Imaging:
CT A/P ___ - wet read):
1. Dilated appendix measuring up to 1.8-cm with surrounding
inflammatory changes concerning for acute appendicitis. There is
a focus of gas within the tip of the lumen. No abscess is
identified, however there is a small amount of pelvic free
fluid.
2. Heterogeneous, enlarged uterus is concerning for fibroids.
Brief Hospital Course:
Ms. ___ was admited to the ___ service with HPI as stated
above and went to the OR for an uncomplicated lap appy, which
procedure she tolerated well. For full details please see the
dictated operative report. She was extubated and went to the
PACU in good condition.
In the PACU she rapidly improved and was quickly ambulating,
voiding, tolerating a regular diet, and saturating well, and she
stated desire to be discharged. She was evaluated by surgery
resident in the PACU and exam was non-concerning (see above).
She is discharged to home on ___ with appropriate
information, warnings, prescriptions, and plans to follow up.
Medications on Admission:
Simvastatin 40 mg PO DAILY
Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Simvastatin 40 mg PO DAILY
2. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Acetaminophen ___ mg PO Q6H:PRN pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
No driving nor operating other machinery while using narcotics
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
Take twice daily while still using narcotic pain meds
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you 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 ___ 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" a couple 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 could have a poor appetite for a couple days. 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 dressings 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. Do not drink alcohol or
drive while taking narcotic pain medication.
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:
___
|
10033661-DS-20 | 10,033,661 | 23,080,369 | DS | 20 | 2162-07-01 00:00:00 | 2162-07-01 12:05:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Celebrex / codeine / Demerol / epinephrine / epinephrine /
Penicillins / scallops / shellfish derived
Attending: ___.
Chief Complaint:
LC1 pelvis fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female history arthritis, COPD, osteoporosis, skin
cancer, glaucoma who presents with right groin pain status post
fall from bed. She states that she was trying get out of bed
when she fell directly onto the ground onto her right side. She
was unable to ambulate after then due to the pain. She was
evaluated outside hospital where there was concern for possible
periprosthetic fracture as well as subarachnoid hemorrhage, so
she was transferred here for further evaluation. On repeat
imaging, no periprosthetic fracture or subarachnoid hemorrhage,
and no other injuries identified by trauma surgery. She is
complaining of severe groin pain and inability to move the leg.
No numbness or tingling. Endorses head strike, but denies loss
of consciousness.
Past Medical History:
COPD, glaucoma, arthritis, osteoporosis, skin cancer
Social History:
___
Family History:
See OMR
Physical Exam:
Vitals: ___ 0720 Temp: 98.1 PO BP: 114/61 HR: 72 RR: 17 O2
sat: 94% O2 delivery: Ra
General: Well-appearing, breathing comfortably
MSK:
- Pelvis stable
- TTP in R groin
- Grossly motor intact bilateral lower extremities
- SILT bilateral lower extremities
Pertinent Results:
See OMR
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 LC1 minimally displaced pelvic fracture and was
admitted to the orthopedic surgery service for pain control and
placement. The patient was given anticoagulation with enoxaparin
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, and the patient was voiding/moving bowels
spontaneously. The patient is weight-bearing as tolerated in the
right lower extremity, and will be discharged on enoxaparin 40mg
SC daily for DVT prophylaxis. The patient will follow up with
Dr. ___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
Omeprazole
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Docusate Sodium 200 mg PO BID
3. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe
Refills:*0
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
Please take with Tylenol, wean ASAP
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours as
needed Disp #*20 Tablet Refills:*0
5. Senna 17.2 mg PO BID
6. Gabapentin 100 mg PO TID
7. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R LC1 pelvis fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for monitoring after your pelvis
fracture. This injury is treated non-operatively, and you may
continue to work on walking and building your strength back at
the rehab facility.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated, no ROM restrictions
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take ___ tablet every 4 hours as needed x 1 day,
then ___ tablet every 6 hours as needed x 1 day,
then ___ tablet every 8 hours as needed x 2 days,
then ___ tablet every 12 hours as needed x 1 day,
then ___ tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take enoxaparin 40mg daily for 4 weeks
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
- 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
Physical Therapy:
WBAT bilateral lower extremities
No braces needed
Crutches or Walker PRN per physical therapy
Treatments Frequency:
No surgical incisions - non-operative treatment
Followup Instructions:
___
|
10033710-DS-2 | 10,033,710 | 25,343,985 | DS | 2 | 2168-11-29 00:00:00 | 2168-11-29 12:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
codeine
Attending: ___.
Chief Complaint:
Right intertrochanteric femur fracture
Major Surgical or Invasive Procedure:
___: Right trochanteric femoral nail
History of Present Illness:
This is a ___ female who presents to the emergency
department at ___ in transfer from ___
with right intertrochanteric hip fracture, right fifth
metacarpal
neck fracture, and T/L-spine compression fractures status post
an
unwitnessed ground level fall. Patient is oriented only to self
and so much of the history is obtained from discussion with
members of the emergency department staff and review of the
medical records from the outside facilities. Ms. ___ does
endorse pain to her right hip and right hand. She denies pain
elsewhere. She states she has no numbness or tingling of her
right lower extremity. She denies head strike. She denies loss
of consciousness.
Per review of outside facility records the patient was brought
into ___ by ambulance from ___
where the patient resides in the memory care unit. She
reportedly was found down approximately 30 minutes prior to
arrival at that hospital. She initially complained only of
right
hip pain. Evaluation at ___ demonstrated a right
intertrochanteric hip fracture, right fifth metacarpal neck
fracture, question of acute versus chronic right olecranon
fracture, and T/L-spine vertebral compression fx. She was also
found to have an abrasion over the posterior aspect of the
elbow.
Past Medical History:
Atrial fibrillation not on anticoagulation
dementia
Depression
History of clavicle fracture
Glaucoma
Hearing loss
Orthostatic hypotension
Osteoporosis
Vertigo
Open reduction internal fixation closed left hip fracture, ___
Cataract extraction, ___
Social History:
___
Family History:
NC
Pertinent Results:
see OMR
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopaedic surgery team. The patient was found
to have right intertrochanteric femur fracture and was admitted
to the orthopaedic surgery service. The patient was taken to the
operating room on ___ for right trochanteric femoral
nail, which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ 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
weightbearing as tolerated in the right lower extremity, and
will be discharged on Lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Brinzolamide 1% Ophth (*NF* ) 1 drop Other TID
4. Digoxin 0.0625 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Aspirin 325 mg PO DAILY
8. Sertraline 50 mg PO DAILY
9. Levothyroxine Sodium 75 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Right hip fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please
follow your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This
is an over the counter medication.
2) Add low-dose oxycodone as needed for increased pain. Aim
to wean off this medication in 1 week or sooner. This is an
example on how to wean down:
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- 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 greater than 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 call ___ to schedule a 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 any new medications/refills.
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
Physical Therapy:
Activity: Activity: Activity as tolerated
Right lower extremity: Full weight bearing
Encourage turn, cough and deep breathe q2h when awake
Treatments Frequency:
Your incision is closed with Monocryl sutures that will be
assessed at your 2-week postoperative visit.
If the dressing falls off on its own three days after surgery,
no need to replace the dressing unless actively draining.
Followup Instructions:
___
|
10034049-DS-15 | 10,034,049 | 20,693,789 | DS | 15 | 2156-11-10 00:00:00 | 2156-11-10 14:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide
Antibiotics)
Attending: ___.
Chief Complaint:
abdominal pain, AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ PMHx chronic pain on methadone,
chronic BLE venous stasis ulcers and recurrent UTIs who presents
with AMS and abdominal pain.
History is predominant obtained from son and ___ sign-out as
patient is limited by her mental status. Patient at baseline
requires intermittent straight catheterizations due to
intermittent trouble with initiating urinary stream. 2 days
ago, she reportedly developed new urinary incontinence and
symptoms of dysuria as well as malorous urine c/w prior UTI.
She also has been having 2 days of suprapubic abdominal pain.
Since yesterday, she also developed new intermittent confusion
and disorientation.
In the ___, initial VS 97.1, 83, 178/96, 18, 97% on RA. Initial
labs were notable for Na 137, K 3.1, Cr 0.8, WBC 6.3, Hgb 10.8
(baseline Hgb ~12), Plt 182. Lactate 2.1. UA grossly positive
with mod leuks, sm bld, positive nitrites, 69 WBC, and few
bacteria. She was given ceftriaxone prior to transfer to the
floor. Given agitation, she required olanzapine x 1 in the ___
prior to transfer.
Upon arrival to the floor, the patient states that her son is
transitioning her care from ___ to ___. The patient reports
significant suprapubic discomfort and states that she has to
urinate. She states that she self-catheterizes herself at home
intermittently, but cannot explain to me what her underlying
urologic issue is and if she has seen urology in the past. She
does not know if her BLE edema is stable.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
HTN
hypothyroidism
chronic venous stasis ulcers
recurrent UTIs
chronic pain
back injury NOS
asthma
COPD
?rheumatoid arthritis
T2DM
Social History:
___
Family History:
NC
Physical Exam:
Admission Physical Exam
Vitals- 98.3 159 / 88 84 20 96 RA
GENERAL: well-appearing elderly female lying in bed in NAD
HEENT: MMM, NCAT, EOMI, anicteric sclera
CARDIAC: RRR, nml S1 and S2, no m/r/g
LUNGS: Clear to auscultation bilaterally, unlabored respirations
ABDOMEN: soft, obese, somewhat distended
EXTREMITIES: wwp, chronic venous stasis changes bilaterally with
scattered healing wounds
SKIN: chronic venous stasis changes as above
NEUROLOGIC: AOx2 (able to state month, states she is in a
"hospital", and to self), grossly nonfocal
Discharge Physical Exam:
Vital Signs: 98.2 PO 137 / 73 74 18 94 RA
GENERAL: elderly woman sitting up in bed.
HEENT: MMM, anicteric sclera
CARDIAC: RRR
LUNGS: CTAB, no accessory muscle use
ABDOMEN: soft, obese, non-tender, non distended.
EXTREMITIES: wwp, chronic venous stasis changes bilaterally with
scattered healing wounds, dressing that is C/D/I.
SKIN: chronic venous stasis changes as above
NEUROLOGIC: alert, oriented to hospital and to self, moving all
extremities
Pertinent Results:
___ 08:54PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 08:54PM URINE BLOOD-SM NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-MOD
___ 08:54PM URINE RBC-4* WBC-69* BACTERIA-FEW YEAST-NONE
EPI-1
___ 08:54PM URINE MUCOUS-OCC
___ 07:57PM LACTATE-2.1*
___ 07:48PM GLUCOSE-201* UREA N-7 CREAT-0.8 SODIUM-137
POTASSIUM-3.1* CHLORIDE-94* TOTAL CO2-30 ANION GAP-16
___ 07:48PM WBC-6.3 RBC-3.74* HGB-10.8* HCT-31.6* MCV-85
MCH-28.9 MCHC-34.2 RDW-14.1 RDWSD-43.6
___ 07:48PM NEUTS-75.0* LYMPHS-16.1* MONOS-6.6 EOS-1.3
BASOS-0.5 IM ___ AbsNeut-4.75 AbsLymp-1.02* AbsMono-0.42
AbsEos-0.08 AbsBaso-0.03
___ 07:48PM PLT COUNT-182
Micro:
___ BCx x 2 pending
___ UCx pending
Imaging/Studies:
none
Micro:
___ 8:54 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPH AUREUS COAG +. >100,000 CFU/mL.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
Blood Cultures:
Negative
TTE:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are mildly
thickened (?#). No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Physiologic mitral
regurgitation is seen (within normal limits). The tricuspid
valve leaflets are mildly thickened. No masses or vegetations
are seen on the tricuspid valve, but cannot be fully excluded
due to suboptimal image quality. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. No echocardiographic
evidence of endocarditis or pathologic flow. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Elevated PCWP suggested.
MRI:
IMPRESSION:
1. Incomplete examination with acquisition of localizer and
sagittal T2 images
only.
2. Provided images demonstrate levoscoliosis with moderate to
severe L3-L4 and
severe L4-L5 spinal canal stenosis with moderate to severe
multilevel neural
foraminal narrowing, as detailed above. Recommend repeat
examination when the
patient is able to better tolerate the entire exam.
3. Suboptimal evaluation for epidural fluid collection on this
study although
there is no obvious evidence.
Discharge Labs:
___ 06:57AM BLOOD WBC-4.7 RBC-3.84* Hgb-10.7* Hct-32.2*
MCV-84 MCH-27.9 MCHC-33.2 RDW-14.0 RDWSD-42.3 Plt ___
___ 06:57AM BLOOD Glucose-208* UreaN-13 Creat-0.8 Na-136
K-4.4 Cl-95* HCO3-30 AnGap-15
Brief Hospital Course:
Ms. ___ is a ___ PMHx chronic BLE venous stasis
ulcers and recurrent UTIs who presents with AMS and UTI.
# abdominal pain likely ___
# complicated MRSA UTI.
# urinary retention
Patient with history of recurrent UTIs (6 within past ___ years
per son); she is likely at risk for UTIs in the setting of
urinary stasis. It is unclear why the patient requires
intermittent self-catheterization. She has been referred to
uro-gyn by her ___ PCP but unclear if she actually attended any
visits. Per son, she has history of a "lady cancer" with
episodes of recurrence necessitating chemo/randiation, last was
~ ___ years ago. CT scan without clear etiology for pain. Urine
culture with MRSA in urine. No growth in blood cultures. MRI as
suboptimal study but without clear epidural collection. In the
setting of MRSA bactermia up to 27% of patients with have
bacteruria but in studies of patients with MRSA bacteruria only
1 in 30 patients has MRSA bactermia. MRI L-spine incomplete
study but no definitive abscess and patient would like to not
complete pain at baseline level. TTE suboptimal study but no
frank vegetations and negative blood cultures make risk of TEE
higher than benefit. She was treated with IV vancomycin and then
transitioned to doxycycline (given sulfa allergy will not use
Bactrim) for complicated UTI for
10 day course when her blood culture finalized as negative.
# Encephalopathy
Likely induced in the setting of acute infection as described
above. Patient without other evidence of metabolic derangements
at this time. Home methadone and pain regimen initially held and
then restarted slowly as mental status improved. She returned to
her baseline mental status.
# Concern for elder abuse: Patient reported verbal abuse from
her son with whom she lives with. No evidence of physical abuse
on my exam. Mental status is improved and long discussion with
PCP and SW. I spoke for some time about the situation with her
son. She reports that he is not physically abusive but is
verbally and is nervous about him. When we discussed she reports
that she does not want to move forward with a police filing or a
restraining order because of what it would do to her family. I
was also able to speak with her PCP for about ___ minutes who
reports that they have had similar concerns but that she has
declined reporting in the past due to the same concerns. Her PCP
reports that she can be difficult to engage in follow up be
reported that at her baseline (which she is at) she has been
found to have capacity to make her own decisions.as well. Social
work was involoved and relayed information to the open elder
services case.
# Hypothyroidism
TSH is very abnormal though notably with normal free T4. Home
levothyroxine continued.
# Chronic pain
# Rheumatoid arthritis
Home prednisone continued. Home methadone continued. Home
oxycodone restarted.
# HTN: Continued home losartan, amlodipine, triamterene-HCTZ
# HLD: Continued home statin
# Depression. Continued home sertraline
# GERD. Continued home omeprazole
# T2DM: Home metformin held and patient managed with ISS.
Restarted at discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
2. amLODIPine 10 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Gabapentin 300 mg PO QID
5. Levothyroxine Sodium 150 mcg PO DAILY
6. Losartan Potassium 50 mg PO DAILY
7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
8. Methadone 10 mg PO QHS
9. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
10. Aspirin 81 mg PO DAILY
11. Methotrexate 2.5 mg PO Frequency is Unknown
12. Nabumetone 500 mg PO BID
13. Omeprazole 20 mg PO DAILY
14. Sertraline 100 mg PO DAILY
15. PredniSONE 5 mg PO DAILY
16. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*14 Capsule Refills:*0
3. Senna 8.6 mg PO BID:PRN constipation
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q8H:PRN Pain -
Severe
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 6 hours Disp
#*10 Tablet Refills:*0
5. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
6. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
7. amLODIPine 10 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 20 mg PO QPM
10. Levothyroxine Sodium 150 mcg PO DAILY
11. Losartan Potassium 50 mg PO DAILY
12. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
13. Methadone 10 mg PO QHS
RX *methadone 10 mg 10 mg by mouth at bedtime Disp #*3 Tablet
Refills:*0
14. Methotrexate 10 mg PO QSUN
15. Multivitamins 1 TAB PO DAILY
16. Nabumetone 500 mg PO BID
17. Omeprazole 20 mg PO DAILY
18. PredniSONE 5 mg PO DAILY
19. Sertraline 100 mg PO DAILY
20. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
21. HELD- Gabapentin 300 mg PO QID This medication was held. Do
not restart Gabapentin until follow up with PCP.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
urinary tract infection
encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for confusion and concern for urinary tract
infection. You were treated with IV antibiotics and found to
have a MRSA UTI. You were investigated for a bloodstream source
ant it was negative. Both TTE and MRI did not show any focus of
infection. Please take your medications as directed and follow
up with your PCP once discharge.
Followup Instructions:
___
|
10034049-DS-18 | 10,034,049 | 24,278,210 | DS | 18 | 2157-11-23 00:00:00 | 2157-11-23 10:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide
Antibiotics)
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of
rheumatoid arthritis on daily prednisone, HTN, HLD,
hypothyroidism, DM2, asthma, depression, anxiety who presents
with AMS.
The patient's son is not present, but the patient tells me that
he brought her to the ED. She says "he's an ex ___, he thinks
he knows everything but knows nothing. I think he jumped the gun
bringing me here, overreading into things". She was noted to be
reportedly lethargic in the ED. The patient is oriented to ___, ___, and can recite the days of the weeks backwards. She
says she has had 2 days of malaise and feeling overall unwell.
No
myalgias, subjective fever, nausea, vomiting, dysuria,
hematuria.
However she does have suprapubic discomfort the past 2 days. She
denies flank or back pain. No dyspnea or chest pain.
Of note she was admitted/discharged ___ for AMS due to UTI
and
found to have enterococcus.
___ as outpatient she had urine culture for urinary
urgency/dysuria by PCP and that showed GBS. She completed a 5
day
course of Macrobid for that.
ED: ___. Got IV Tylenol, IV vanc, IV CTX for presumed UTI.
Past Medical History:
Chronic pain 30+ years back, hands
Rheumatic fever
Rheumatoid arthritis
HTN
HLD
Type 2 DM
Asthma
?cervical CA s/p hysterectomy ___
?uterine CA
Hypothyroidism
Venous stasis
Depression
Anxiety
HTN
Hypothyroidism
Chronic venous stasis ulcers
Recurrent UTIs
Chronic pain
Back injury NOS
Asthma
COPD
?rheumatoid arthritis
T2DM
Social History:
___
Family History:
Patient states her family had "medical conditions" but she
cannot describe more specifically.
Physical Exam:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: sitting up in chair
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, mildly TTP across upper
abdomen. Bowel sounds present.
MSK: Neck supple, moves all extremities
NEUROLOGIC: Oriented to person, place, and situation
Pertinent Results:
___ 05:06AM BLOOD TSH-20*
CT ABD
1. Bladder appears mildly inflamed, correlate for cystitis. No
signs of
pyelonephritis.
2. Marked degenerated disease at L4-5, similar to prior, better
assessed on
prior CT and MRI. Please correlate clinically.
3. Renal hypodensities, possibly cysts, several too small to
characterize.
___ 7:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
Ms. ___ is a ___ female with history of
rheumatoid arthritis on daily prednisone, HTN, HLD,
hypothyroidism, NIDDM2, asthma, depression, anxiety who presents
with AMS and fever, found to have a UTI.
#UTI
#Metabolic encephalopathy: The patient presented with increased
frequency of urination, foul-smelling urine, and disorientation.
Pt's UCx grew Ecoli that was sensitive to CTX and cipro. Pt
improved after IV ceftriaxone and was transitioned to PO cipro,
to complete a 7d course (last day = ___ for
complicated UTI. Pt was then discharged to ___ Rehab.
When discussing a discharge plan with the patient, she reported
that she would like to stay in the hospital a little longer.
When asked why this was the case, she alluded to issues at home
and with her son with whom she lives. She explained that her son
is a former ___ and has anger management issues. She reported
theft of her personal property and suggested verbal abuse.
Before providing more details, however, the patient became very
nervous and shut down, expressing regret that she said anything
at all, fearful of suffering retaliation. Based on patient's
reports in the morning, an online EPS report was filed.
#Slow-transit constipation: Exacerbated by chronic opioid use.
Employing docusate, senna, polyethylene glycol, and bisacodyl
suppositories titrated to have daily bowel movements.
#Rheumatoid arthritis: Pt's home 5mg pred was continued. Of
note, on presentation due to concerns for sepsis, pt received
one dose of stress dose steroids, 100mg hydrorcortisone IV x1,
which were then discontinued when pt was stable upon arrival to
the floor.
#NIDDM2
- SSI while inpatient, held home oral agents. Resume at
discharge
#HTN
- Continued home losartan, amlodipine, HCTZ-triamterene
#HLD
- Continued home statin
#Anxiety
- Continued home zoloft
#Hypothyroidism
- Continued home synthroid (takes weekly ___ mcg/kg x7)) to
help with compliance. TSH was elevated at 20, and the patient's
son reported she has not been taking at home.
#TRANSITIONAL:
[ ] On CT A/P: Marked degenerated disease at L4-5, similar to
prior,
better assessed on prior CT and MRI. Nothing on exam to suggest
myelopathy at this time; for outpatient follow up.
[ ] Complete ciprofloxacin 500 mg q12 hr on ___
Ms. ___ was seen and examined on the day of discharge
is clinically stable for discharge today. The total time spent
today on discharge planning, counseling and coordination of care
today was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Losartan Potassium 50 mg PO DAILY
7. Methadone 10 mg PO Q8H:PRN severe back pain
8. Nabumetone 500 mg PO BID
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Omeprazole 20 mg PO DAILY
11. PredniSONE 5 mg PO DAILY
12. Senna 8.6 mg PO BID:PRN constipation
13. Sertraline 200 mg PO DAILY
14. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID lesions
15. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
16. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
17. Gabapentin 600 mg PO QID
18. Levothyroxine Sodium 1000 mcg PO EVERY ___
19. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
20. Multivitamins 1 TAB PO DAILY
21. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN BREAKTHROUGH
PAIN
22. Travatan Z (travoprost) 0.004 % ophthalmic (eye) QHS
Discharge Medications:
1. Bisacodyl 10 mg PR ONCE Duration: 1 Dose
2. Ciprofloxacin HCl 500 mg PO Q12H
3. Polyethylene Glycol 17 g PO BID
4. Ramelteon 8 mg PO QHS
Should be given 30 minutes before bedtime
5. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
6. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
7. amLODIPine 10 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 20 mg PO QPM
10. Docusate Sodium 100 mg PO BID
11. Gabapentin 600 mg PO QID
12. Levothyroxine Sodium 1000 mcg PO EVERY ___
13. Losartan Potassium 50 mg PO DAILY
14. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
15. Methadone 10 mg PO Q8H:PRN severe back pain
16. Multivitamins 1 TAB PO DAILY
17. Nabumetone 500 mg PO BID
18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
19. Omeprazole 20 mg PO DAILY
20. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN BREAKTHROUGH
PAIN
21. PredniSONE 5 mg PO DAILY
22. Senna 8.6 mg PO BID:PRN constipation
23. Sertraline 200 mg PO DAILY
24. Travatan Z (travoprost) 0.004 % ophthalmic (eye) QHS
25. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID lesions
26. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
UTI
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 ___,
You were hospitalized for a very severe infection. Now that you
are stable, you are able to leave and be discharged to ___ Rehab. Please be sure to follow-up with your
appointments listed below.
We wish you the best with your health.
Warm regards,
___ Health
Followup Instructions:
___
|
10034049-DS-19 | 10,034,049 | 20,053,563 | DS | 19 | 2158-03-02 00:00:00 | 2158-03-02 18:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide
Antibiotics)
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F w/ severe RA w/ leukocytoclastic vasculitis, venous
insufficiency, hypothyroid, DM, presenting with abdominal pain
and AMS.
Per EMS, found seated hunched over on portable commode in
bedroom
of residence, alert and oriented x4 with warm, dry skin. Pt
complained of constipation x2 days with associated abdominal
pain. Family member reports pt had two bowel movements today but
pt reports still feeling "urgent need to go." Pt reports that
she
is "very blocked up."
On our assessment, patient intermittently reports abdominal
pain.
Also mentions a fall, unsure when. Reports some mid back pain.
Unable to obtain other significant history.
Recent ___ admission for fall, thought to be due to
deconditioned/meds, also hypothyroid, restarted on
levothyroxine.
D/c to SAR. Noted to have difficulty with med compliance.
EMS physical: L sided tenderness in LUQ on palpation. No
distention, rigidity or masses felt. Pt had multiple large
bruises all over her body which family member and pt report are
from repeated falls in residence. Pt denied chest pain,
shortness
of breath, nausea, vomiting, fever or chills. Pt was extricated
via stair chair, secured to stretcher and transported to BID
with
no further change in condition.
In the ED:
On EMS arrival, the patient endorsed LUQ tenderness.
Notably, the patient recently had a ___ admission for a fall due
to suspected deconditioning. The patient was noted to have
difficulty with med compliance. The patient reports bilateral ___
pain. Denies fever, chills, dyspnea, chest pain, or n/v.
Initial vital signs were notable for:
97.7 83 130/69 18 98% RA
Exam notable for:
Patient AAOx2, trying to get out of bed.
PERLA, EOMI, no obvious head trauma
No C spine tenderness, mild T spine tenderness
Flinches with abdominal palpation, especially on the left side.
But is soft and not notably distended
LEs with bilaterally venous stasis changes and multiple open
wounds that do not appear actively infected
Labs were notable for:
141 95 12
---------------< 147
3.6 28 1.0
8.3 > 10.7/33.6 < 207
UA: Large leuks, 30 protein, 40 WBCs
Studies performed include:
CT head:
No acute intracranial process.
Diffuse hypodensities in the white matter again seen, similar in
extent to CT head dated ___ and ___ which
could be related to prior therapy or due to extensive small
vessel disease.
CT C-Spine
1. No acute fracture or traumatic malalignment.
2. Multilevel degenerative changes including mild
anterolisthesis
of C2 on C3,
intervertebral disc space narrowing, and osteophytosis worse at
C4-C5.
CT Abd/Pelvis with contrast:
1. Ground-glass opacification in the posterior segment of the
right upper lobe
that may represent infection.
2. No intrathoracic or intra-abdominal sequela of trauma.
3. Irregularity and lucency at the superior endplate of L5 and
inferior
endplate of L4 are slightly progressed when compared to prior
dated ___ and infection cannot be excluded.
4. Nonspecific, unchanged prominent pelvic lymph nodes.
5. Prominent bilateral external iliac lymph node are again seen
measuring up
to 0.9 cm in short axis, nonspecific.
6. Mild stranding adjacent to the left adrenal may represent
possible adrenal injury.
7. Unchanged, indeterminate renal lesion in the interpolar
region
of the right kidney seen since ___. Non emergent
follow-up renal ultrasound is recommended if no prior
characterization has been performed.
Pt was given:
Olanzapine for agitation
Tylenol
Cefpodoxime 200mg
Ceftriaxone 1g
Azithro
IVF
sitter for agitation
Consults: None
Vitals on transfer: T102.7, BP 171/92, HR90, RR20, 94% RA
Upon arrival to the floor, pt was somnolent and stated she had
L-sided pain of her torso. Her attention waxed/waned and she
responded somewhat appropriately when prodded. Vital signs were
significant for hypertension and febrile to 102.7 reduced to 100
with IV Tylenol. Her HCP, her son, was called for assessment of
her baseline which he says is AOx4 and occasionally combative.
She has a history of recurrent UTIs which present with similar
delirium. Has mild baseline dementia with forgetfulness of
certain memories but functional and independent otherwise.
Past Medical History:
Chronic pain 30+ years back, hands
Rheumatic fever
Rheumatoid arthritis
HTN
HLD
Type 2 DM
Asthma
?cervical CA s/p hysterectomy ___
?uterine CA
Hypothyroidism
Venous stasis
Depression
Anxiety
HTN
Hypothyroidism
Chronic venous stasis ulcers
Recurrent UTIs
Intermittent urinary retention
Chronic pain
Back injury NOS
Asthma
COPD
?rheumatoid arthritis
T2DM
Social History:
___
Family History:
Patient previously stated her family had "medical conditions"
but she cannot describe more specifically.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T102.7, BP171/92, HR90, RR20, 94%RA
GENERAL: Somnolent, responds appropriately intermittently. In
mild distress ___ abd pain.
HEENT: NCAT. Sclera anicteric and without injection.
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.
BACK: Unable to evaluate for CVA tenderness ___ pt refusal.
ABDOMEN: Soft, non distended, tender to palpation in left
quadrants (LUQ worse than LLQ). Healed surgical scar on R.
EXTREMITIES: B/L ___ erythema with multiple bruises and scars in
various stages of healing with overlying blanching
well-demarcated erythema. Warm to touch. L leg erythema
outlined
on ___. Pulses DP/Radial 2+ bilaterally.
SKIN: See Ext above. Warm.
NEUROLOGIC: Sensation intact in ___.
DISCHARGE PHYSICAL EXAM:
============================
VITALS: 98.5 PO 99 / 58 71 16 95 RA
GEN: Lying in bed on her left side, eyes closed
CV: Normal rate, regular rhythm, no m/r/g
Pulm: CTAB
Abdomen: Deferred due to abdominal pain
Ext: B/L ___ with erythema with bruising and skin breakdown c/w
venous stasis changes
Neuro: EOMI, R facial droop, R upper extremity can elevate
without resistance, can move R toes and ankle, improved from
prior, grossly normal on the Left side
Pertinent Results:
ADMISSION LABS:
=================
___ 03:31AM BLOOD WBC-8.3 RBC-3.80* Hgb-10.7* Hct-33.6*
MCV-88 MCH-28.2 MCHC-31.8* RDW-15.5 RDWSD-49.9* Plt ___
___ 03:31AM BLOOD Neuts-87.3* Lymphs-6.8* Monos-4.6*
Eos-0.4* Baso-0.4 Im ___ AbsNeut-7.36* AbsLymp-0.57*
AbsMono-0.39 AbsEos-0.03* AbsBaso-0.03
___ 03:25AM BLOOD Glucose-147* UreaN-12 Creat-1.0 Na-141
K-3.6 Cl-95* HCO3-28 AnGap-18
___ 03:25AM BLOOD ALT-9 AST-10 AlkPhos-113* TotBili-0.7
___ 03:25AM BLOOD Lipase-10
___ 10:45AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.4*
___ 03:25AM BLOOD Albumin-4.3
___ 02:29AM BLOOD Glucose-112* Lactate-2.3* Na-139 K-3.4
Cl-98 calHCO3-26
INTERVAL LABS:
===============
___ 07:25AM BLOOD ___ PTT-28.5 ___
___ 07:25AM BLOOD Ret Aut-2.3* Abs Ret-0.08
___ 03:30AM BLOOD Lipase-79*
___ 03:00PM BLOOD Calcium-9.4 Phos-3.1 Mg-1.7 Cholest-118
___ 07:25AM BLOOD calTIBC-229* VitB12-731 Ferritn-186*
TRF-176*
___ 03:00PM BLOOD %HbA1c-6.1* eAG-128*
___ 03:00PM BLOOD Triglyc-181* HDL-40* CHOL/HD-3.0
LDLcalc-42
___ 10:45AM BLOOD TSH-43*
___ 10:45AM BLOOD Free T4-0.7*
___ 10:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS:
=================
___ 06:43AM BLOOD WBC-4.9 RBC-3.51* Hgb-10.1* Hct-30.3*
MCV-86 MCH-28.8 MCHC-33.3 RDW-15.1 RDWSD-47.8* Plt ___
___ 06:43AM BLOOD Glucose-157* UreaN-19 Creat-0.8 Na-140
K-3.7 Cl-98 HCO3-26 AnGap-16
___ 06:30AM BLOOD Glucose-137* UreaN-26* Creat-0.9 Na-139
K-3.8 Cl-98 HCO3-26 AnGap-15
___ 06:43AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.9
MICROBIOLOGY:
===============
___ AND ___ URINE CULTURES:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ URINE CULTURE: NO GROWTH.
___ 4:00 pm BLOOD CULTURE **FINAL REPORT ___ Blood
Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE
NEGATIVE. Isolated from only one set in the previous five days.
___ BLOOD CULTURE: NO GROWTH
___ BLOOD CULTURE X2: NGTD
___ BLOOD CULTURE: NGTD
IMAGING:
===========
CT C-SPINE W/O CONTRAST Study Date of ___
1. No acute fracture or traumatic malalignment.
2. Multilevel degenerative changes including mild
anterolisthesis of C2 on C3, intervertebral disc space
narrowing, and osteophytosis worse at C4-C5.
3. Multilevel posterior osteophytosis and calcified disc bulge
result in
moderate spinal canal narrowing most severe at C3-C4.
4. Multilevel uncovertebral facet joint hypertrophy resulting
mild neural
foraminal stenosis worse than right C3-C4 facet joint.
CT HEAD W/O CONTRAST Study Date of ___
No acute intracranial process.
Diffuse hypodensities in the white matter again seen, similar in
extent to CT head dated ___ and ___ which
could be related to prior therapy or due to extensive small
vessel disease.
CT CHEST a/p W/CONTRAST Study Date of ___
1. Nodular, ground-glass opacification in the posterior right
upper lobe
concerning for pneumonia. In the setting of trauma, underlying
pulmonary
contusion is not excluded.
2. Mild stranding between the left adrenal gland and kidney is
nonspecific, but may relate to acute injury or ascending GU
infection.
3. Irregularity and lucency at the superior endplate of L5 and
inferior
endplate of L4 are slightly progressed when compared to prior
dated ___ and infection cannot be excluded.
4. Nonspecific, unchanged prominent pelvic lymph nodes.
CT ABD & PELVIS WITH CONTRAST Study Date of ___
1. No etiology identified for severe abdominal pain.
Specifically, no
intra-abdominal abscess or small bowel obstruction.
2. The bladder wall appears mildly thickened, which may be
related to
nondistention, however, cystitis should be considered and
correlation with
urinalysis is recommended.
3. Redemonstration of the irregularity and lucency at the
superior endplate of L5 in the inferior endplate of L4, which is
unchanged compared to ___ but slightly progressed
compared to ___. Findings may represent progressive
neuropathic degenerative changes however underlying infection
cannot be excluded.
4. Unchanged, nonspecific prominent/enlarged pelvic/inguinal
lymph nodes.
MR HEAD W/O CONTRAST Study Date of ___
1. Late acute to subacute in the left corona radiata. No
intracranial
hemorrhage.
2. Atrophy and stable extensive white matter signal abnormality,
possibly
related to prior therapy or chronic small vessel ischemic
disease.
3. Additional findings described above.
CTA HEAD AND CTA NECK Study Date of ___
1. Redemonstration of a focus of late acute to subacute infarct
in the left corona radiata. No intracranial hemorrhage.
2. Atrophy and stable extensive white matter disease, possibly
related to
prior therapy or chronic small vessel ischemic disease.
3. No severe vascular stenosis, occlusion or aneurysm. Mild
atherosclerotic disease is noted in the posterior cerebral
arteries and cavernous internal carotid arteries.
4. Improved nodular and ground-glass opacities in the posterior
right upper lobe, consistent with resolving infection or
contusion.
5. Additional findings as described above.
TTE Study Date of ___
IMPRESSION: Mild symmetric left ventricular hypertophy with
normal cavity sizes, and regional/global systolic function. No
definite structural cardiac source of embolism identified.
Compared with the prior TTE (images not available for review) of
___, the findings are similar.
Brief Hospital Course:
Ms. ___ is a ___ year old lady with history of
rheumatoid arthritis on chronic prednisone, leukocytoclastic
vasculitis, hypothyroidism, diabetes, and question of recent
stroke with residual R sided weakness, who presents with toxic
metabolic encephalopathy in setting of pyelonephritis, with MRI
confirming subacute left corona radiata CVA.
# Pyelonephritis
# Abdominal pain
Patient presented with fever to 102.7F and diffuse abdominal
pain, with pyuria on U/A as well as CTA/P remarkable for
stranding surrounding bladder and near L adrenal/kidney, which
was repeated later in hospital course for ongoing abdominal pain
and distension, unrevealing for a new source of pain. Other
sources of fever considered included possible PNA, given ground
glass changes in RUL seen on CT chest, however patient without
cough or hypoxia. She completed 7 day course of antibiotics with
vancomycin + ceftriaxone ending ___, given history of MRSA UTI
(at that time with indwelling foley cathether), with resolution
of fever. Urine cultures returned as mixed bacterial flora, and
blood cultures notable for only 1 bottle in one set positive for
coag negative staph after >48 hours, thought to be a
contaminant. Given clinical stability patient did not receive
stress dose steroids.
# Toxic metabolic encephalopathy
# Delirium
In ED patient was very agitated, refusing care, requiring
multiple doses of IM zyprexa, then on medical floor was
initially somnolent, with negative CTH. By hospital day 2 was AO
x 3 after treatment of infection as above. Throughout hospital
course mental status waxed and waned, likely with component of
delirium, but improved back to her baseline by discharge
(oriented and able to perform ___ backwards) as her antibiotics
course was ending. ___ oxycodone, methadone, gabapentin were
held in setting of altered mental status, restarted methadone
partway through hospital course, held others, to be restarted at
rehab if needed.
# Right hemiparesis
# Subacute L corona radiata stroke
On HD1, patient noted to have R sided hemiparesis. This was
previously documented in PCP note from ___, and upon further
investigation, appeared that patient had presented to ___
___ in ___ with complaint of right sided weakness.
Per their discharge summary, "patient was not a candidate for
intravenous alteplase, MRI/MRA of brain was ordered but patient
was not cooperative. We spoke again with her and family members
and patient is insisting in refusing brain MRI." She was
discharged with aspirin 324 mg and Lipitor 80 mg daily. Their
exam documents "AOx2 strength ___ in LUE, ___ ___ in L
leg and ___ in R leg. Sensation in L arm dull when compared to
right". There was also report of patient saying "this is not the
first time she is having this right sided weakness and usually
recovers". After prolonged discussion, MRI ___ was obtained
showing late acute to subacute infarct in the left corona
radiata, no intracranial hemorrhage. Note was also made of
extensive white matter signal abnormality likely related to
chronic small vessel ischemic disease. CTA head and neck
revealed no severe vascular stenosis, occlusion or aneurysm. TTE
with no definite structural cardiac source of embolism
identified. Patient was initially maintained on telemetry
without any report of atrial fibrillation but ultimately
declined to continue monitoring. Long-term event monitoring
could be discussed as an outpatient. Regarding other stroke risk
factors, LDL was 42, TSH 43/fT4 0.7, A1c 6.1. She was placed on
aspirin 81 mg, atorvastatin 80 mg. ___ and OT evaluated patient
and recommended rehab, and she was agreeable.
# +BCx for coag negative staph: Aerobic bottle from ___
positive for coag negative staph ___ bottles) after >48 hours
of growth, likely contaminant. However, patient did receive
vancomycin x 7 days given history of MRSA UTI.
# Hypothyroidism: Note patient with TSH 43, fT4 0.7, was
evaluated by endocrine at ___ and also seen for this at ___,
attributed to medication noncompliance, started 125 mcg daily
weight based in ___ which was continued this stay. She will
need repeat TSH within 6 weeks.
# Hypertension: Continued ___ amlodipine. Initially held ___
triamterene-HCTZ and losartan I/s/o normotension, held on
discharge for mild ___.
# ___: Noted to have elevated Creatinine 1.2 from 0.9 and BUN 26
from 12 one day prior to discharge I/s/o receiving multiple
contrast loads. Held ___ antihypertensives as above.
# Chronic back and ___ pain: Continued ___ methadone 10 mg
TID:PRN (confirmed with ___ that patient takes methadone 10
mg TID:PRN + oxycodone 5 mg TID). ___ oxycodone and gabapentin
held as above. Please note that per last pain clinic note
___, there may be an element of opioid induced hyperalgesia
as well as opioid tolerance. There was recommendation for
continued gradual taper 10% reduction starting with breakthrough
oxycodone over ___ intervals then methadone. Her narcotics
contract from ___ was reviewed (Dr. ___, with
documentation of plan for taper by 10% every 4 weeks- does not
appear that this had been done. ___ benefit from new pain clinic
referral.
CHRONIC ISSUES:
=================
# Diabetes: Continued on SSI while in house, resumed ___
metformin on discharge.
# Rheumatoid arthritis with leukocytoclastic vasculitis:
Continued ___ prednisone 5mg daily
# Urinary retention:
# Recurrent UTIs:
Patient at baseline requires intermittent straight
catheterizations due to intermittent trouble with initiating
urinary stream. Previously referred to
uro-gyn by her ___ PCP, unclear if followed up. Required
intermittent straight cath during hospitalization.
# Normocytic anemia: Mixed iron deficiency and anemia of chronic
inflammation
# Chronic venous stasis ulcerations: ___ care RN previously
recommended waffle boots, ace wraps to b/l LEs.
TRANSITIONAL ISSUES:
====================
[] Neurology follow up for CVA
[] Started aspirin 81 mg, atorvastatin 80 mg daily
[] Resumed Levothyroxine 125 mg daily
[] Held gabapentin and oxycodone for altered mental status,
consider pain clinic followup to taper off methadone
[] Held ___ triamterene-HCTZ and losartan for mild ___, please
restart in 1 week if needed for BP control
[] Consider re-referral to uro-gyn for ongoing urinary retention
[] Monitor BMs and uptitrate bowel regimen as needed
[] Continue to address long term event monitor as outpatient to
workup stroke
[] Social work in contact with ___ to
increase patient's ___ services, which she adamantly refused,
would continue to readdress at rehab
[] Please recheck TSH ___ (TSH 43, Free T4 0.7 on ___
[] Noted on CT A/P incidentally: fusion of the L3-L4 vertebral
bodies with irregularity and lucency of the superior endplate L5
and the inferior endplate L4, which is similar compared to prior
but mildly progressed compared to ___, Unchanged,
nonspecific prominent/enlarged pelvic/inguinal lymph nodes.
Further followup if clinically warranted.
#CODE: DNR/DNI (MOLST in chart, ___
#CONTACT: ___ (HCP, noted in chart, Son):
___
Greater than 30 minutes was spent in care coordination and
counseling on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 5 mg PO Q12H
2. Methadone 10 mg PO Q8H:PRN moderate pain
3. Gabapentin 600 mg PO QID
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
5. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
6. Sertraline 100 mg PO BID
7. PredniSONE 5 mg PO DAILY
8. Nabumetone 500 mg PO BID
9. MetFORMIN (Glucophage) 500 mg PO DAILY
10. Losartan Potassium 50 mg PO DAILY
11. Levothyroxine Sodium 1000 mcg PO 1X/WEEK (___)
12. amLODIPine 10 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Atorvastatin 20 mg PO QPM
15. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Polyethylene Glycol 17 g PO DAILY
4. Simethicone 80 mg PO QID dyspepsia, gas
5. Atorvastatin 80 mg PO QPM
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Methadone 10 mg PO TID:PRN moderate-severe pain
RX *methadone 10 mg 1 tab by mouth three times per day Disp #*9
Tablet Refills:*0
8. Senna 8.6 mg PO BID
9. amLODIPine 10 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. MetFORMIN (Glucophage) 500 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. PredniSONE 5 mg PO DAILY
14. Sertraline 200 mg PO DAILY
15. HELD- Gabapentin 600 mg PO QID This medication was held. Do
not restart Gabapentin until there is need for it
16. HELD- Losartan Potassium 50 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until your kidneys
recover and your blood pressure is higher
17. HELD- Nabumetone 500 mg PO BID This medication was held. Do
not restart Nabumetone until you have more pain
18. HELD- OxyCODONE (Immediate Release) 5 mg PO Q12H This
medication was held. Do not restart OxyCODONE (Immediate
Release) until your kidneys recover and your blood pressure is
higher
19. HELD- Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY This
medication was held. Do not restart Triamterene-HCTZ (37.5/25)
until your kidneys recover and your blood pressure is higher
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Toxic metabolic encephalopathy
Sepsis
Urinary tract infection/pyelonephritis
Right-sided weakness
Late acute to subacute stroke in the left corona radiata
Abdominal pain
Constipation
Secondary:
Hypertension
Hypothyroidism
Type 2 diabetes
Rheumatoid arthritis with a history of leukocytoclastic
vasculitis
Venous insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
You came to the hospital because of confusion and belly pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You got antibiotics for a urinary tract infection that went to
your kidneys (pyelonephritis)
- You had pictures of your brain that confirmed you had a
stroke, which is the cause of the weakness on your right side.
- You had pictures taken of your belly which did not show why
you were having so much pain, but restarting your ___ methadone
was helpful for your pain.
- You were evaluated by our physical therapists, who recommended
that you go to rehab to get stronger before you go ___.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- It is very important to participate in the rehab program so
you can get as much of your strength back as possible before you
go ___.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10034345-DS-3 | 10,034,345 | 27,724,752 | DS | 3 | 2184-10-09 00:00:00 | 2184-10-14 19:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ glyburide
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of CAD s/p multiple stents and CABG presents
with acute onset back pain. Pt was in his usual state of health
and had eating breakfast this morning as usual when he later had
acute onset of pain affecting his entire back while walking
through kitchen. Pain radiated around rib cage, not into arms or
up neck. Describes it as sharp, extreme pain, ___ in
severity. Pain grew worse despite sitting and despite applying
heating pad. It was accompanied by shortness of breath and
diaphoresis, "sweating buckets." No nausea/vomiting or
palpitations. He also reports severe shaking all over; denies
loss of consciousness or mental status change. Pain lasted about
8:30 to 9:30 am and was improved by receiving NTG spray x3 by
EMS, along with pain killer (300mics fentanyl) and fluids. Also
received ASA 325mg. En route to hospital, ECG by EMS reportedly
showed ST elevations in inferior leads, though initial ECG in ED
was without ischemic changes.
In the ED, initial vitals were 98 64 155/58 18 98% 3L. Labs
showed WBC 7.5, Hgb 14.5, Hct 41.1, Plt 121. Initial trop <0.01.
BUN 23, Cr 1.0. PTT 134.6 as pt had already been started on
heparin drip.
On arrival to floor, VS 97.5 162/70 65 16 98% RA. He has had no
recurrence of pain since the initial episode which has resolved.
Of note, he has had no prior pain like today's back pain. His
prior anginal pain resulting in stent placement manifested as
left arm pain. He reports mowing his own lawn two days before
without pain or other problems, and he does not usually get
musculoskeletal pain while doing labor.
On review of systems, he denies nasal congestion, sore throat,
cough, abdominal pain. +Diarrhea x 2 days, light brown. No
hematochezia. MSK ROS + occasional cramps. No dysuria/hematuria.
No rash, no LAD, no abnormal bruising/bleeding.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (+) Diabetes type II, (+) Dyslipidemia
(goal LDL<70), (+) essential HTN/white coat hypertension (home
blood pressure readings all well controlled except to readings
just over 140 per progress note ___
2. CARDIAC HISTORY:
- CABG: In ___
- PERCUTANEOUS CORONARY INTERVENTIONS: ___: Adjunctive
ReoPro of 99% stenosis mid-RCA (also 40-60% ___ RCA); 70% ___
LAD; 50% ___. RCA stenting c/b dissection, requiring five
stents to maintain patent vessel. Cardiac cath ___: normal
LMCA with minimal distal narrowing. ___ LAD 60-70%, distal LAD
___. 60% ___ stenosis in obtuse marginal, 50% stenosis true
circumflex. Cardiac cath ___: 50% LMCA, 95% mid LAD, 90% D1,
70-80% OM1; he was then referred for CABG, which was done in
___ at ___.
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Diabetes mellitus type 2, c/b neuropathy, nephropathy. HgbA1c
5.1 on ___
CKD stage 3
Hiatal hernia, GERD
Adenomatous colon polyp
Basal cell cancer
Actinic keratosis
Social History:
___
Family History:
Father died at ___ with heart problem. Mother has heart problem
at age ___.
Physical Exam:
ADMISSION
VS: VS 97.5 162/70 65 16 98% RA
General: WDWN male, comfortable appearing, laying in bed.
HEENT: No scleral icterus. EOMI. PERRL. MMM. Scant dried blood
on left upper lip, attributed to shaving.
CV: RRR, no m/g/r.
Lungs: CTA b/l. No wheezes/rhonchi/crackles.
Abdomen: +BS, soft, nontender, nondistended.
Ext: No clubbing/cyanosis/edema. Feet without any sores.
Neuro: CN ___ intact. MOTOR: ___ b/l elbow flexion/extension,
___ b/l ankle plantar/dorsiflexion. SENSORY: intact light touch
sensation distal UEs/LEs.
Skin: Moist, warm skin on back while laying in bed.
PULSES: 2+ DP pulses b/l.
DISCHARGE
VS: 98.0 (max 98.4) 157/57 (140s-150s/50s-60s) 57 (48-50s) 16
98% RA
Weight 60.8kg Blood sugar ___ 148 116
Gen: No apparent distress
HEENT: EOMI, anicteric
CV: RRR, no m/g/r
Pulm: No rales, no wheezes
Abd: +BS, soft, nontender
Ext: Warm, no edema
Neuro: Alert, nonfocal
Psych: Calm, appropriate
Pertinent Results:
ADMISSION LABS
___ 11:45AM ___ PTT-134.6* ___
___ 11:45AM PLT COUNT-121*
___ 11:45AM NEUTS-75.6* LYMPHS-13.4* MONOS-5.7 EOS-4.7*
BASOS-0.5
___ 11:45AM WBC-7.5 RBC-4.53* HGB-14.5 HCT-41.1 MCV-91
MCH-32.0 MCHC-35.3* RDW-13.0
___ 11:45AM CALCIUM-9.2 PHOSPHATE-1.9* MAGNESIUM-1.9
___ 11:45AM cTropnT-<0.01
___ 11:45AM GLUCOSE-174* UREA N-23* CREAT-1.0 SODIUM-141
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15
___ 09:00PM CK-MB-9 cTropnT-<0.01
___ 09:00PM CK(CPK)-171
DISCHARGE LABS
___ 06:50AM BLOOD WBC-7.3 RBC-4.74 Hgb-14.8 Hct-43.7 MCV-92
MCH-31.2 MCHC-33.8 RDW-12.6 Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD Glucose-106* UreaN-28* Creat-0.9 Na-141
K-4.1 Cl-102 HCO3-25 AnGap-18
___ 06:50AM BLOOD Calcium-10.0 Phos-4.2 Mg-1.8
IMAGING / STUDIES
CTA chest ___ is no axillary, mediastinal or hilar
lymphadenopathy. The
thyroid is normal. The airways are patent to the subsegmental
level. The
esophagus is normal. There is no filling defect in the
pulmonary arteries to
the subsegmental level. The aorta is normal in caliber. Mild
atherosclerotic
calcifications. No evidence of dissection. There are coronary
artery
calcifications. No pericardial effusion. Heart size is normal.
There is no
pleural effusion, focal consolidation, or pneumothorax. There
is no acute
bony abnormality. Patient is status post sternotomy.
IMPRESSION:
1. No evidence of aortic dissection. No pulmonary embolism.
2. Coronary artery calcifications.
Brief Hospital Course:
___ with h/o CAD s/p CABG, HTN, HLD, DMII, CKD stage 3, presents
with acute onset back pain, SOB and diaphoresis, thought likely
to be aborted STEMI.
ACTIVE DIAGNOSES
# Back pain: Pt presented with acute onset severe diffuse back
pain radiating around ribs to anterior torso. Sx resolved with
EMS administration of ASA and SL nitro x3. One tracing from EMS
reportedly showed ST elevations in inferior leads (see below)
but this was not seen on EKG at OSH on arrival nor on EKG at
___. Troponins negative x 2 at ___ and x 1 per report from
OSH.
Initially concern was for anginal equivalent, though pt's
presentation was atypical for ACS. He was started on heparin
drip, which was discontinued the morning following admission.
At that point, CTA chest was checked due to concern for aortic
dissection, and it was negative for aortic abnormality. Back
pain resolved and did not recur in hospital. Ultimately the
episode of acute back pain was thought to be likely aborted
STEMI; treatment of aborted STEMI/coronary artery disease is
described below.
# Aborted STEMI: ECG without ischemic changes here, although by
report the ECG by EMS showed inferior STE. Trop negative x 2
here. He was initially treated with heparin drip, though this
was discontinued the morning following admission.
Obtained a copy of ECG by EMS via OSH, though due to incomplete
labeling with incorrect patient age, it was unclear whether the
ECG truly belonged to patient. (Direct discussion with EMS
personnel who transported patient also corroborated STE in
inferior leads verbally over the phone.) Based on the
description of the event and available information about ST
elevation by EMS, the episode is concerning for an aborted
STEMI, with spontaneous lysis of the clot. Pain did not recur in
the hospital. Aspirin 325mg daily and beta-blockade with home
dose atenolol 50mg PO daily were continued. Home simvastatin
was replaced by high-dose atorvastatin. Plavix was added to
home medication list prior to discharge. He was advised to seek
immediate medical attention for any recurrence of symptoms.
CHRONIC DIAGNOSES
# DMII: Well controlled, HgbA1c 5.1 on ___. DCed glipizide
while in hospital and replaced with low-dose sliding scale
insulin.
# History of CKD stage III: Cr 0.9-1.1 this admission. Avoided
nephrotoxins and monitored daily Cr.
# HTN: Continued home atenolol 50mg daily, lisinopril 20mg
daily, amlodipine 10mg daily, and HCTZ 25mg daily.
# Chronic pain: No acute exacerbation of chronic disease.
Continued home gabapentin.
# GERD: No acute exacerbation of chronic disease. Continued
omeprazole.
TRANSITIONAL ISSUES
- Follow up with primary care doctor within one week. Obtain a
referral to a cardiologist as an outpatient.
- Advise ETT MIBI to assess for coronary artery disease/bypass
graft disease as an outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. GlipiZIDE XL 2.5 mg PO QAM
5. Simvastatin 20 mg PO QHS
6. Atenolol 50 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Gabapentin 200 mg PO QAM
9. Gabapentin 200 mg PO QPM:PRN pain
10. Gabapentin 300 mg PO HS
11. Multivitamins 1 TAB PO DAILY
12. Aspirin (Buffered) 325 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Gabapentin 200 mg PO QAM
8. Gabapentin 200 mg PO QPM:PRN pain
9. Gabapentin 300 mg PO HS
10. GlipiZIDE XL 2.5 mg PO QAM
11. Aspirin (Buffered) 325 mg PO DAILY
12. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
13. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Aborted STEMI
Secondary diagnoses: Coronary artery disease s/p CABG,
hypertension, hyperlipidemia, diabetes type II
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 ___
___. As you know, you went to the hospital due to
acute back pain. You were transferred to ___ for further
management. The lab values and rhythm tracings here did not
suggest damage to the heart muscle, though the description of
the event and the description of the rhythm tracing in the
ambulance are concerning for a blockage in a vessel supplying
blood to the heart. Your pain resolved, indicating that the
clot broke up on its own. You had a CT scan of the chest which
did not show a problem of the aorta. If you have any recurrence
of symptoms, please seek immediate medical attention.
Please see the attached sheets for changes to your home
medication regimen. Plavix has been added, which is a drug to
help prevent blood clots from forming in the heart vessels.
Simvastatin is replaced by atorvastatin.
Followup Instructions:
___
|
10034354-DS-21 | 10,034,354 | 27,657,995 | DS | 21 | 2159-05-14 00:00:00 | 2159-05-16 09:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right hand clumsiness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year-old man with hx of controlled HTN and
hpl, presented here as a transfer from OSH as a code stroke
around ___, code stroke was called at ___, he was seen around
___.
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
He said tonight he and his wife decided to go out for dinner,
around 1745 when they started to have their dinner, he noticed
that his right hand is clumsy and funny: lighter and slower than
before and he dropped the fork multiple times before he could
grab it and use it, his wife also noticed that but the did not
pay attention and had their dinner, when they wanted to go home,
he wanted to clean the car windshield with the sponge, but he
could not hold it in his hand and dropped it multiple times. At
this time his wife told him that they need to go to the
hospital,
they went to ___ and as the CT machine was not
working there, he was transferred here after initial evaluation
and blood work, his BP was around 120-130s.
He said after 45 min his hand clumsiness improved but still not
normal.
It was not weak, it was not numb, but he could not control it.
He denies headache, loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Controlled HTN for ___ years, controlled HPL, GERD
He has hx of bilateral shoulder surgery
Social History:
___
Family History:
Father had 4 MI and stroke before ___.
There is no history of seizures, developmental disability,
learning disorders, migraine headaches, strokes less than 50,
neuromuscular disorders, or movement disorders.
Physical Exam:
98.4 102 136/84 18 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Full range of motion OR decreased neck rotation and
flexion/extension.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Calves SNT bilaterally.
Skin: no rashes or lesions noted.
Neurological examination:
___ Stroke Scale score was 0
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
- Mental Status:
ORIENTATION - Alert, oriented x 3
The pt. had good knowledge of current events.
SPEECH
Able to relate history without difficulty.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors.
Speech was not dysarthric.
NAMING Pt. was able to name both high and low frequency objects.
READING - Able to read without difficulty
ATTENTION - Attentive, able to name ___ backward without
difficulty.
REGISTRATION and RECALL
Pt. was able to register 3 objects and recall ___ at 5 minutes.
COMPREHENSION
Able to follow both midline and appendicular commands
There was no evidence of apraxia or neglect
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Blinks to
threat bilaterally. Funduscopic exam reveals no papilledema,
exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal pursuits and
saccades.
V: Facial sensation intact to light touch. Good power in muscles
of mastication.
VII: No facial weakness, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with normal velocity movements.
- Motor: Normal bulk, tone throughout.Although because of his
shoulder surgery he has int rotation in his arm, but he has a
mild pronator drift in the right hand, finger tap is slower than
the left.
No adventitious movements, such as tremor, noted. No asterixis
noted.
SAbd SAdd ElF ElE WrE FFl FE IO HipF HipE KnF KnE AnkD ___
L 5 5 ___ ___ 5 5 5 5 5 5 5
R 5 5 ___ ___ 5 5 5 5 5 5 5
- Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout in UE and ___. No
extinction to DSS.
- DTRs:
BJ SJ TJ KJ AJ
L ___ 2 1
R ___ 2 1
There was no evidence of clonus.
___ negative. Pectoral reflexes absent.
Plantar response was flexor bilaterally.
- Coordination: No intention tremor, normal finger tapping. No
dysdiadochokinesia noted. No dysmetria on FNF or HKS
bilaterally.
- Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
***************
Discharge neuro exam: normal
Pertinent Results:
___ 09:15PM CREAT-1.1
___ 09:15PM CREAT-1.1
___ 09:14PM GLUCOSE-106* NA+-144 K+-3.7 CL--99 TCO2-31*
___ 09:13PM UREA N-22*
___ 09:13PM WBC-8.2 RBC-5.78 HGB-16.0 HCT-47.0 MCV-81*
MCH-27.7 MCHC-34.0 RDW-13.9
___ 09:13PM PLT COUNT-192
___ 09:13PM ___ PTT-35.0 ___
CT head with CTP and CTA ___:
Normal CT head. Normal CT perfusion head. Normal CT
angiography
of the head and neck.
MR head ___:
No evidence for acute ischemia.
ECHO ___:
Likely patent foramen ovale with early appearance of
microbubbles in the left heart after intravenous injection at
rest. Otherwise normal study with normal biventricular cavity
sizes with preserved regional and global biventricular systolic
function and normal valvular pathology and absence of pathologic
flow.
Brief Hospital Course:
___ year-old right-handed man with HTN and HLD who p/w an
one-hour episode of right hand clumsiness. MRI negative for
ischemic infarct. Given risk factors, concerning for TIA. He was
continued on ASA 81 and simvastatin. Risk factors assessment
revealed: LDL (110) and HbA1c (5.9). Etiology likely small
vessel disease from HTN and HLD although TTE with bubbled did
show potential PFO. He is referred for outapatient lower
extremity doppler to rule out DVT and paradoxical embolus.
# Transitional issues
- f/u lower extremity doppler
- f/u in stroke clinic
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? () Yes (LDL =
110) - () No
5. Intensive statin therapy administered? (x) Yes - () No [if
LDL >100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL > 100)
6. Smoking cessation counseling given? () Yes - (x) No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100 or
on a statin prior to hospitalization, reason not discharged on
statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - (x) N/A
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Cialis (tadalafil) 5 mg oral daily
2. Hydrochlorothiazide 25 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Potassium Chloride 20 mEq PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Co Q-10 (coenzyme Q10;<br>coenzyme Q10-vitamin E) 60 mg oral
daily
8. Glucosamine (glucosamine sulfate) 500 mg oral daily
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. Simvastatin 40 mg PO DAILY
RX *simvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*3
4. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
5. Cialis (tadalafil) 5 mg oral daily
6. Co Q-10 (coenzyme Q10;<br>coenzyme Q10-vitamin E) 60 mg oral
daily
7. Glucosamine (glucosamine sulfate) 500 mg oral daily
8. Hydrochlorothiazide 25 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Potassium Chloride 20 mEq PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
TRANSIENT ISCHEMIC ATTACK (TIA)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro exam: Normal
Discharge Instructions:
Dear Mr ___,
You were hospitalized due to symptoms of right hand clumsiness
resulting from an TRANSIENT ISCHEMIC ATTACK (TIA), a condition
where a blood vessel providing oxygen and nutrients to the brain
is transiently blocked by a clot.
TIA can have many different causes, so we assessed you for
medical conditions that might raise your risk of having TIA or
stroke. In order to prevent future TIA or strokes, we plan to
modify those risk factors.
Your risk factors are:
Hypertension
High cholesterol
We are changing your medications as follows:
- we added aspirin 81mg daily to decrease your stroke risk
- we increased your simvastatin to 40mg daily to better control
your high cholesterol
- please take Bactrim twice a day for one week to treat your
urinary tract infection.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10034742-DS-18 | 10,034,742 | 27,391,040 | DS | 18 | 2152-06-14 00:00:00 | 2152-06-14 10:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
gait instability
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
HPI: ___ is a ___ F with a history of chronic back pain
s/p multiple lumar surgeries and hypothyroidism who is
transferred from ___ where she presented with 4
days of maliase, unsteady gait and slurring of speech which
started after a brief episode of fever to 101 and a transient
headache. The headache was bifrontal and pressure like and
pounding in quality, more severe than any headache she has had
in
the past. It came on gradually and lasted for roughly 24hours
before abating. It has not returned. The slurring of speech has
occurred intermittently and usually lasts on the order of hours
when present. There is no difficulty with language. She does not
have any word finding difficulty and has not made any errors in
her speech. Her husband describes the difficulty walking and
speaking as appearing as if she is drunk. The unsteadiness on
the
feet has been gradually worsening since onset and has been
continuously present. She has not had any exacerbation in her
She has not fallen. She does report awaking with an episode of
vertigo a few days before the current symptoms, which was
similar
to episodes of BPPV she has had in the past. Currently she
denies
any changes in vision. There is no new weakness or numbness. No
problems swallowing. She has chronic urinary incontinence
related
to her chronic back problems, but this has not worsened. She
denies any problems with her bowels. She does endorse some light
headedness upon standing. ___ obtained at ___ showed
dilatation of the ventricals concerning for a communicating
hyrocephalus.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysphagia, vertigo, tinnitus or hearing difficulty.
Denies difficulties producing or comprehending speech. Denies
focal weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
chronic back pain s/p multiple lumar surgeries
Urinary incontinence
Radicular BLE pain
hypothyroidism
Social History:
___
Family History:
non contributory
Physical Exam:
Alert, oriented x 3.
Able to relate history without difficulty.
Attentive.
Language is fluent with intact repetition and comprehension.
Normal prosody.
There were no paraphasic errors.
Speech was not dysarthric.
Able to follow both midline and appendicular commands.
Good knowledge of current events.
No evidence of apraxia or neglect.
CN:
II:
PERRLA 3 to 2mm and brisk.
Fundoscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI, no nystagmus. Normal saccades.
V: Sensation intact to LT.
VII: Facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate rise symmetric.
XI: Trapezius and SCM ___ bilaterally.
XII: Tongue protrudes midline.
Motor:
Normal bulk, tone throughout. No pronator drift bilaterally.
No adventitious movements. No asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 4+ 5- 5 5
R ___ ___ ___ 4+ 5- 5 5
Sensory: No deficits to light touch, pinprick, vibratory sense.
Mild impairment in proprioception at toes, R>L. No extinction to
DSS.
Reflexes:
Bi Tri ___ Pat Ach
L ___ 2 1
R ___ 2 1
Toes downgoing bilaterally
Coordination:
No intention tremor, no dysdiadochokinesia noted. No dysmetria
on
FNF or HKS bilaterally.
Gait:
Good initiation. Wide based, unsteady. Falls backward on Romberg
testing
Pertinent Results:
___ 04:22AM CEREBROSPINAL FLUID (CSF) PROTEIN-25
GLUCOSE-65
___ 04:22AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-4* POLYS-0
___ ___ 01:10PM PLT COUNT-363
___ 01:10PM WBC-8.4 RBC-4.33 HGB-12.6 HCT-38.6 MCV-89
MCH-29.1 MCHC-32.6 RDW-13.0
___ 01:10PM CALCIUM-9.1 PHOSPHATE-3.9 MAGNESIUM-2.2
___ 01:10PM GLUCOSE-126* UREA N-14 CREAT-0.6 SODIUM-144
POTASSIUM-5.3* CHLORIDE-104 TOTAL CO2-31 ANION GAP-14
Brief Hospital Course:
#Neuro: Mrs. ___ was found to have mild gait instability on exam
upon admission. She had no other focal neurological findings. We
believed her instability to be secondary to dehydration. We gave
her aggressive IV fluid rehydration overnight and on day 2 of
admission she had significant improvement in her gait. She was
evaluated by physical therapy who had initially recommended
outpatient physical therapy but on reevaluation on day 2, felt
that she had no physical therapy needs. Her csf studies were
unremarkable so she was discharged home on ___ with the plan to
follow up with Dr. ___ in the neurology clinic in ___ weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 112 mcg PO DAILY
2. Oxybutynin 10 mg PO DAILY
3. Pregabalin 100 mg PO TID
4. TraMADOL (Ultram) 50 mg PO TID
5. Diazepam 10 mg PO Q6H:PRN pain
6. Gabapentin 300 mg PO TID
7. Imipramine 25 mg PO Frequency is Unknown
8. Diclofenac Sodium ___ ___ is Unknown PO Frequency is Unknown
9. Alendronate Sodium 70 mg PO 1X/WEEK (MO)
10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN respiratory
distress
Discharge Medications:
1. Diclofenac Sodium ___ 75 mg PO TID
2. Gabapentin 300 mg PO TID
3. Gabapentin 300 mg PO HS
4. Imipramine 25 mg PO HS
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Oxybutynin 5 mg PO BID
7. Pregabalin 100 mg PO TID
8. TraMADOL (Ultram) 50 mg PO TID:PRN pain
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN respiratory
distress
10. Alendronate Sodium 70 mg PO 1X/WEEK (MO)
11. Diazepam 10 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
DEHYDRATION
GAIT INSTABILITY
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to the ___ Service
after presenting with gait instability due to DEHYDRATION. ___
had a head CT that showed age-related changes that was
unremarkable. ___ had a lumbar puncture that did not show signs
of increased pressure or infection. We gave ___ aggressive IV
fluid hydration and your symptoms improved overnight.
There were no changes made to your medications.
Followup Instructions:
___
|
10034933-DS-22 | 10,034,933 | 28,591,708 | DS | 22 | 2111-12-18 00:00:00 | 2111-12-18 13:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fatigue, New Effusion
Major Surgical or Invasive Procedure:
Bone marrow biopsy ___
History of Present Illness:
___ PMH Bipolar Disorder, HTN, Metastatic HCC (on nivolumab, s/p
recent XRT to skull bony mets), CVA, MCA Aneurysm, presented to
ED with fatigue and new pleural effusion
As per call in, patient initially presented to OSH with
increasing confusion, CTH with stable skull mets, but further
workup revealed neutropenia, and CXR with new loculated pleural
effusion. Accordingly, he was given vanc/cefepime, and was
transferred to ___ for thoracic evaluation.
Patient's wife is unavailable at time of admission to the
oncology floor however patient was alert and oriented and able
to
provide adequate history. He noted that he was not confused but
instead was fatigued for 2 days and that was the reason that his
wife brought him to the outside hospital. He noted that he was
without fever, chills, cough, sore throat, nausea, vomiting,
diarrhea, abdominal pain, dysuria, rash, sick contacts. He
noted
that his oral intake has been less than optimal. He noted that
he has been voiding/stooling without issue. He denied any
respiratory issues, shortness of breath or labored breathing.
In the ED, initial vitals: 98.0 78 148/78 16 100% RA. WBC 1.0,
(8% PMN, 8% bands), Hgb 8.0, plt 58, INR 1.2, ALT 73 AST 118,
TBili 3.5, AP 368, Alb 2.3, Phos 2.2, Na 129, Lactate 0.8, UA +
Glc /Prot/Bili but no e/o infection.
CT Chest revealed:
1. New, lobulated, right greater than left, small pleural
effusions.
2. No evidence of new or growing pulmonary nodules.
3. Cirrhotic liver, with multiple hepatic masses measuring up to
8.1 cm, compatible with known multifocal hepatocellular
carcinoma, not fully assessed on this study.
4. New, wedge-shaped hypodensity within the spleen, which could
be due to contrast bolus timing, although a splenic infarct
could
have a similar appearance.
5. Stable bilateral adrenal metastases.
6. No significant change in osseous metastatic disease of the
ribs and vertebral bodies.
7. Other findings, as described above.
Thoracic surgery consulted, noted that they will followup CT
results. Patient was given normal saline and admitted for
further
care.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
As per last clinic note by Dr ___:
- ___: Presented with back pain thought to be due to
epidural abscess, a complication of his recent spinal surgery,
found to have multiple spinal mets.
- ___: Imaging shows multiple liver lesions and enlarged
abdominal lymph nodes, metastases of the spine, skull, L adrenal
gland, C2/3 paraspinal mass with cord impingement.
- ___: Radiation therapy to C1-5 and associated
paraspinal mass (20 Gy in 5 fx).
- ___: plan port placement
- ___: C1D1 FOLFOX
- ___: C2D1 FOLFOX ___ bolus d/c for mouth sores)
- ___: C3D1 held for hypokalemia
- ___: C3D1 FOLFOX ___ bolus d/c), Zometa
- ___: C4D1 FOLFOX ___ bolus d/c). D15 ___ CI ___ 20% for
mucositis. (Zometa held for hypoPhos)
- ___: C5D1 FOLFOX ___ bolus d/c, ___ CI ___ 20% for
mucositis)
- ___: C5D15 FOLFOX held for thrombocytopenia
- ___: C6D1 FOLFOX ___ bolus d/c, CI ___ 20%, oxali ___ 20%
for thrombocytopenia)
- ___: Zometa only (Phos improved)
- ___: C1 nivolumab
PAST MEDICAL HISTORY:
Bipolar Disorder
Hypertension
Pre-diabetes
GERD
Patient-reported Hemochromatosis (s/p phlebotomy, last done ___
years ago)
s/p L3-S1 lumbar decompression with duraplasty in ___
s/p right hip replacement in ___
Chronic neoplasm related pain
MCA Aneurysm
CVA
Social History:
___
Family History:
Aunt with hemochromatosis
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: ___ 0118 Temp: 98.3 PO BP: 125/58 HR: 77 RR: 18 O2
sat: 100% O2 delivery: Ra
GENERAL: Chronically ill-appearing man, Laying in bed, appears
comfortable, no acute distress, cachectic
EYES: Pupils equally round and reactive to light, anicteric
sclera
HEENT: Oropharynx clear, dry mucous membranes
NECK: Supple, normal range of motion
LUNGS: Clear to auscultation bilaterally without any wheezes
rales or rhonchi, no increased respiratory rate, speaks in full
sentences
CV: Regular rate and rhythm, normal distal perfusion, no edema
ABD: Soft nontender nondistended, normoactive bowel sounds
GENITOURINARY: No Foley or suprapubic tenderness
EXT: Cachectic extremities, decreased muscle bulk, normal muscle
tone
SKIN: Warm dry, no rash
NEURO: Alert and oriented x3, fluent speech, able to describe
his
medical history in detail
ACCESS: Port in right chest, dressing clean/dry/intact
DISCHARGE PHYSICAL EXAM:
___ 0815 Temp: 98.3 PO BP: 147/81 HR: 66 RR: 18 O2 sat: 94%
O2 delivery: Ra
GENERAL: Very pleasant but cachectic man sitting up in bedside
chair in no distress.
HEENT: Anicteric slcera, PERLL, OP clear, dry MM. Large 3cm
circumscribed bony mass over left brow
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, crackles at bases
bilaterally with good air movement. Speaking in full sentences.
ABD: Soft, non-tender, moderately distended and dull to
percussion, positive bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, decreased
muscle bulk.
NEURO: A&Ox3, good attention and linear thought. Strength full
throughout. Sensation to light touch intact. No asterixis.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:45PM BLOOD WBC-1.0* RBC-2.65* Hgb-8.0* Hct-23.7*
MCV-89 MCH-30.2 MCHC-33.8 RDW-19.0* RDWSD-62.8* Plt Ct-58*
___ 04:45PM BLOOD Neuts-8* Bands-8* Lymphs-63* Monos-19*
Eos-0* ___ Metas-2* AbsNeut-0.16* AbsLymp-0.63* AbsMono-0.19*
AbsEos-0.00* AbsBaso-0.00*
___ 04:45PM BLOOD ___ PTT-34.1 ___
___ 04:45PM BLOOD Glucose-104* UreaN-13 Creat-0.6 Na-129*
K-4.0 Cl-101 HCO3-18* AnGap-10
___ 04:45PM BLOOD ALT-73* AST-118* AlkPhos-368*
TotBili-3.5*
___ 04:45PM BLOOD Albumin-2.3* Calcium-7.3* Phos-2.2*
Mg-1.6
___ 04:55PM BLOOD Lactate-0.8
DISCHARGE LABS:
===============
___ 05:12AM BLOOD WBC-6.6 RBC-2.92* Hgb-8.6* Hct-25.6*
MCV-88 MCH-29.5 MCHC-33.6 RDW-18.5* RDWSD-57.7* Plt Ct-48*
___ 05:16AM BLOOD Neuts-66 Bands-18* Lymphs-14* Monos-2*
Eos-0* Baso-0 AbsNeut-4.70 AbsLymp-0.78* AbsMono-0.11*
AbsEos-0.00* AbsBaso-0.00*
___ 05:12AM BLOOD Ret Aut-0.4 Abs Ret-0.01*
___ 05:12AM BLOOD Glucose-150* UreaN-15 Creat-0.6 Na-131*
K-4.6 Cl-98 HCO3-27 AnGap-6*
___ 05:16AM BLOOD ALT-70* AST-92* LD(LDH)-175 AlkPhos-388*
TotBili-2.3*
___ 05:12AM BLOOD Calcium-7.6* Phos-2.3* Mg-1.7
MICROBIOLOGY:
___ Blood Culture x 2 - Pending
___ Urine Culture - No Growth
BONE MARROW BX ___:
Core Biopsy - PND
Flow Cytometry - PND
Cytogenetics - PND
IMAGING:
___HEST W/CONTRAST
1. New, lobulated, right greater than left, small pleural
effusions.
2. No evidence of new or growing pulmonary nodules.
3. Cirrhotic liver, with multiple hepatic masses measuring up to
8.1 cm, compatible with known multifocal hepatocellular
carcinoma, not fully assessed on this study.
4. New, wedge-shaped hypodensity within the spleen, which could
be due to contrast bolus timing, although a splenic infarct
could have a similar appearance.
5. Stable bilateral adrenal metastases.
6. No significant change in osseous metastatic disease of the
ribs and vertebrae.
___ Imaging LIVER OR GALLBLADDER US
1. Cirrhotic liver with redemonstration of a large,
heterogeneous left hepatic mass. Additional masses are better
appreciated on prior CT.
2. Sequela of portal hypertension including mild splenomegaly
and small to moderate volume ascites.
3. Persistent moderate intrahepatic biliary ductal dilatation,
primarily in the left hepatic lobe, similar to prior.
Noevidence of common bile duct dilatation.
4. Focal, wedge shaped area of hypoechogenicity along the
lateral margin of the spleen may represent a splenic infarct.
___ Imaging MRCP (MR ABD ___
1. Probable progression of multifocal HCC compared to ___ with increased number and size of multiple lesions,
although comparison is suboptimal due to differences in
modality.
2. Worsening tumor thrombus in left portal venous branches.
3. Mild/moderate intrahepatic biliary dilation in segments
II/III, worse compared to ___. No evidence of
cholangitis or hepatic microabscess.
4. Bilateral adrenal and multiple osseous metastases.
5. Small bilateral pleural effusions, appearing slightly
loculated on the right.
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION:
Mr. ___ is a ___ male with history of bipolar
disorder, hypertension, CVA, MCA aneurysm, and metastatic HCC on
nivolumab who presents with fatigue, falls, and new pleural
effusion.
# Neutropenia (resolved)
# Pure red cell aplasia:
# Thrombocytopenia:
He was found to have a hypoproliferative
pancytopenia/neutropenia for which he started neupogen on ___.
Etiology was thought potentially immune mediated reaction to
nivolumab, and he underwent BM biopsy on ___ with initiation of
prednisone. His WBC count improved, but he continued to have a
pure red cell aplasia (per prelim BM bx results) and his retic
count remained low. He received two tranfusions of pRBC and we
increased his steroids to 60mg bid. Should be monitored closely
on follow up. With extended prednisone taper. We did start
Bactrim for PJP ppx, but DC'd on discharge given possible marrow
suppressive side effects.
# Hyperbilirubinemia: Patient with stable AST/ALT but elevated
TBili that rose on admission. RUQUS and MRCP showed stable
persistent moderate intrahepatic biliary ductal dilatation and
no obvious intervenable lesion. Now improved upon discharge. We
discontinued his statin.
# Fatigue:
# Fall:
# Ascites: Fatigue likely to dehydration/malnutrition, anemia,
medication effect. No clear source of infection and neuro exam
was
normal. Generally improved and he was cleared for DC home with
home ___. We stopped his lisinopril and lorazepam.
# Pleural Effusion: New small lobulated right pleural effusion
on imaging. Likely due to metastatic disease. Less likely
infection given no symptoms. Per Thoracic surgery very small
effusion and given asymptomatic do not recommended drainage,
would need CT-guidance if wish to drain. We deferred.
# Concern for Splenic Infarct
# PVT : CT was suggestive of infarct, but could also have been
___ contrast timing. No role for A/C for now given
thrombocytopenia.
# Metastatic HCC:
# Secondary Neoplasm of Adrenal:
# Secondary Neoplasm of Bone: Rising AFP and new effusion
concern for disease progression despite initial treatment with
FOLFOX and single dose of nivolumab. Unfortunately unlikely he
will be able to resume nivolumab. Will need to discuss further
plans with his outpatient oncologist.
# Hyponatremia: Stable. Likely secondary to poor PO intake at
baseline as well as poor renal perfusion with ascites.
# Cancer-Related Pain: Continued home oxycontin and oxycodone. I
refilled his RX on discharge. Continued bowel regimen
# Hypophosphatemia
- Repleted prn with oral repletion
# Moderate Protein-Calorie Malnutrition
- Nutrition consulted
- Sent supplements
# History of CVA
- Held ASA given thrombocytopenia
- Held Lipitor given transaminitis
- Cont home atenolol
# Hypertension
- Continue home atenolol
- Held home lisinorpil and monitor BPs
# Bipolar Disorder
- Continued home lamictal
# Hypothyroidism
- Continued home levothyroxine
# Billing: >30 minutes spent coordinating this discharge plan
TRANSITIONAL ISSUES:
- Started Prednisone 60mg bid
- Consider non-marrow suppressive PJP ppx
- Stopped atorvastatin, lisinopril, and lorazepam
- Holding ASA due to thrombocytopenia
- Please check CBC with reticu count on follow up
- Consider outpatient paracentesis pending PLT/WBC stability
- Will need prolonged steroid taper
- ___ final bone marrow biopsy results
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE SR (OxyconTIN) 120 mg PO Q8H
2. Atenolol 100 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. LamoTRIgine 200 mg PO BID
5. Lisinopril 40 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Senna 8.6 mg PO BID
10. Aspirin 81 mg PO DAILY
11. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain -
Moderate
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of
breath/wheezing
13. Levothyroxine Sodium 25 mcg PO DAILY
14. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting/anxiety/insomnia
15. Potassium Chloride 20 mEq PO BID
16. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
17. Calcium Carbonate 600 mg PO BID
18. Vitamin D ___ UNIT PO DAILY
19. Magnesium Oxide 280 mg PO DAILY
20. Lidocaine Viscous 2% 15 mL PO Q3H:PRN throat pain
21. Phosphorus 250 mg PO DAILY
22. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID:PRN
mouth/throain pain
23. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
24. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. PredniSONE 60 mg PO BID
RX *prednisone 20 mg 3 tablet(s) by mouth twice a day Disp #*180
Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of
breath/wheezing
3. Atenolol 100 mg PO DAILY
4. Calcium Carbonate 600 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. LamoTRIgine 200 mg PO BID
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Magnesium Oxide 280 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
12. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 20 mg 1 tablet(s) by mouth q4 hours Disp #*120
Tablet Refills:*0
13. OxyCODONE SR (OxyconTIN) 120 mg PO Q8H
RX *oxycodone 60 mg 2 tablet(s) by mouth q8 hours Disp #*180
Tablet Refills:*0
14. Phosphorus 250 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Potassium Chloride 20 mEq PO BID
17. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
18. Senna 8.6 mg PO BID
19. Vitamin D ___ UNIT PO DAILY
20. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until your platelet counts are better
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Immune mediated pan-cytopenia
# Hepatocellular cancer
# Ascites
# Pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for weakness. We found you had
very low blood counts, along with increasing fluid in your
abdomen and a small amount around your lungs. We believe you
have had an immune reaction to your recent nivolumab
immunotherapy, causing damage to your bone marrow. We gave you
injections to help increase your white blood cell count, started
you on steroids, and performed a bone marrow biopsy. You also
received two blood tranfusions. We elected against interventions
on the fluid in your belly or lung, as you began to feel better.
You will need to follow up with Dr. ___ closely to evaluate
for recovery in your bone marrow and future treatment planning
for your liver cancer.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10035631-DS-13 | 10,035,631 | 21,476,294 | DS | 13 | 2115-12-08 00:00:00 | 2115-12-08 18:55:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers, chills and fatigue; concern for acute leukemia
Major Surgical or Invasive Procedure:
___ placement ___
Bone Marrow Biopsy ___
History of Present Illness:
Mr. ___ is a ___ y/o male with a history of stage IIA breast
cancer ___- s/p left mastectomy and currently on
tamoxifen, also with a history of intermediate risk AML s/p
reduced intensity allogeneic stem cell transplant ___, MRD
sister) currently in remission who presented with myalgias,
night sweats, fatigue and leukocytosis.
Patient was in his usual stated of health until 4 days prior to
admission when he received the influenza vaccine. Following
vaccination he developed severe left arm pain. The patient
subsequently developed upper body pain, back spasms, headaches,
drenching night sweats and rigors. He also complained of severe
fatigue and myalgias. He was afebrile. He has been taking
ibuprofen 400 mg q3h for symptom control. Patient also reports
having had a tick bite approximately ___ weeks ago. Denies
bleeding, bruising, gingival hyperplasia, rashes, cough.
Today the patient presented to ___ Urgent Care at which point
a CBC showed a WBC 33, Hb 15, PLT 30. Patient was referred to
___ for further evaluation. Upon arrival to the ED, T 98.7,
HR 100, BP 109/65, RR 18, 91% RA (rechecked and was 96% RA).
Labs were notable for a white count of 32.7 (80% others, 7%
neutrophils, 11% lymphocytes), Hb 14.6, Hct 41.4, platelet 24. K
4.1, Cr 1.1, lactate 2.9, Ca 9.2, Mg 2.0, Phos 2.4, LDH 682, UA
5.3, haptoglobin 143, INR 1.2.
Upon arrival to the floor, the patient was complaining of back
pain and headache.
Review of Systems:
A full 10 point review of systems was performed and negative
unless stated above.
Past Medical History:
AML, Intermediate risk (normal cytogenetics, FLT3/NPM1 neg,
diagnosed in ___. Enrolled in ECOG 2906, received indection
with 7+3 with ___, consolidation with midAC x 1. MRD AlloSCT
with reduced intensity flu/bu on ECOG 2906, d0 ___.
Received 4.62 x 10^6 CD34+/kg cells.
Male Breast Cancer s/p Mastectomy (___)
Aspergillosis (___)
Prostatitis (___)
Seizure vs. Syncope (___) - Holter/MRI/MRA/EEG all negative
Lyme Disease (___)
Social History:
___
Family History:
Mr. ___ has one brother with history of stroke. His father
died of lung cancer at age ___. His mother died at age ___.
Physical Exam:
ADMISSION:
==========
Vitals: Tc 98.2, BP 126/78, HR 85, RR 20, 96% RA
Gen: A+Ox3, NAD, well nourished male
HEENT: No conjunctival pallor. No icterus. MMM. OP clear. No
petechiae.
NECK: supple, no JVD
LYMPH: No cervical, axillary, supraclav, inguinal LAD
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND. No hepatosplenomegaly.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3.
LINES: right PIV
DISCHARGE:
==========
VS: ___ 97.6 PO 116 / 64 79 18 100 RA
Weight: 78.2 kg (77.11 on ___
I/O ytd: ___ BMx1 soft
Gen: A+Ox3, Sitting in bed in no acute distress
HEENT: EOMI, PERRL. MMM. No petechiae
NECK: supple, JVP not elevated
LYMPH: No significant cervical or supraclavicular LAD
CHEST: Non-tender to palpation
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No incr WOB. No w/r/r.
ABD: Normoactive bowel sounds. No tenderness to palpation.
EXT: WWP. No ___ edema.
SKIN: TEDS off this AM. Petechiae on bilateral shins.
NEURO: A&Ox3, CN II-XII grossly intact. Sensation and strength
grossly intact.
LINES: R PICC is c/d/i
Pertinent Results:
ADMISSION:
==========
___ 01:00PM BLOOD WBC-32.7*# RBC-4.25* Hgb-14.6 Hct-41.4
MCV-97 MCH-34.4* MCHC-35.3 RDW-13.0 RDWSD-45.8 Plt Ct-24*#
___ 01:00PM BLOOD Neuts-7* Bands-0 Lymphs-11* Monos-0 Eos-2
Baso-0 ___ Myelos-0 Blasts-80* Other-0 AbsNeut-2.29
AbsLymp-3.60 AbsMono-0.00* AbsEos-0.65* AbsBaso-0.00*
___ 01:00PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Spheroc-OCCASIONAL Tear
Dr-OCCASIONAL
___ 01:00PM BLOOD ___ PTT-25.4 ___
___ 01:00PM BLOOD Ret Aut-0.3* Abs Ret-0.01*
___ 01:00PM BLOOD Glucose-193* UreaN-16 Creat-1.1 Na-139
K-4.1 Cl-99 HCO3-25 AnGap-19
___ 01:00PM BLOOD ALT-50* AST-35 LD(LDH)-682* AlkPhos-69
TotBili-0.3
___ 01:00PM BLOOD Albumin-4.2 Calcium-9.2 Phos-2.4* Mg-2.0
UricAcd-5.3
___ 01:00PM BLOOD Hapto-143
___ 01:00PM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Negative
___ 01:00PM BLOOD HCV Ab-Negative
___ 01:06PM BLOOD Lactate-2.9*
___ 07:37PM BLOOD Lactate-1.8
___ 07:26AM BLOOD Lactate-2.4*
___ 02:29AM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 02:29AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 02:29AM URINE Color-Yellow Appear-Clear Sp ___
___ 1:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:45 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
NADIR:
=====
___ 12:00AM BLOOD Neuts-17* Bands-3 ___ Monos-0 Eos-1
Baso-0 ___ Myelos-0 Blasts-57* AbsNeut-1.92
AbsLymp-2.11 AbsMono-0.00* AbsEos-0.10 AbsBaso-0.00*
___ 12:04AM BLOOD WBC-0.3* RBC-3.12* Hgb-10.4* Hct-29.8*
MCV-96 MCH-33.3* MCHC-34.9 RDW-12.2 RDWSD-42.5 Plt Ct-9*
___ 12:00AM BLOOD WBC-0.4* RBC-3.09* Hgb-10.3* Hct-28.4*
MCV-92 MCH-33.3* MCHC-36.3 RDW-11.9 RDWSD-39.8 Plt Ct-9*
___ 12:00AM BLOOD WBC-0.4* RBC-2.69* Hgb-8.9* Hct-25.2*
MCV-94 MCH-33.1* MCHC-35.3 RDW-11.7 RDWSD-39.8 Plt Ct-33*
___ 12:00AM BLOOD Neuts-0 Bands-0 Lymphs-99* Monos-0 Eos-0
Baso-0 ___ Myelos-0 Blasts-1* AbsNeut-0.00*
AbsLymp-0.40* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD Neuts-1* Bands-0 Lymphs-98* Monos-1*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.00*
AbsLymp-0.29* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 12:01AM BLOOD WBC-0.4* RBC-2.31* Hgb-7.7* Hct-21.3*
MCV-92 MCH-33.3* MCHC-36.2 RDW-11.5 RDWSD-38.4 Plt Ct-15*
MICRO:
======
___ 2:29 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 1:30 pm Blood (LYME)
**FINAL REPORT ___
Lyme IgG (Final ___:
POSITIVE BY EIA.
(Reference Range-Negative).
EIA RESULT NOT CONFIRMED BY WESTERN BLOT.
NEGATIVE BY WESTERN BLOT.
Refer to outside lab system for complete Western Blot
results.
Lyme IgM (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
Negative results do not rule out B. burg___ infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody.
___ 9:34 pm STOOL CONSISTENCY: WATERY
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
IMAGING:
========
___ 8:13 ___
CT HEAD W/O CONTRAST
IMPRESSION:
No evidence of acute intracranial hemorrhage.
___ 10:___HEST W/CONTRAST
IMPRESSION:
1. New ground-glass opacities with septal thickening and
dependent small pleural effusions, most suggestive of
hydrostatic edema. Differential agnosis includes atypical
infection and less likely leukemic nfiltration.
2. Pre-existing lung nodules are difficult to compare to the
prior CT due to technical limitations of today's exam. Consider
a ___ month followup CT to allow more precise comparison of a
potentially growing left upper lobe nodule in order to exclude
the possibility of a slowly growing lesion within the lung
adenocarcinoma spectrum.
___ 10:___BD & PELVIS WITH CONTRAST
IMPRESSION:
1. No intra-abdominal infection or hemorrhage is identified.
2. Splenomegaly (similar to ___ CT)
PATHOLOGY:
==========
___ FLOW CYTOMETRY REPORT
Cell marker analysis demonstrates that a major subset of the
cells isolated from this peripheral blood are in the CD45
dim/low side scatter blast" region. They express CD38, immature
antigens CD34, ___, nTdT (dim subset ~39%), myeloid
associated antigens cytoplasmic MPO, CD117 and CD33. They
co-express CD56.
They lack B-cell associated antigens (CD19, cCD22, cCD79a), T
cells (cCD3) associated antigens and are negative for CD13,
CD14, CD64, CD11b.
Blast cells comprise 88% of total analyzed events.
INTERPRETATION
Immunophenotypic findings consistent with involvement by acute
myeloid leukemia.
Correlation with clinical, morphologic (see separate pathology
report ___ cytogenetic findings is recommended.
___ HEMATOPATHOLOGY REPORT - Final
DIAGNOSIS:
RELAPSED ACUTE MYELOID LEUKEMIA, SEE NOTE.
NOTE: By flow cytometry, blasts comprise >90% of total analyzed
events and have a myeloid immunophenotype expressing CD38, CD34,
HLADR, nTdT (subset), CD117, CD33, cyMPO, along with CD56.
Please correlate with cytogenetics (___-1550) findings.
Findings discussed at interdepartmental ___ conference on
___.
ASPIRATE SMEAR:
The aspirate material is adequate for evaluation and consists of
multiple cellular spicules. The cellularity is almost entirely
comprised of blasts with cytomorphologic features similar to
those described above. Residual hematopoiesis is extremely
scant.
DISCHARGE:
==========
___ 12:00AM BLOOD WBC-1.4* RBC-2.64* Hgb-8.2* Hct-24.3*
MCV-92 MCH-31.1 MCHC-33.7 RDW-12.9 RDWSD-39.9 Plt Ct-88*
___ 12:00AM BLOOD Neuts-20.1* ___ Monos-28.1*
Eos-0.0* Baso-0.0 NRBC-2.9* Im ___ AbsNeut-0.28*
AbsLymp-0.71* AbsMono-0.39 AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
___ 12:00AM BLOOD ___ PTT-27.1 ___
___ 12:00AM BLOOD Glucose-113* UreaN-18 Creat-1.0 Na-137
K-4.4 Cl-102 HCO3-27 AnGap-12
___ 12:00AM BLOOD ALT-18 AST-17 LD(LDH)-180 AlkPhos-106
TotBili-0.2
___ 12:00AM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.1 Mg-2.3
Brief Hospital Course:
Mr. ___ is a ___ y/o male with a history of stage IIA breast
cancer ___- s/p left mastectomy and currently on
tamoxifen, also with a history of intermediate risk AML s/p
reduced intensity allogeneic stem cell transplant ___, MRD
sister) currently in remission who presented with myalgias,
night sweats, fatigue and leukocytosis concerning for acute
leukemia.
ACTIVE ISSUES:
==============
# Relapsed acute leukemia: BM Bx ___ consistent with relapse.
Treated w/ MEC (D1 = ___, no blasts on D23 sustained.
Sluggish count recovery. Given low counts, repeat BM deferred to
outpatient setting (f/u apt scheduled ___.
# Abx: After completing tx for febrile neutropenia (cefepime,
doxy), maintained on PPX with ciprofloxacin, acyclovir,
voriconazole.
# Dizziness/ Orthostatic symptoms: Differential includes
autonomic neuropathy ___ chemo vs medication side effect
(reported on voriconazole PI but incidence not included).
Endocrine and cardiac sources less likely based on normal ___
stim (___), normal TSH (___), and normal LVEF (___). The
role of anemia has also been considered, however, the Hgb has
been stable for several days. Switched fludrocort -> midodrine
___. Midodrine titrated with good effect. Discharged on
midodrine 7.5mg QAM and at noon, and 10mg QPM given symtoms
occur o/n or in early AM
CHRONIC ISSUES:
===============
# Stage IIA breast cancer s/p mastectomy: Continued tamoxifen
daily
# Atypical chest pain: Had point tenderness above mastectomy
scar and in R axilla, at different points during
hospitalization. Most likely MSK or neuropathic and resolved
prior to discharge. However, given h/o breast CA, there was
concern for recurrent breast cancer. If symptoms worsen, would
obtain chest imaging (CT v. MRI) to evaluate for masses.
RESOLVED ISSUES:
================
# Pulmonary Edema/Borderline O2 sats: Acute pulmonary edema in
setting of fluids with medications and as treatment for acute
leukemia ___, improved O2 sats ___ and ___ after diuresis.
Repeat TTE showed normal EF. Responded to Lasix 20mg IV PRN
# Tick exposure: tick bite ___ wks prior to presentation.
Treated w/ doxycycline x2 weeks. Serologies returned negative.
# Pain: Severe multifocal pain on admission, worst site low back
spasms; significantly improved. Improvement coincident with
chemotherapy suggests cancer-related pain most likely;
differential includes infection and electrolyte shifts. Negative
lyme serologies argue against infection. Not requiring pain
management today.
# Loose stools: Loose stools for several days without abdominal
pain or tenderness. Differential is medication side effect,
infection or GVHD. Given benign abdomen and no history of
chronic GHVD, most likely medication effect. C diff negative
___ and ___. Resolved w/ discontinuation of cefepime___.
TRANSITIONAL:
=============
- ORTHOSTATIC HYPOTENSION: If persistent orthostatic sx, refer
to ___ clinic
- CHEST PAIN: Had intermittent chest pain near mastectomy site.
If progresses while patient immunosuppressed, please consider
the need for imaging/ recurrence
--------------
Discharge CBC: 1.4 > 8.2 / ___.3 < 88, ___ 280
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
2. Tamoxifen Citrate 20 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
Discharge Medications:
1. Acyclovir 400 mg PO TID
RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*60 Tablet Refills:*0
3. Midodrine 10 mg PO QPM
RX *midodrine 10 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
4. Midodrine 7.5 mg PO QAM
RX *midodrine 5 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. Midodrine 7.5 mg PO NOON
RX *midodrine 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. Voriconazole 200 mg PO Q12H
RX *voriconazole 200 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
7. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
8. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
9. Multivitamins 1 TAB PO DAILY
10. Tamoxifen Citrate 20 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
Acute myelogenous leukemia, relapsed
Orthostatic hypotension
SECONDARY DIAGNOSES:
====================
Lyme disease prophylaxis
Male breast cancer (ER+/PR+, HER2-)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to ___ because you had
fevers, chills and pain. You were admitted because your blood
counts were concerning for infection or leukemia.
What was done while you were in the hospital?
- You were diagnosed with relapsed leukemia
- You were treated with medications for acute leukemia
- You were received medications for pain and infections
- You had lightheadedness, possibly as a side effect of these
treatments. We treated this with a new medication called
midodrine.
- We monitored your blood counts daily
What should you do now that you are leaving the hospital?
- Attend your doctor appointments as scheduled
- Take your medications as prescribed
- If you develop fever, severe pain, or other concerning
symptoms, go to an emergency room right away
It was a pleasure participating in your care. Wishing you all
the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10035631-DS-7 | 10,035,631 | 29,462,354 | DS | 7 | 2112-10-17 00:00:00 | 2112-10-17 14:14:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea on exertion, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male without significant past medical
history who presented to his PCP with dyspnea on exertion. In
___ he had an episode of diarrhea as well as fatigue which
was self limiting and resolved. Over the past few days he
presented with new dyspnea on exertion and fatigue. At his PCP's
office, a CBC with diff, TSH, and chem 10 were checked. His
hematocrit was 25 and his platelets were 11.
He has also noted a breast mass over the past week which is new.
Vitals in the ED: 97.8 59 145/69 16 100% ra
He was sent directly to ___ per the instructions of the heme/onc
team for full evaluation.
Past Medical History:
Prostatitis in ___
Seizure vs. Syncope - ___, holter, MRI/MRA, EEG all negative
Lyme Disease in ___
Social History:
___
Family History:
Brother Alive ___
Father ___ at ___ Cancer; Diabetes - Unknown Type
Mother ___ at ___
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS - T 97.8, HR 64, BP 158/80, RR 20, sat 100%
General: NAD, NC/AT, healthy appearing middle aged male
HEENT: MMM, OP clear, EOMI, anicteric sclera
LYMPH: No LAD
CHEST: 2cm ___ mass, NT to palpation on the left chest
CV: Normal rate, reg rhythm
RESP: CTAB, no wheezes, rales, rhonchi
GI: Soft, NT, ND, NABS
GU: No foley
Ext: Warm, well profused, no edema
Neuro: Oriented, appropriate, linear thought, no gross deficits
DERM: No active rash
DISCHARGE PHYSICAL EXAM
VITALS - Tmax 98.9, Tcurr 98.3, BP 114/64, HR 73, RR 18, Sat
100% on RA
General: NAD, healthy appearing middle aged male
HEENT: NCAT, MMM, OP clear, no oral lesions or ulcers
LYMPH: No LAD
CV: RRR, S1/S2, no murmurs, rubs, gallops, or clicks
RESP: CTAB, no wheezes, rales, rhonchi
GI: Soft, NT, ND, NABS
GU: No foley
Ext: Warm, well profused, no edema
Neuro: Oriented, appropriate, linear thought, no gross deficits
DERM: No rash, petechiae, or ecchymosis
Pertinent Results:
ADMISSION LABS
___ 08:30PM BLOOD WBC-5.0 RBC-2.82* Hgb-9.7* Hct-27.7*
MCV-98 MCH-34.4* MCHC-35.0 RDW-18.9* Plt Ct-12*
___ 08:30PM BLOOD Neuts-30* Bands-0 Lymphs-47* Monos-4
Eos-5* Baso-0 ___ Metas-1* Myelos-1* Promyel-7* Blasts-5*
NRBC-13* Other-0
___ 08:30PM BLOOD ___ PTT-28.2 ___
___ 08:30PM BLOOD ___ 03:15AM BLOOD QG6PD-9.9
___ 08:30PM BLOOD Ret Aut-3.8*
___ 08:30PM BLOOD Glucose-124* UreaN-18 Creat-1.1 Na-139
K-4.2 Cl-102 HCO3-26 AnGap-15
___ 08:30PM BLOOD ALT-41* AST-48* LD(___)-558* AlkPhos-63
TotBili-1.3
___ 08:30PM BLOOD Calcium-9.7 Phos-3.2 Mg-2.1 UricAcd-6.0
___ 08:30PM BLOOD D-Dimer-535*
___ 08:30PM BLOOD Hapto-<5*
___ 08:30PM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE
___ 08:30PM BLOOD HIV Ab-NEGATIVE
___ 08:30PM BLOOD ___
HOSPITAL COURSE
___ 03:15AM BLOOD WBC-4.7 RBC-2.79* Hgb-9.5* Hct-26.9*
MCV-96 MCH-33.9* MCHC-35.2* RDW-18.9* Plt Ct-11*
___ 06:15AM BLOOD WBC-3.3* RBC-2.57* Hgb-8.7* Hct-24.8*
MCV-97 MCH-33.8* MCHC-34.9 RDW-18.8* Plt Ct-8*
___ 07:30PM BLOOD WBC-2.9* RBC-2.09* Hgb-7.2* Hct-20.3*
MCV-97 MCH-34.3* MCHC-35.3* RDW-19.0* Plt Ct-44*#
___ 04:23AM BLOOD WBC-3.0* RBC-2.55* Hgb-8.4* Hct-23.6*
MCV-93 MCH-32.8* MCHC-35.4* RDW-18.8* Plt Ct-43*
___ 12:00AM BLOOD WBC-3.5* RBC-2.71* Hgb-8.8* Hct-26.0*
MCV-96 MCH-32.4* MCHC-33.9 RDW-18.8* Plt Ct-42*
___ 10:59PM BLOOD WBC-1.7*# RBC-2.42* Hgb-8.4* Hct-22.9*
MCV-95 MCH-34.7* MCHC-36.7* RDW-18.2* Plt Ct-28*
___ 12:31AM BLOOD WBC-0.6*# RBC-2.21* Hgb-7.2* Hct-20.7*
MCV-94 MCH-32.4* MCHC-34.6 RDW-17.8* Plt Ct-17*
___ 12:00AM BLOOD WBC-0.4* RBC-2.36* Hgb-7.6* Hct-21.8*
MCV-93 MCH-32.4* MCHC-35.0 RDW-17.6* Plt Ct-10*
___ 12:34AM BLOOD WBC-0.6* RBC-2.33* Hgb-7.4* Hct-21.6*
MCV-93 MCH-31.7 MCHC-34.3 RDW-17.1* Plt Ct-31*
___ 12:00AM BLOOD WBC-0.6* RBC-2.07* Hgb-6.6* Hct-19.2*
MCV-93 MCH-31.9 MCHC-34.4 RDW-16.7* Plt Ct-22*
___ 12:00AM BLOOD WBC-0.8* RBC-2.44* Hgb-7.7* Hct-22.3*
MCV-92 MCH-31.5 MCHC-34.4 RDW-16.1* Plt Ct-21*
___ 12:00AM BLOOD WBC-0.9* RBC-2.34* Hgb-7.7* Hct-20.9*
MCV-89 MCH-33.0* MCHC-37.0* RDW-15.4 Plt Ct-10*#
___ 12:16AM BLOOD WBC-0.5* RBC-2.43* Hgb-7.9* Hct-21.6*
MCV-89 MCH-32.3* MCHC-36.4* RDW-14.7 Plt Ct-25*
___ 11:02PM BLOOD WBC-0.4* RBC-2.40* Hgb-7.9* Hct-21.4*
MCV-89 MCH-32.9* MCHC-37.0* RDW-14.6 Plt Ct-17*
___ 11:30PM BLOOD WBC-0.5* RBC-2.50* Hgb-7.9* Hct-22.1*
MCV-88 MCH-31.8 MCHC-35.9* RDW-14.4 Plt Ct-13*
___ 12:00AM BLOOD WBC-0.4* RBC-2.67* Hgb-8.6* Hct-23.4*
MCV-88 MCH-32.3* MCHC-36.9* RDW-14.0 Plt Ct-8*
___ 12:00AM BLOOD WBC-0.4* RBC-2.55* Hgb-8.3* Hct-22.1*
MCV-87 MCH-32.6* MCHC-37.6* RDW-13.9 Plt Ct-19*
___ 12:01AM BLOOD WBC-0.4* RBC-2.48* Hgb-7.8* Hct-21.7*
MCV-87 MCH-31.3 MCHC-35.8* RDW-14.0 Plt Ct-12*
___ 12:00AM BLOOD WBC-0.4* RBC-2.53* Hgb-7.9* Hct-22.8*
MCV-90 MCH-31.3 MCHC-34.7 RDW-13.7 Plt Ct-10*
___ 12:00AM BLOOD WBC-0.1*# RBC-2.03* Hgb-6.3* Hct-17.7*
MCV-87 MCH-31.0 MCHC-35.5* RDW-13.3 Plt Ct-25*
___ 12:58PM BLOOD Hct-23.8*#
___ 06:10AM BLOOD WBC-.1* RBC-2.76*# Hgb-8.2*# Hct-23.2*
MCV-84 MCH-29.8 MCHC-35.4* RDW-15.7* Plt Ct-16*
___ 06:35AM BLOOD WBC-0.1* RBC-2.56* Hgb-7.7* Hct-21.9*
MCV-85 MCH-30.2 MCHC-35.4* RDW-15.1 Plt Ct-16*
___ 08:00AM BLOOD WBC-0.2*# RBC-2.68* Hgb-8.0* Hct-22.6*
MCV-85 MCH-29.9 MCHC-35.4* RDW-14.6 Plt Ct-30*#
___ 06:25AM BLOOD WBC-0.5*# RBC-2.97* Hgb-9.0* Hct-25.4*
MCV-86 MCH-30.2 MCHC-35.3* RDW-14.6 Plt Ct-50*#
___ 06:55AM BLOOD WBC-1.3*# RBC-3.24* Hgb-9.8* Hct-28.1*
MCV-87 MCH-30.2 MCHC-34.8 RDW-14.6 Plt ___
___ 06:15AM BLOOD WBC-4.1# RBC-3.16* Hgb-9.5* Hct-27.6*
MCV-87 MCH-30.2 MCHC-34.5 RDW-14.5 Plt ___
___ 09:10AM BLOOD WBC-5.1 RBC-3.63* Hgb-10.7* Hct-31.8*
MCV-88 MCH-29.6 MCHC-33.7 RDW-14.8 Plt ___
___ 06:45AM BLOOD WBC-3.4* RBC-3.21* Hgb-9.7* Hct-28.5*
MCV-89 MCH-30.2 MCHC-34.0 RDW-14.8 Plt ___
___ 07:10AM BLOOD WBC-4.9 RBC-3.49* Hgb-10.3* Hct-29.9*
MCV-86 MCH-29.5 MCHC-34.4 RDW-15.1 Plt ___
___ 06:25AM BLOOD WBC-5.0 RBC-3.48* Hgb-10.2* Hct-30.4*
MCV-87 MCH-29.3 MCHC-33.7 RDW-15.6* Plt ___
___ 06:15AM BLOOD ___ PTT-27.4 ___
___ 04:23AM BLOOD ___ PTT-29.2 ___
___ 12:34AM BLOOD ___ PTT-24.9* ___
___ 12:16AM BLOOD ___ PTT-25.3 ___
___ 12:00AM BLOOD ___ PTT-30.2 ___
___ 06:10AM BLOOD ___ PTT-31.0 ___
___ 02:45PM BLOOD ___
___ 06:35AM BLOOD ___ PTT-27.3 ___
___ 08:00AM BLOOD ___ PTT-27.1 ___
___ 06:25AM BLOOD ___ PTT-30.9 ___
___ 06:15AM BLOOD Glucose-113* UreaN-12 Creat-0.9 Na-144
K-4.6 Cl-110* HCO3-28 AnGap-11
___ 10:59PM BLOOD Glucose-158* UreaN-20 Creat-0.9 Na-138
K-3.8 Cl-108 HCO3-25 AnGap-9
___ 12:00AM BLOOD Glucose-168* UreaN-22* Creat-0.8 Na-137
K-4.2 Cl-106 HCO3-25 AnGap-10
___ 12:00AM BLOOD Glucose-137* UreaN-24* Creat-0.9 Na-136
K-3.6 Cl-105 HCO3-24 AnGap-11
___ 12:00AM BLOOD Glucose-120* UreaN-19 Creat-0.9 Na-136
K-4.1 Cl-102 HCO3-26 AnGap-12
___ 06:10AM BLOOD Glucose-155* UreaN-14 Creat-0.9 Na-135
K-3.7 Cl-102 HCO3-22 AnGap-15
___ 08:00AM BLOOD Glucose-125* UreaN-13 Creat-0.8 Na-134
K-3.5 Cl-101 HCO3-24 AnGap-13
___ 06:55AM BLOOD Glucose-116* UreaN-8 Creat-0.7 Na-137
K-3.2* Cl-101 HCO3-26 AnGap-13
___ 09:10AM BLOOD Glucose-171* UreaN-9 Creat-0.8 Na-135
K-4.0 Cl-99 HCO3-26 AnGap-14
___ 07:10AM BLOOD Glucose-107* UreaN-12 Creat-0.8 Na-137
K-4.3 Cl-102 HCO3-30 AnGap-9
___ 06:25AM BLOOD Glucose-107* UreaN-13 Creat-0.8 Na-136
K-4.7 Cl-100 HCO3-29 AnGap-12
___ 06:15AM BLOOD ALT-28 AST-32 LD(LDH)-403* AlkPhos-48
TotBili-0.9
___ 12:00AM BLOOD ALT-31 AST-34 LD(LDH)-453* AlkPhos-51
TotBili-1.1
___ 12:31AM BLOOD ALT-43* AST-38 LD(___)-383* AlkPhos-48
TotBili-0.8
___ 12:00AM BLOOD ALT-50* AST-31 LD(___)-290* AlkPhos-46
TotBili-0.8
___ 12:00AM BLOOD ALT-46* AST-23 LD(___)-250 AlkPhos-43
TotBili-0.7
___ 12:16AM BLOOD ALT-39 AST-20 LD(___)-224 AlkPhos-38*
TotBili-0.8
___ 11:02PM BLOOD ALT-38 AST-19 LD(___)-226 AlkPhos-46
TotBili-0.6
___ 11:30PM BLOOD ALT-36 AST-17 LD(___)-218 AlkPhos-48
TotBili-0.6
___ 12:00AM BLOOD ALT-38 AST-24 LD(LDH)-214 AlkPhos-63
TotBili-0.8
___ 12:01AM BLOOD ALT-42* AST-23 LD(LDH)-203 AlkPhos-70
TotBili-0.7
___ 12:00AM BLOOD ALT-44* AST-23 LD(___)-200 AlkPhos-86
TotBili-0.6
___ 12:00AM BLOOD ALT-52* AST-30 LD(___)-191 AlkPhos-98
TotBili-0.9
___ 06:10AM BLOOD ALT-51* AST-21 LD(___)-196 AlkPhos-109
TotBili-1.9* DirBili-0.9* IndBili-1.0
___ 02:45PM BLOOD ALT-43* AST-13 AlkPhos-93 TotBili-1.4
DirBili-0.7* IndBili-0.7
___ 08:00AM BLOOD ALT-28 AST-12 LD(___)-181 AlkPhos-101
TotBili-1.4
___ 06:25AM BLOOD ALT-48* AST-34 LD(___)-206 AlkPhos-134*
TotBili-1.1
___ 06:55AM BLOOD ALT-67* AST-39 AlkPhos-163* TotBili-0.7
___ 06:15AM BLOOD ALT-76* AST-39 LD(___)-280* AlkPhos-160*
TotBili-0.6
___ 09:10AM BLOOD ALT-101* AST-51* LD(___)-289*
AlkPhos-174* TotBili-0.5
___ 06:45AM BLOOD ALT-100* AST-50* LD(___)-239 AlkPhos-154*
TotBili-0.4
___ 07:10AM BLOOD ALT-114* AST-57* LD(___)-226 AlkPhos-145*
TotBili-0.4
___ 06:25AM BLOOD ALT-110* AST-49* LD(LDH)-216 AlkPhos-142*
TotBili-0.4
___ 06:15AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.3
___ 04:26PM BLOOD Calcium-8.7 Phos-2.8 Mg-2.0 UricAcd-3.4
___ 12:31AM BLOOD Calcium-8.0* Phos-3.3 Mg-2.1 UricAcd-3.5
___ 12:00AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.3 UricAcd-3.2*
___ 12:34AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.2 UricAcd-2.8*
___ 12:00AM BLOOD Calcium-9.2 Phos-2.7 Mg-2.2 UricAcd-2.6*
___:00AM BLOOD Calcium-8.2* Phos-2.2* Mg-2.3
UricAcd-2.6*
___ 11:30PM BLOOD Calcium-8.8 Phos-3.6 Mg-2.1
___ 12:01AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.1
___ 12:00AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.0
___ 08:00AM BLOOD Calcium-8.2* Phos-1.2* Mg-2.1
___ 06:15AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.0
___ 06:45AM BLOOD Albumin-3.4* Calcium-8.5 Phos-3.2 Mg-2.3
___ 07:10AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.4
___ 06:25AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.4
___ 06:10AM BLOOD Vanco-6.2*
___ 08:00AM BLOOD Vanco-10.4
___ 06:55AM BLOOD Vanco-17.1
___ 09:10AM BLOOD Vanco-18.1
___ 06:25AM BLOOD Vanco-28.3*
___ 08:30PM BLOOD HIV Ab-NEGATIVE
___ 08:30PM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE
___ 08:30PM BLOOD Hapto-<5*
___ 11:08AM BLOOD Hapto-<5*
___ 08:30PM BLOOD D-Dimer-535*
DISCHARGE LABS
___ 06:35AM BLOOD WBC-4.5 RBC-3.51* Hgb-11.2* Hct-31.8*
MCV-91 MCH-32.0 MCHC-35.4* RDW-16.1* Plt ___
___ 06:35AM BLOOD Neuts-77* Bands-3 Lymphs-8* Monos-4 Eos-2
Baso-2 ___ Metas-1* Myelos-3*
___ 06:35AM BLOOD Glucose-109* UreaN-17 Creat-0.8 Na-137
K-4.8 Cl-100 HCO3-30 AnGap-12
___ 06:35AM BLOOD ALT-112* AST-51* LD(LDH)-211 AlkPhos-135*
TotBili-0.4
___ 06:35AM BLOOD Albumin-3.5 Calcium-9.3 Phos-3.4 Mg-2.4
MICRO
___ 3:30 pm BLOOD CULTURE Source: Line-TLCL.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
VIRIDANS STREPTOCOCCI.
Isolated from only one set in the previous five days.
SENSITIVITY REQUESTED BY ___. ___ ___.
Sensitivity testing performed by Sensititre.
CLINDAMYCIN <= 0.12 MCG/ML. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
VIRIDANS STREPTOCOCCI
|
CLINDAMYCIN----------- S
ERYTHROMYCIN---------- =>8 R
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
Chest CT without contrast ___:
IMPRESSION:
1. Numerous small ground glass and semi-solid pulmonary nodules
are randomly distributed throughout all lobes of both lungs and
are new since the prior study. Although this finding is not
concerning for malignant disease, their presence in a
neutropenic patient could represent an inflammatory or
infectious process such as viral pneumonia. No evidence of
bacterial or fungal pneumonia.
2. Interval decrease in size of left breast nodule, in keeping
with a
hematoma as described on recent diagnostic mammogram from
___.
3. Numerous bilateral axillary and mediastinal lymph nodes are
not
pathologically enlarged.
4. Trace left pleural effusion (5:206).
TTE ___
IMPRESSION: Preserved regional and global biventricular systolic
function. Trace aortic regurgitation.
CT chest/abdomen/pelvis ___. Left breast nodule as described that should be further
correlated with tissue biopsy.
2. Right axillary lymph nodes, not pathologically enlarged but
multiple.
3. Several pulmonary nodules that should be reassessed in three
months for assessment of stability.
4. Mild splenomegaly.
5. Sigmoid diverticulosis but no diverticulitis.
Bilateral Diagnostic Mammography ___
1. There are two echogenic/hypoechoic masses lateral to the left
nipple having the appearance of hematomas.
2. Bilateral moderate gynecomastia.
BI-RADS 3 -- probably benign.
Brief Hospital Course:
BRIEF SUMMARY: Mr. ___ is a ___ year old male without
significant past medical history originally presenting w/ DOE,
fatigue, and diarrhea found to have anemia and thrombocytopenia.
Bone marrow biopsy consistent with AML on ECOG 2906 and
randomized to 7+3 (day ___ now C1D28 with course complicated
by neutropenic fever likely secondary to strep viridans
bacteremia.
ACTIVE ISSUES:
# AML: Patient presented with fatigue, diarrhea, and DOE, found
to have anemia and thrombocytopenia. Prelim reading on smear
shows multiple blasts concerning for AML. Bone marrow biopsy
was performed and confirmed AML. The patient was started on a
clinical trial and randomized to the 7+3 arm (Day ___. FISH
negative. Karyotype normal. NPM negative, FLT3 negative
consistent with intermediate Risk genotype. Hemoglobin
electrophoresis with 100% Hgb A. Day 14 bone marrow is ablated,
no blasts. A bone marrow donor screen was begun and the
patient's sister is a confirmed donor match. The patient had a
repeat bone marrow on Day ___, the day of discharge.
# Neutropenic Fever: Patient spiked fever to 102.5 on ___
w/ exam significant for erythema around line site. CXR/UA were
both negative. Pt. c/o headache and sinus pressure. Underwent
Head-CT without any acute infectious process noted. Blood
cultures positive for strep viridans 2 out of 4 bottles.
Central line (originally placed ___ pulled for concern of
line infection. Pt. was started on vancomycin and cefepime but
continued to spike fevers for several days. Pt.'s ongoing
fevers were thought to be related to subtherapeutic vanc level
vs. fungal infection vs. endocarditis without source control vs.
G-CSF as pt. was started on neupogen around time of first fever.
TTE returned without evidence of endocarditis. Given continued
fevers, pt. was started on empiric micafungin and a chest CT was
done which showed possible early viral vs. fungal pneumonia.
Pulm was consulted who indicated that this could be early fungal
pneumonia but that BAL at this point would not be useful. Pt's
neutropenia resolved. He had a B glucan, galactomannan, and DFA
viral swab which all returned negative. ID recommended treating
Strep bacteremia for 10 day course with nafcillin. Pt. without
central line, therefore continued vanc for ___ompleted on day of discharge.
# Headache: The patient experienced significant frontal
headaches during his admission. He had a Head CT which was
normal. At first, his headaches were thought to be due to
anemia as they improved slightly with pRBC transfusions. His
anemia resolved and his headaches continues. The patient
underwent a Head MRI given the acute onset of a sharp headache
that woke pt. from sleep in the early morning of ___. MRI
revealed no evidence of acute intra-cranial process. The
headaches improved dramatically when the patient was taken off
of his neupogen. This was thought to be the cause.
# Mild Transaminitis: Both hepatocellular and cholestatic
hepatitis new as of ___. Mostly likely ___ to
fluconazole. As such, fluconazole was discontinued. At time of
discharge, pt.'s LFTs have plateaued and seem to be somewhat
downtrending.
# Diarrhea: The patient had several days of ongoing diarrhea
during his hospitalization. C. diff PCR was negative. Diarrhea
resolved.
Transitional Issues:
1. CT Scan: Pt. had a CT scan which showed semi-solid nodules
randomly distributed in lung fields possibly consistent with
early viral pneumonia. A repeat chest CT without contrast was
recommended. You have a CT scheduled on ___.
2. Infectious Disease Consult: Pt. requires outpatient
infectious disease consult prior to transplant
3. Dental Clearance: Pt. has a dental appointment on ___.
He will bring with him the transplant paperwork to be completed
at his appointment.
4. Flu Shot: The decision was made not to give the flu vaccine
given the pt's future chemotherapy and likely immunosuppressed
state.
5. Transaminitis: Pt. had elevated LFTs likely ___ to
fluconazole on ___ The fluconazole was d/c'ed at this time
and his LFTs plateaued in the several days leading up to
discharge. Please assess for resolution with repeat LFTs. If
does not resolve, consider imaging for infectious source.
Medications on Admission:
None
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Capsule Refills:*0
2. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth Daily Disp #*30 Capsule Refills:*0
3. Lorazepam 0.5 mg PO HS:PRN insomnia
RX *lorazepam [Ativan] 0.5 mg 1 tab by mouth at bedtime Disp
#*30 Tablet Refills:*0
(Per pt., he had been on ativan at home prior to admission).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
1. Acute Myelogenous Leukemia
2. Neutropenic fever secondary to strep viridans bacteremia
3. Anemia
4. Transaminitis secondary to fluconazole
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 presented with shortness of
breath and fatigue and were found to have very low blood counts.
A bone marrow biopsy was done that confirmed acute myelogenous
leukemia (AML). You enrolled in a clinical trial and received
7+3 (cytarabine and danorubicin). You tolerated the
chemotherapy very well. Your repeat day 14 bone marrow biopsy
showed an ablated marrow without blasts (diseased cells). You
spiked a fever and were started on broad spectrum antibiotics
and your central line was removed. Urine culture and chest xray
were clear but your blood cultures were positive for a bacteria
known as strep viridans. Your antibiotics were narrowed to
treat the bacteria and you no longer had any fevers. You also
had significant headaches during your hospitalization. You had
both a CT scan and MRI which showed no concerning process. Your
headache was thought to be due to the neupogen (filgrastim) that
you were receiving. We stopped the medication and your
headaches resolved. You had a bone marrow biopsy on your day of
discharge that you tolerated very well.
All the best,
Your ___ Team
Followup Instructions:
___
|
10035780-DS-12 | 10,035,780 | 22,919,435 | DS | 12 | 2131-08-10 00:00:00 | 2131-08-12 15:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / lisinopril / metformin / amlodipine
Attending: ___.
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Interview conducted with assistance of telephone interpreter
with patient's daughter.
Mrs. ___ is a ___ y/o woman with a PMH of CKD V (recently started
on ___ HD ___, T2DM, HTN, CAD, HBV/HCV, GERD, gout, and
osteoporosis, recently discharged from ___, who was found to
have C. difficile during the course of her admission and was
discharged on a 10 day course of PO Flagyl (to be completed
___, who presented from rehab with persistent diarrhea. Per
the patient's daughter, the diarrhea improved ___ days after
discharge, but it has been worsening over the last two to three
days. She had mixed watery and formed stools, with 3 this
morning; she was unable to complete HD and was sent to the ED.
In the ED, initial vitals were:T 98.5F P92 BP 149/63 RR 22 O2
99% RA
Labs were notable for: Na 134, K 3.5, Cl 96, HCO3 27, BUN 21, Cr
2.2, Gluc 121. WBC of 11.0 (Neut of 59.7%, Lymph 22.9%), H/H of
9.4/28.8, Plts of 174.
Patient was given:
___ 18:32 PO/NG Vancomycin Oral Liquid ___ mg
Consults: nephrology, transplant surgery
On the floor, the patient reported that the diarrhea was
non-bloody, yellow in color, and originally started two weeks
ago. Her daughter is uncertain if she has been taking the Flagyl
upon discharge (reportedly, her younger sister ___ is in
charge of her medications). Called younger sister, however the
conversation was inhibited by limited ___ proficiency. She
says that she will be in the hospital tomorrow to discuss with
the assistance of an interpreter. The patient's primary
complaint was that she was hungry.
Denies fevers, chills, nausea, vomiting, constipation,
hematochezia, dysuria, hematuria, headache, dizziness. She has
also had a cough and runny nose for the past two weeks, but this
does not appear to be bothering her; she denies any sputum
production.
Past Medical History:
Her past medical history is also significant for Type II
diabetes, hypertension, osteoarthritis(pain in both knees),
osteoporosis, hyperlipidemia, asthma, anemia, Hepatitis B
and hepatitis C, gout, GERD, s/p laparoscopic cholecystectomy in
___.
1) Hypertension.
2) Asthma.
3) Renal insufficiency.
4) Hepatitis B and hepatitis C
5) knee pain
LUE AVG ___
Social History:
___
Family History:
She is widowed and she has 7 children, and in apparently good
health.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 98.2F BP 149/68 mmHg P 96 RR 18 O2 100% RA
General: Alert, elderly woman, comfortable, NAD.
HEENT: Sclera anicteric, MMM, OP clear, EOMs intact, PERRL.
Neck: IJ tunnelled line with dressing c/d/i. Supple; no LAD.
CV: RRR, no MRGs; normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, mildly and diffusely tender to palpation. No
organomegaly NABS.
GU: No foley
Ext: Warm and well-perfused. 2+ pulses; 2+ pitting edema.
Neuro: A&Ox3; CNs II-XII grossly intact. Gait deferred.
DISCHARGE PHYSICAL EXAM:
VS - 97.7 85 18 132/57 100% sat on RA
General: Alert, elderly woman, comfortable, NAD.
HEENT: Sclera anicteric, MMM, OP clear, EOMs intact, PERRL.
Neck: R IJ tunnelled line with dressing c/d/i. Supple, mild
tenderness to palation; no LAD.
CV: RRR, no MRGs; normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, mildly/diffusely tender to palpation. No organomegaly
NABS.
GU: No foley
Ext: Warm and well-perfused. 2+ pulses; 2+ pitting edema.
Neuro: A&Ox3; CNs II-XII grossly intact. able to walk with cane
AV Graft: Left arm, mild redness, indurated, areas of hardness
distal to graft; graft is palpable thrill, bruit audible.
Pertinent Results:
ADMISSION LABS
===============
___ 05:20PM BLOOD WBC-11.0* RBC-2.98* Hgb-9.4* Hct-28.8*
MCV-97 MCH-31.5 MCHC-32.6 RDW-15.7* RDWSD-54.8* Plt ___
___ 05:20PM BLOOD Neuts-59.7 ___ Monos-12.0 Eos-3.1
Baso-1.1* Im ___ AbsNeut-6.54* AbsLymp-2.51 AbsMono-1.32*
AbsEos-0.34 AbsBaso-0.12*
___ 05:20PM BLOOD Glucose-121* UreaN-21* Creat-2.2* Na-134
K-3.6 Cl-96 HCO3-27 AnGap-15
PERTINENT FINDINGS
===================
CXR ___:
There is a dialysis catheter overlying the right chest with the
tip in the cavoatrial junction. Heart size is stable. The
mediastinal and hilar
contours are stable. The pulmonary vasculature is normal. Lungs
are clear. No pleural effusion or pneumothorax is seen. There
are no acute osseous abnormalities.
C. Diff ___
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
C. Diff ___:
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.
___ 1:12 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
___ 03:10PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 03:10PM URINE Blood-MOD Nitrite-NEG Protein-600
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG
___ 03:10PM URINE RBC-15* WBC->182* Bacteri-MOD Yeast-NONE
Epi-0
___ 03:10PM URINE WBC Clm-MANY
DISCHARGE LABS
===============
___ 06:46AM BLOOD WBC-8.3 RBC-2.74* Hgb-8.6* Hct-26.3*
MCV-96 MCH-31.4 MCHC-32.7 RDW-15.2 RDWSD-53.2* Plt ___
___ 06:46AM BLOOD Glucose-114* UreaN-36* Creat-2.5* Na-132*
K-3.4 Cl-92* HCO3-28 AnGap-15
___ 06:46AM BLOOD Calcium-9.2 Phos-4.5 Mg-1.6
Brief Hospital Course:
This is a ___ year old female with past medical history of ESRD
on HD (recently initiated ___, type 2 diabetes with
complications, CAD, recent admission at ___ (___) for
initiation of dialysis course complicated by poorly functioning
AV graft requiring tunneled line placement and diarrhea
attributed to cdiff colitis, discharged to rehab on flagyl,
subsequently readmitted ___ w several days of worsening
diarrhea, found to be cdiff negative x 2, but also
reporting new dysuria, found to have a UTI, with urinary
symptoms improving on empiric antibiotics, diarrhea resolving
without additional intervention, discharged back to rehab.
ACUTE
-------
# Diarrhea: At her previous hospitalication, Ms. ___ was
discharged with diagnosis of Clostridium Difficile Colitis, and
started on a course of Flagyl 500mg PO TID for 10 days total
(___). In rehab her diarrhea improved, but shortly
returned. On ___ patient began to have worsening diarrhea
forcing her to miss HD. She was brought to ___ for evaluation
and concern for failure to treat. ___ found to be 12.8. She was
started on PO Vancomycin 125mg Q6hr. Stool cultures and found
to be negative. C. Diff toxin were sent off twice and found to
be negative twice. While C. diff toxin PCR assays may often
linger longer even if infection is cleared, the PCR assay is
highly sensitive, and 2 negatives results is strongly suggestive
that there is no C. Diff infection. It was determined that it
was likely viral enteritis. Patient had no abdominal pain, 2
well formed but soft stools in 24 hrs with downtrending
leukocytosis (8.7 by day of discharge). Patient was discharged
with plan for no further antibiotics. If patient reports
significantly worsening or persistent symptoms, she should
represent for further evaluation.
# UTI: Patient presented with history of blood in Urine. Urine
cultures grew skin and fecal contimaint. Patient was not
complaining of dysuria, but began to develop urinary frequency.
A UA was ordered, found to be positive for infection and patient
was started on Ciprofloxacin 250mg PO Qdaily for 3 day course
(___).
CHRONIC
--------
#CKD V: Thought to be from diabetic nephropathy, the patient
recieves dialysis ___. She missed dialysis ___ in the
setting of diarrhea. She recieved one session of HD on ___ and
___. Her home regimen of neprhocaps was also maintained.
#AV GRaft: Previous admission deemed immature and not ready for
cannulation. Currently has tunneled right IJ in place. Graft
was evaluated and deemed improved by transplant surgery. Graft
was not used for HD, but will be evaluated further in AV care
clinic in the future.
#T2DM. Patient's oral hypoglycemics were discontinued on
previous admission. She was maintained on humolog insulin
sliding scale.
#GERD: Asymptomatic. Continued home omeprazole 20 mg PO bid.
#Asthma: Stable throughout hosital stay. Continue home albuterol
q6h PRN, home fluticasone-salmeterol BID, home montelukast 10 mg
daily.
#Osteoporosis: Stable, continued alendronate 35 mg QWED and home
calcium carbonate + vitamin D
#Gout: Continue home allopurinol ___ mg every other day without
symptoms.
#CAD. No chest pain. Continued home aspirin 325 daily
#HTN: Continue home metoprolol succinate 200 mg and nifedipine
90 mg PO daily.
TRANSITIONAL ISSUES
====================
- On Ciprofloxacin 250mg PO Q24 3 day ___
- Will need AV graft care follow up to assess for maturation and
readiness for use, and patient will receive HD through the IJ
line in the interim. IJ will need to be removed when forearm
graft able to be used
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
2. Aspirin EC 325 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares
5. Furosemide 80 mg PO BID
6. Losartan Potassium 100 mg PO 4X/WEEK (___)
7. NIFEdipine CR 90 mg PO DAILY
8. Omeprazole 20 mg PO BID
9. TraMADOL (Ultram) 50 mg PO BID:PRN pain
10. Vitamin D 1000 UNIT PO DAILY
11. Metoprolol Succinate XL 200 mg PO DAILY
12. Montelukast 10 mg PO DAILY
13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
14. Allopurinol ___ mg PO EVERY OTHER DAY
15. Nephrocaps 1 CAP PO DAILY
16. Alendronate Sodium 35 mg PO QWED
17. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
19. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
2. Allopurinol ___ mg PO EVERY OTHER DAY
3. Aspirin EC 325 mg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Furosemide 80 mg PO BID
7. Losartan Potassium 100 mg PO 4X/WEEK (___)
8. Metoprolol Succinate XL 200 mg PO DAILY
9. Montelukast 10 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. NIFEdipine CR 90 mg PO DAILY
12. Omeprazole 20 mg PO BID
13. TraMADOL (Ultram) 50 mg PO BID:PRN pain
14. Vitamin D 1000 UNIT PO DAILY
15. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
16. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares
17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
18. Alendronate Sodium 35 mg PO QWED
19. Ciprofloxacin HCl 250 mg PO Q24H Duration: 2 Days
Please give first dose ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
- UTI
- Diarrhea, unclear etiology, likely Acute viral enteritis
- CKD
Secondary
- T2DM
- HISS
- GERD.
- Asthma.
- Osteoporosis.
- Gout
- CAD
- HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for
acute episodes of diarrhea, concerning for C. diff colitis
recurrence. While in the hospital you underwent hemodialysis.
The stool was evaluated and not found to have any sign of
infection. It may have been caused by a virus. You were found
to have a urinary tract infection and were given antibiotics.
You were discharged back to your rehabilitation center with
antibiotics for the UTI.
It was a pleasure to take care of you at ___ and we wish you
the best in the future. If you have any questions about the care
you received, please do not hesitate to ask.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10035780-DS-13 | 10,035,780 | 25,186,901 | DS | 13 | 2131-11-17 00:00:00 | 2131-11-17 17:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / lisinopril / metformin / amlodipine
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ y/o female with a past medical history of ESRD on
HD (MWF), DMII, HTN, CAD, HBV/HCV, GERD, Gout and osteoporosis
who present with fever, cough and general malaise. History was
obtained via review of records and via phone interpreter.
Majority of history was obtained from daughter. Patient was
recently treated for a UTI with PO antibiotics and she has been
doing well until yesterday when she developed general malaise,
fever, nausea and lightheadedness. Also has been complaining of
shortness of breath which has improved with albuterol inhalers.
This morning the patient had 2 episodes of emesis as well as a
productive cough. Today during HD she was found to have a fever
to 100.8 and leukocytosis and was transferred to ___ for
further evaluation.
In the ED, initial vitals: T 98.5, BP 147/54, HR 95, RR 18, 98%
RA.
Labs were significant for WBC 17 (85% PMN), Hb 8.9, PLT 268. Na
132, Cr 2.6 (on HD), gluc 190, AP 152, AST 85, ALT 47, BNP 7841.
UA + WBC + epi. Flu was negative. BCx and UCx were drawn.
CXR showed no acute cardiopulmonary process and no
consolidation.
Patient received ceftriaxone 1 g, levofloxacin 750 mg, vanco
1000 mg.
Vitals prior to transfer: T 98.8, HR 83, BP 137/60, RR 17, 99%
RA.
Upon arrival to the floor Tc 87.7, BP 149/59, HR 83, RR 20, 100%
RA, weight 59.6 kg. Patient was resting in bed and in no acute
distress. Reported that her breathing was uncomfortable but
improved with inhalers. Also reported a heavy sensation on her
chest which has persisted throughout the day. States that she
get dizzy when going from a sitting to a standing position.
ROS: reports fever at HD today. No chills. + SOB as stated
above. Chronic cough, no change. No sick contacts. No travel. +
nausea, + vomiting. No diarrhea. + mild lower extremity edema.
No rashes. No recent dysuria (however just finished treatment
for a UTI and had dysuria at the beginning of that course).
Otherwise, ___ ROS was negative unless stated above.
Past Medical History:
- DMII
- ESRD on HD MWF, LUE AVG ___
- HTN
- osteoarthritis
- osteoporosis
- HLD
- asthma
- anemia
- HBV
- HCV
- gout
- GERD
- s/p lap cholecystectomy in ___
- h/o C diff
Social History:
___
Family History:
She is widowed and she has 7 children, and in apparently good
health.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: Tc 97.7, BP 149/59, HR 83, RR 20, 100% RA, weight 59.6 kg
GEN: Alert, lying flat in bed, no acute distress; oriented to
self, but not place or time
HEENT: sclera anicteric, oropharynx MMM, EOMI
NECK: Supple without LAD, unable to visualize JVD
PULM: bibasilar crackles R>L, no wheezing
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, ___, mildly distended, no fluid wave, normal
bowel sounds
EXTREM: Warm, ___, trace peripheral edema b/l; LUE
fistula with palpable thrill
NEURO: CN ___ grossly intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM
========================
VS: Tc 97.9, Tm 99.0, BP ___, HR ___, RR 18, 98% RA,
weight 57.6 kg, BMx5 (small soft stools), finger stick 130s
GEN: Alert, sitting up in bed, no acute distress
HEENT: sclera anicteric, oropharynx MMM, EOMI
NECK: Supple, unable to visualize JVD
PULM: CTAB, no wheezing
COR: RRR normal S1 and S2, ___ systolic murmur heard throughout
ABD: Soft, ___, mildly distended, no fluid wave, normal
bowel sounds
EXTREM: Warm, ___, trace peripheral edema b/l; LUE
fistula
NEURO: CN ___ grossly intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
================
___ 09:40AM BLOOD ___
___ Plt ___
___ 09:40AM BLOOD ___
___
___ 09:40AM BLOOD ___
___ 09:40AM BLOOD ___
___ 09:40AM BLOOD cTropnT-<0.01
___ 07:18PM BLOOD ___ cTropnT-<0.01
___ 05:40AM BLOOD cTropnT-<0.01
___ 09:40AM BLOOD ___
___ 06:35AM BLOOD ___
___ 09:08AM BLOOD ___
___
___ 09:08AM BLOOD HCV ___
DISCHARGE LABS
================
___ 07:00AM BLOOD ___
___ Plt ___
___ 07:00AM BLOOD ___
___
___ 07:00AM BLOOD ___
IMAGING
================
___ TTE
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(?#) appear structurally normal with good leaflet excursion.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Mild pulmonary artery systolic hypertension. Increased PCWP.
___
RUQ US
1. No evidence of focal hepatic lesions.
2. No ascites.
3. Dilatation of the common bile duct is similar to prior, and
likely relates to ___ state.
___ CXR
No acute cardiopulmonary process. No focal consolidation to
suggest
pneumonia.
MICRO
==============
___ 10:49 am URINE TAKEN FROM ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
ENTEROCOCCUS SP.. ___ ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| |
AMIKACIN-------------- 4 S
AMPICILLIN------------ =>32 R <=2 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
VANCOMYCIN------------ 1 S
___ 11:55 am 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 ___.
___ 9:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:45 am BLOOD CULTURE #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
Ms. ___ is a ___ y/o female with a past medical history of ESRD on
HD (MWF), DMII, HTN, CAD, HBV/HCV, GERD, Gout and osteoporosis
who present with fever, cough and general malaise found to have
E coli UTI. Hospital course was complicated by AF with RVR.
Hospital course is outlined below by problem:
# E coli UTI: Pt endorsed dysuria prior to presentation. She was
started on vanc/cefepime empirically. UCx grew E coli sensitive
to ceftriaxone and her antibiotics were transitioned to
ceftriaxone. She received a 7 day course of antibiotics. Her
last day of antibiotics was ___.
# AF with RVR: patient was found to have new afib with RVR
during this hospitalization. Her AF was controlled with AV nodal
agents. TSH was wnl. TTE was performed and did not show valvular
disease. We discussed anticoagulation with the patient and her
daughter. We explained that there is a risk of stroke in the
setting of AF however given that the patient is a high fall and
bleeding risk we wanted to discuss the risks/benefits of
anticoagulation with her outpatient provider. Her primary care
doctor was called but was unreachable. Anticoagulation will be a
transitional issue and should be discussed in the outpatient
setting. She remained on aspirin 325 mg daily and metoprolol 200
mg XL daily.
# Chest pain: patient had chest pain on admission with negative
troponins and EKG. This was likely due to palpitations in the
setting of AF with RVR. Her pain improved with better HR
control.
# Dyspnea: patient complained of dyspnea on admission. The
patient had a difficult time explaining her symptoms but quickly
resolved. CXR did not show an acute process. She remained on RA
and received inhalers for asthma.
# Transaminitis, alk phos elevation: patient has known HCV and
HBV but no diagnosis of cirrhosis. AST/ALT 85/47 and ALK phos
152 TB 0.3 on admission. A RUQ US was performed and did not show
evidence of cholangitis or hepatic lesions. LFTs were noted to
downtrend.
# Diarrhea: patient had diarrhea after receiving antibiotics.
There was concern for C diff initially and she was started on
empiric treatment with flagyl. Her C diff returned negative,
however given that she had C diff in the past she received
flagyl prophyalxis while on ceftriaxone. Her diarrhea was
attributed to antibiotic associated diarrhea and received
Imodium prn.
# Hyponatremia: patient's sodium was noted to decrease to
___. This was attributed to low solute intake and she was
encouraged to eat more during meals.
CHRONIC ISSUES
# Gout: continued allopurinol ___ mg QOD
# DM: patient was placed on a sliding scale and required small
amounts of Humalog during her hospitalization. It is unclear
what she takes as an outpatient for her diabetes but possibly
takes Januvia. This will need to be clarified.
# HTN: continued ___, metoprolol, nifedipine
# ESRD on HD: continued ___ dialysis. Patient will need to have
HD on ___ and ___ the week of
___. Her regular HD schedule will resume the following
week on ___.
# GERD: continued home PPI
TRANSITIONAL ISSUES
=====================
- patient is considered to be a high fall risk and the risk of
starting anticoagulation may outweigh the benefit in the setting
of AF. A discussion was held with her family about this issue.
The patient and family will need to discuss anticoagulation for
Afib with outpatient PCP
- discharged to rehab, will need f/u with outpatient PCP
- ___ the week of ___, patient will need HD on
___ and ___. Her regular HD schedule will resume
the following week on ___.
- patient was kept on a SSI during this hospital stay with
minimal insulin requirements. It is unclear what medication she
takes at home for her diabetes (possibly Januvia). This will
need to be clarified.
# CODE STATUS: Full
# CONTACT: daughter ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
2. Allopurinol ___ mg PO EVERY OTHER DAY
3. Aspirin EC 325 mg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. ___ Diskus (250/50) 1 INH IH BID
6. Furosemide 80 mg PO BID
7. Losartan Potassium 100 mg PO 4X/WEEK (___)
8. Metoprolol Succinate XL 200 mg PO DAILY
9. Montelukast 10 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. NIFEdipine CR 90 mg PO DAILY
12. Omeprazole 20 mg PO BID
13. TraMADOL (Ultram) 50 mg PO BID:PRN pain
14. Vitamin D 1000 UNIT PO DAILY
15. Calcium 600 + D(3) (calcium ___ D3) 600
mg(1,500mg) -400 unit oral BID
16. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares
17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
18. Alendronate Sodium 35 mg PO QWED
Discharge Medications:
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. Aspirin EC 325 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares
5. ___ Diskus (250/50) 1 INH IH BID
6. Furosemide 80 mg PO BID
7. Losartan Potassium 100 mg PO 4X/WEEK (___)
8. Metoprolol Succinate XL 200 mg PO DAILY
9. Montelukast 10 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. NIFEdipine CR 90 mg PO DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
13. Omeprazole 20 mg PO BID
14. TraMADOL (Ultram) 50 mg PO BID:PRN pain
15. Vitamin D 1000 UNIT PO DAILY
16. Calcium 600 + D(3) (calcium ___ D3) 600
mg(1,500mg) -400 unit oral BID
17. Alendronate Sodium 35 mg PO QWED
18. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
19. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: urinary tract infection, atrial fibrillation
Secondary diagnosis: ESRD, hypertension, DM, diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted with a fever. While you were here you received
antibiotics and your symptoms improved. You also received
dialysis. You were found to have an abnormal heart rhythm call
atrial fibrillation. We spoke to you about starting a blood
thinner and you will need to continue having conversations with
your primary care doctor. You are being discharged to a rehab
facility to get stronger before you go home.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
10035780-DS-14 | 10,035,780 | 21,074,018 | DS | 14 | 2132-05-19 00:00:00 | 2132-05-21 08:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / lisinopril / metformin / amlodipine
Attending: ___.
Chief Complaint:
Fever/Lethargy/Confusion
Major Surgical or Invasive Procedure:
Hemodialysis ___
History of Present Illness:
This patient is a ___ yo F with a hx of ESRD on HD (MWF), DMII,
HTN, CAD, HBV/HCV presenting with lethargy and fever following
dialysis. The patient's daughter noted that she was not as
interactive when she was receiving dialysis yesterday, and
complaining of feeling hot. She brought her into the ED where
she was febrile to 100.8, and found to have a WBC of 19.1,
lactate of 2.6, and UA showing numerous WBCs (CT head negative).
A trigger was called for unresponsiveness. She responded well to
empiric coverage with vanc/cefepime/flagyl. The daughter
mentioned that she has been getting UTIs frequently, and her
last one in ___ was similar in presentation.
On transfer to the floor, the patient was doing much better.
This morning, she appeared 60% of her baseline (in terms of
mental status) as per her daughter's report. Currently, she
denies dysuria, f/c, abdominal pain, chest pain, or leg pain.
Past Medical History:
- DMII
- ESRD on HD MWF, LUE AVG ___
- HTN
- osteoarthritis
- osteoporosis
- HLD
- asthma
- anemia
- HBV
- HCV
- gout
- GERD
- s/p lap cholecystectomy in ___
- h/o C diff
Social History:
___
Family History:
She is widowed and she has 7 children, and in apparently good
health.
Physical Exam:
ADMISSION
=========
VITALS: 97.6 | 135/57 | 89 | 18 | 97 RA
GENERAL: NAD, ___ only, alert, oriented x 2
(knew name, ___," and ___ but couldn't give date or
year)
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, fistula at R
forearm w/ dressing
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength 4+/5 in all extremities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE
==========
VITALS: 98.2 | 153/62 | 81 | 20 | 97RA
GENERAL: NAD, ___ only, alert
HEENT: anicteric sclera, pink conjunctiva, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, slight holosystolic murmur at the base
LUNG: CTAB, breathing comfortably without use of accessory
muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, slight peripheral edema in ___, fistula
at L forearm
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII grossly intact, mildly weak in all extremities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
CBC
====
___ 06:19AM BLOOD WBC-8.5 RBC-3.37* Hgb-11.0* Hct-32.9*
MCV-98 MCH-32.6* MCHC-33.4 RDW-14.6 RDWSD-51.3* Plt ___
___ 08:20AM BLOOD WBC-8.8 RBC-3.46* Hgb-11.2 Hct-34.5
MCV-100* MCH-32.4* MCHC-32.5 RDW-14.8 RDWSD-53.1* Plt ___
___ 07:30AM BLOOD WBC-7.9 RBC-3.34* Hgb-10.8* Hct-33.4*
MCV-100* MCH-32.3* MCHC-32.3 RDW-14.8 RDWSD-53.7* Plt ___
___ 06:22AM BLOOD WBC-10.6* RBC-3.48* Hgb-11.2 Hct-33.9*
MCV-97 MCH-32.2* MCHC-33.0 RDW-14.4 RDWSD-51.1* Plt ___
___ 08:11AM BLOOD WBC-10.9* RBC-3.60* Hgb-11.7 Hct-35.3
MCV-98 MCH-32.5* MCHC-33.1 RDW-14.7 RDWSD-53.0* Plt ___
___ 03:37PM BLOOD WBC-19.1* RBC-4.37 Hgb-14.2# Hct-41.9
MCV-96 MCH-32.5* MCHC-33.9 RDW-14.7 RDWSD-51.5* Plt ___
BMP
====
___ 06:19AM BLOOD Glucose-109* UreaN-76* Creat-3.6*# Na-133
K-4.3 Cl-93* HCO3-25 AnGap-19
___ 08:20AM BLOOD Glucose-101* UreaN-55* Creat-3.2* Na-135
K-4.4 Cl-94* HCO3-27 AnGap-18
___ 07:30AM BLOOD Glucose-107* UreaN-36* Creat-2.6* Na-136
K-4.2 Cl-97 HCO3-27 AnGap-16
___ 06:22AM BLOOD Glucose-143* UreaN-69* Creat-3.6* Na-132*
K-3.9 Cl-95* HCO3-22 AnGap-19
___ 08:11AM BLOOD Glucose-114* UreaN-40* Creat-3.0* Na-132*
K-3.9 Cl-96 HCO3-23 AnGap-17
___ 03:37PM BLOOD Glucose-179* UreaN-24* Creat-2.2* Na-128*
K-7.6* Cl-87* HCO3-26 AnGap-23*
LFTs
====
___ 07:30AM BLOOD ALT-80* AST-109* AlkPhos-119* TotBili-0.3
___ 08:11AM BLOOD ALT-86* AST-104* AlkPhos-125* TotBili-0.4
___ 03:37PM BLOOD ALT-101* AST-219* AlkPhos-142*
TotBili-0.5
LACTATE
=======
___ 10:39AM BLOOD Lactate-1.0
___ 03:58PM BLOOD Lactate-2.6*
URINE
=====
___ 12:30PM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:00PM URINE Color-Yellow Appear-Hazy Sp ___
___ 12:30PM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-LG
___ 12:30PM URINE RBC-3* WBC-47* Bacteri-FEW Yeast-NONE
Epi-3
___ 04:00PM URINE RBC-1 WBC-143* Bacteri-MANY Yeast-NONE
Epi-<1
MICRO
======
___ 12:49 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).
Time Taken Not Noted Log-In Date/Time: ___ 9:59 pm
URINE Site: NOT SPECIFIED CHEM S# ___ UCU
ADDED 05.18.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
CT HEAD- ___
============
IMPRESSION:
No acute intracranial process. Lacunar infarct in the right
pons. Additional chronic changes. MRI is more sensitive in
detecting acute ischemia.
RUQ US= ___
============
IMPRESSION:
Prominent extra hepatic bile duct measuring up to 10 mm without
intrahepatic dilatation. This finding is stable since prior exam
however if LFTs suggest biliary obstruction further evaluation
with MRCP could be obtained.
Brief Hospital Course:
Ms. ___ is a ___ yo F with a hx of ESRD on HD (MWF), DMII, HTN,
CAD, HBV/HCV presenting with lethargy and fever following
dialysis. The patient's daughter noted that she was not as
interactive when she was receiving dialysis on ___, and
complaining of feeling hot. She brought her into the ED where
she was febrile to 100.8, and found to have a WBC of 19.1,
lactate of 2.6, and UA showing numerous WBCs (CT head negative).
A trigger was called for unresponsiveness in the ED. She
responded well to empiric coverage with vanc/cefepime/flagyl
before transfer to the floor. Of note, the daughter mentioned
that she has been getting UTIs frequently, and that her last one
in ___ was similar in presentation.
# Urinary tract infection: Ms. ___ was treated with IV
ceftriaxone until her UCx speciation returned positive for
multidrug resistant E. coli. Her WBC continued to downtrend from
the initial level of 19 on admission. She was switched to IV
ceftazadime once her sensitivities returned, and completed her
treatment course on ___. Given her history of multiple
UTIs recently, it was suggested that her PCP consider
imaging/urogynocological evaluation or prophylactic abx moving
forward.
# Transaminitis: Patient has a history of HCV/HBV coinfection,
however, it was thought that her initial transaminitis on
admission (ALT 101 AST 219) was due to septic pathology
(possibly insufficient hepatic perfusion from hypotension during
volume shifts during dialysis). There was no evidence of
cirrhosis or synthetic dysfunction (RUQ US with no change). Her
LFTs continued to downtrend throughout the admission.
# Elevated lactate- she initially presented with an elevated
lactate of 2.5, likely caused by urosepsis vs. hypotension in
the setting of volume shifts during dialysis. The lactate
downtrended to 1 by the first day of admission.
# Acute Encephalopathy: Ms. ___ presented with altered mental
status on admission likely secondary to toxic metabolic effects,
and had a negative head CT in the ED. Her mental status steadily
improved with IV antibiotics and was close to baseline at the
time of discharge.
# Dialysis- Ms. ___ received dialysis on her usual MWF schedule
while admitted. Last dialysis session was ___.
# Chronic- Ms. ___ received her home medications for DM, HTN,
osteoporosis, asthma, and gout while admitted.
TRANSITIONAL ISSUES:
====================
[] F/u with PCP within one week to discuss urogyn evaluation,
further imaging, or prophylactic antibiotics to prevent future
UTIs (based on her prior speciation/sensitivities, however,
there may not be a good oral antibiotic for prophylaxis in her
case)
[] Discuss possible need for anticoagulation with PCP given
diagnosis of atrial fibrillation with RVR (diagnosed during
___ admission, never in afib during current admission)
[] Discuss possible need to uptitrate antihypertensive
medications (systolic BPs in the 140s-160s while admitted)
[] F/u ___ blood cultures to final result
[] consider checking LFTs at PCP appointment on ___
[] NEW MEDICATIONS: Loperamide 2mg every 2 hrs as needed for
diarrhea
[] CHANGED MEDICATIONS: none
[] STOPPED MEDICATIONS: none
[] APPOINTMENTS: PCP appointment on ___ at 11am
[] follow 2gm low salt diet, 2g potassium
CODE STATUS: FULL CODE
HCP/CONTACT: daughter, ___ To ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO BID
2. Aspirin EC 325 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Furosemide 80 mg PO BID
6. Losartan Potassium 100 mg PO 4X/WEEK (___)
7. Metoprolol Succinate XL 200 mg PO DAILY
8. Montelukast 10 mg PO DAILY
9. NIFEdipine CR 90 mg PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. Omeprazole 20 mg PO BID
12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral TID
13. Alendronate Sodium 35 mg PO QWED
14. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
15. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
16. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY
17. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
18. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes
19. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
2. Alendronate Sodium 35 mg PO QWED
3. Allopurinol ___ mg PO BID
4. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes
5. Aspirin EC 325 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Furosemide 80 mg PO BID
9. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
10. Losartan Potassium 100 mg PO 4X/WEEK (___)
11. Metoprolol Succinate XL 200 mg PO DAILY
12. NIFEdipine CR 90 mg PO DAILY
13. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral TID
14. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain
15. Montelukast 10 mg PO DAILY
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
17. Omeprazole 20 mg PO BID
18. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY
19. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
20. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 1 tablet by
mouth four times a day Disp #*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Urinary Tract Infection
- Transaminitis
Secondary Diagnoses:
- DMII
- ESRD on HD MWF, LUE AVG ___
- HTN
- Osteoporosis
- HLD
- Asthma
- Anemia
- HBV /HCV
- Gout
- GERD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to ___ on ___
because of lethargy, confusion, and fever after your dialysis
session. When you came to the hospital, we found out that you
had a urinary tract infection, similar to ones you have had in
the past. This is likely what caused your symptoms. After
treating you with IV antibiotics, your confusion and fever
improved. You finished your last dose of antibiotics on ___
___, and won't require any antibiotics on discharge.
While here, you also had some diarrhea. This can often happen
when on antibiotics. We determined that it was not caused by a
separate intestinal infection. It should resolve over the next
several days.
To prevent urinary tract infections, it is important to practice
good hygiene. The most common source of bacteria is stool, so
ensuring that you clean well after stooling is important. You
should discuss with your PCP whether or not long term
antibiotics to prevent infection is an option for you.
Please continue to take all your medications as prescribed. See
below for a list of follow up appointments.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Medicine team
Followup Instructions:
___
|
10035780-DS-16 | 10,035,780 | 28,030,709 | DS | 16 | 2132-12-14 00:00:00 | 2132-12-14 18:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / lisinopril / metformin / amlodipine
Attending: ___
Chief Complaint:
Head Injury, s/p Fall
Major Surgical or Invasive Procedure:
EUS with biopsy ___
Mediastinoscopy with biopsy ___
History of Present Illness:
Ms. ___ is a ___ yo woman with PMH of ESRD on HD (MWF), DMII, HTN,
CAD, HBV/HCV co-infection presenting after a fall.
History obtained via son and daughter at bedside as patient
speaks only ___. The patient reports that she got up to
use commode ___ bedroom today then slipped off of it. She denies
LOC, lightheadedness, or weakness and states it was purely due
to
slipping. She struck the bed and was reportedly down for 30
minutes with moderate blood loss from a head wound. The family
put tobacco into the wound to try to stop the bleeding. She
denies fevers though she reports feeling "cold" this AM. She
denies dysuria or changes ___ urination aside from mildly reduced
UOP. She has been eating and drinking normally. She denies
feeling confused. She reports constipation over the last several
hours, but denies focal numbness/tingling/weakness. She denies
cough/SOB/rhinorrhea. She does note rare night sweats and ___ lb
weight loss over 2 months. She had some blood ___ stool several
days ago which self-resolved without further issues. She denies
neck pain or any other pain elsewhere.
___ ED, initial vitals 97.4 88 150/66 20 100% RA. Imaging notable
for CT Torso with LAD c/f lymphoma and segmental colitis; CT
head
without fracture or ICH; minimal anterolisthesis of C4 on C5 and
C7 on T1 likely degenerative. Labs notable for WBC 16.7 with
74%PMN, Hgb 9.7 (most recent baseline ~11); trop negative x1; UA
with >182 WBC and many bacteria, pos nit; lactate 2.1; Na 131
(recent baseline 127-132), Cr 3.3 (baseline around ___, Bicarb
17 with AG 20 (similar to recent values ___. Seen by spine,
who note minimal anterolisthesis of C4-C5, likely degenerative
and recommend keeping ___ hard C-collar spine as well as
nonemergent MRI which can be performed inpt as pt is stable w/ a
normal neuro exam. Received CTX 1g, TDaP x1. Skin staples placed
to close head wound.
Vitals on transfer 82 138/64 16 100% RA.
On arrival to floor, patient denies complaints but requests
water
and to sit up ___ bed if possible.
ROS: Positive as per HPI, all other systems reviewed and
negative.
Past Medical History:
- DMII
- ESRD on HD MWF, LUE AVG ___
- HTN
- osteoarthritis
- osteoporosis
- HLD
- asthma
- anemia
- HBV
- HCV
- gout
- GERD
- s/p lap cholecystectomy ___ ___
- h/o C diff
Social History:
___
Family History:
She is widowed and has 7 children, all ___
apparently good health. No notable family hx.
Physical Exam:
ADMISSION
VS: 97.8 174 / 82 97 16 95 RA
General: Well appearing elderly woman lying ___ bed ___ NAD, hard
C-collar ___ place
Eyes: PERLL, EOMI, sclera anicteric
HENT: Semicircular wound on right anterior scalp with closed
with
staples, c/d/i without notable erythema, no bleeding. MMM,
oropharynx clear without exudate or lesions.
Respiratory: CTAB without crackles, wheeze, rhonchi on anterior
exam, limited by positioning with C-collar
Cardiovascular: RRR, normal S1 and S2, no murmurs, rubs or
gallops
Gastrointestinal: Soft, nondistended, +BS, no masses or HSM,
mild
suprapubic tenderness to palpation
Extremities: Warm and well perfused, no peripheral edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert and oriented x2-3 (knows name, at ___,
year
___ but unsure of date), CN2-12 intact, ___ strength ___ UE and
___ bilaterally, follows commands appropriately
Discharge exam:
Vitals: 98.1 PO 178/71 88 18 97 RA
Gen - tired appearing, initially sleeping on entry into the
room, seated upright ___ bed, breathing comfortably
HEENT - head laceration is well healed, staples are removed,
EOMI, poor dentition with multiple fillings/artificial teeth
Heart - RR, ___ systolic murmur over R/LUSB, no r/g
Lungs - clear to auscultation bilaterally, no wheezing or
rhonchi noted today
Abd - soft nontender, normoactive bowel sounds
Ext - no edema, WWP
Neuro - awake, alert, conversant ___ ___, moving all
extremities purposefully with normal strength, no tremor or
focal deficits appreciated
Skin - there is some bruising at the clavicles at site of
mediastinoscopy which is stable and some scattered bruising on
her arms at phlebotomy sites
Pertinent Results:
LABS
==========================
ADMISSION LABS
___ 09:00AM BLOOD WBC-16.7*# RBC-2.89* Hgb-9.7* Hct-30.6*
MCV-106* MCH-33.6* MCHC-31.7* RDW-14.3 RDWSD-55.7* Plt ___
___ 09:00AM BLOOD Glucose-173* UreaN-28* Creat-3.3* Na-131*
K-4.3 Cl-94* HCO3-17* AnGap-24*
DISCHARGE LABS:
___ 07:56AM BLOOD WBC-8.5 RBC-2.57* Hgb-8.3* Hct-24.7*
MCV-96 MCH-32.3* MCHC-33.6 RDW-18.6* RDWSD-66.0* Plt ___
___ 07:56AM BLOOD Glucose-108* UreaN-41* Creat-3.0*#
Na-131* K-3.4 Cl-96 HCO3-23 AnGap-15
___ 07:56AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.5*
MICRIOBIOLOGY
==========================
___ 4:30 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ blood culture x 2 NGTD
___ 2:11 am SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): pending
___ 5:53 pm SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
MTB Direct Amplification (Preliminary):
M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: A negative NAAT
cannot rule
out TB or other mycobacterial infection.
.
NAAT results will be followed by confirmatory testing with
conventional culture and DST methods. This TB NAAT method
has not
been approved by FDA for clinical diagnostic purposes.
However, ___
___ (___) has established assay
performance by
___ validation ___ accordance with ___ standards.
.
PERFORMED AT THE ___, ___.
.
RESULT REC'D BY PHONE-SAMPLE WILL BE FINALIZED UPON
RECEIPT OF
WRITTEN REPORT.
___ 11:06 am SPUTUM Site: INDUCED Source: Induced.
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ CLUSTERS.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): pending
___ 10:08 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..
___ Influenza A and B negative
___ RPR negative
___ cryptococcal antigen negative
___ 5:59 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ blood culture x 2 no growth final
___ 12:55 pm URINE CATHETER.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING:
==========================
___ CXR
FINDINGS:
Trace pleural effusions. Mild left basilar opacity, likely
atelectasis ___ the setting of shallow inspiration.
___ CXR
IMPRESSION:
___ comparison with the scout radiograph from the CT of ___, there is little overall change. Prominence of these hilar
and mediastinal regions are concerning for underlying
malignancy.
Following mediastinoscopy, there is no evidence of pneumothorax
or pneumomediastinum.
___ MRI C-spine w/o con (wetread)
Again seen is minimal anterolisthesis of C4 on C5 and C7 on T1,
likely degenerative. There is no prevertebral edema or evidence
of ligamentous injury. There is no evidence of acute fracture.
Cord signal is within normal limits. Again seen is moderate
right neural foraminal stenosis due to a facet osteophyte. Small
posterior intervertebral osteophytes at multiple levels, but no
high-grade spinal canal stenosis.
___ CT Torso w/con
1. No evidence of traumatic injury within the chest, abdomen or
pelvis.
2. Numerous enlarged mediastinal lymph nodes, with gastrohepatic
and portacaval lymph node conglomerate measuring up to 3.5 x 2.0
cm with cystic components, suspicious for malignancy, although a
definite primary is not visualized on this examination. Lymphoma
is a consideration.
3. Focal segment of proximal transverse colon demonstrating wall
thickening and surrounding fat stranding, which likely
represents
segmental colitis. No nodularity to suggest an underlying
primary malignancy.
4. Grade 1 anterolisthesis of L4 on L5, unchanged.
___ CT C spine without contrast
1. Minimal anterolisthesis of C4 on C5 and C7 on T1, likely
degenerative ___ nature, however there are no priors for
comparison.
2. No acute fractures.
3. Moderate right neural foraminal stenosis at C4-5.
___ CT Head w/o contrast
Skin staples overlying a small right frontoparietal scalp
hematoma without evidence of underlying fracture or intracranial
hemorrhage.
___ MRI Cervical Spine
1. Grade 1 spondylolisthesis without evidence of ligamentous
injury.
2. Mild multilevel degenerative changes of the cervical spine,
as detailed above.
3. No evidence of bony or ligamentous injury.
PATHOLOGY
=================================
___ final report
SPECIMEN_1: LYMPH NODE, MEDIASTINAL 4R LYMPH NODE, EXCISION
SPECIMEN_4: LYMPH NODE, MEDIASTINAL 4L LYMPH NODE, EXCISION.
DIAGNOSIS:
NECROTIZING GRANULOMAS, SEE NOTE.
DIAGNOSIS:
NECROTIZING GRANULOMAS, SEE NOTE.
Note: Sections from Part 1 labeled as 4R lymph node compose of
fragments of lymph nodes with extensive anthracotic pigment and
focal granulomatous lesion. Sections from part 4, labeled as 4L
lymph node, composed of fragments of lymphoid tissue with
fibrosis and extensive necrosis. Special stains for infectious
microorganisms (AFB, GMS, and Gram stain) performed on both
specimens 1 and 2 are negative. The differential diagnosis
includes
infectious etiologies such as tuberculosis, and non-infectious
causes such as necrotizing sarcoidosis, which is a diagnosis of
exclusion. Correlation with clinical findings and microbiology
cultures is highlight recommended.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with past medical history of
dementia, diabetes type 2 complicated by diabetic kidney disease
/ ESRD on HD, HBV/HCV co-infection admitted ___ following
a fall with head laceration, incidentally also reporting recent
GI bleed, with imaging concerning for malignancy
# Fall / head laceration / cervical anterolisthesis: Per family,
patient presented following a mechanical fall with head strike
and large forehead laceration with significant bleeding. ___ the
ED laceration was stapled and hemostasis was obtained. CT Head
and torso were reassuring that there was no serious traumatic
injury. Imaging identified scalp hematoma. CT and MRI C-spine
showed mild anterolisthesis prompting spine service consult, who
felt she had no ligamentous injury, and no acute surgical need.
They recommended soft c-collar as needed with activity. Patient
incidentally found to have several additional new medical issues
listed below
# Lymphadenopathy - Admission CT torso incidentally showed
significant lymphadenopathy, concerning for malignancy /
lymphoma. Oncology was consulted and recommended advanced
endoscopy for EUS and biopsy. Obtained EUS with biopsy which
was non-diagnostic. Patient then underwent midastinoscopy with
thoracic surgery on ___ with lymph node biopsy. Final pathology
consistent with necrotizing granulomas. Patient was r/o for
active TB with 3 negative concentrated smears from induced sputa
and negative NAAT. Rheumatology was consulted for concern for
sarcoid, but did not believe this was likely. Patient should
___ ___ ID and ___ clinic.
# Acute blood loss Anemia / GI Bleed NOS - Patient Hgb nadired
at 5.9 from prior baseline of > 10 ___ setting of above head
wound with significant bleeding at ___. Family also reported
recent isolated episode of blood ___ patient's stool several days
prior to presentation. ___ setting of CT scan with colonic
thickening, and enlarged lymph nodes (as below), there was
concern for malignant cause of recent bleeding. Per discussion
with oncology, initially attempted to obtain EUS (as below) +
colonoscopy to evaluate, however patient was noncompliant with
bowel preparation x 2 successive nights despite counseling with
family and interpreter. Discussed with family, and team felt
that acute benefit of colonoscopy was outweighed by risk of
continued attempts at preparation when patient did not wish to
bowel prep. Given that priority was to obtain lymph tissue
without additional delay, advanced endoscopy performed EUS with
biopsy as below. There were no additional signs of GI bleeding
and Hgb remained stable. Consider outpatient colonoscopy should
patient and family wish to pursue. Patient did require 1 unit
pRBC transition while EPO was held, but EPO was restarted once
lymphoma was ruled out.
# Cough - Patient developed cough during hospitalization. Three
induced sputa with concentrated smears were negative for TB,
NAAT testing was also negative. Sputum grew moderate commensal
flora and multiple CXR were not consistent with pneumonia.
Patient may have underlying non-tuberculous mycobacteria. She
will f/u with ID as outpatient. She was treated symptomatically
with improvement of cough and did not receive any antibiotics.
# Latent TB - Patient's guantiferon gold was positive but as
stated above, active TB testing at time of discharge was
negative. Treatment will be per ID.
# Hypertension - ___ setting of acute bleed on presentation,
patient's antihypertensives were held. Once she was
hemodynamically stable, restarted ___ nifedipine, Lasix,
metoprolol, losartan. Of note, patient's BP noted to be high ___
the mornings prior to morning medication administration.
Consider retiming medications to evening.
# Atrial fibrillation - Patient had episodes of non sustained
afib with RVR while at dialysis ___ setting of holding ___
metoprolol. These episodes were self limited and patient
monitored on telemetry without any episodes of atrial
fibrillation. Would consider outpatient Holter monitor to
evaluate for afib. CHADS2 score of 3 VASc of 4 corresponding to
a 5.9% and 6.4% risk of annual strokerespectively. Acute onset
of AFib with rapid resolution is likely triggered from recent
events described above. She has no prior history and is now ___
sinus rhythm.
# Chest pain - Patient complaining of intermittent chest pain
during hospitalization, likely MSK-related ___ setting of recent
mediastinoscopy and pain exacerbated with coughing. EKG without
any evidence of ischemic changes.
# Urinary Tract Infection - On admission, patient found to have
UA with bacteria and WBCs, as well as leukocytosis. Although it
was unclear if she had symptoms, given her recent history of
sepsis secondary to a UTI. risk of not treatment was felt to be
high. Culture grew Ecoli and patient completed 5 days of IV
CTX.
# Osteoporosis - Given patient ESRD, held alendronate; could
consider restarting at PCP ___.
# ESRD on HD - Continued lasix as above. Continued
calcium/VitD, Triphrocaps. Patient received ___
dialysis during hospitalization for scheduling purposes but was
transitioned back to ___ dialysis prior to discharge. Next
dialysis session should be ___.
# Diabetes type 2 - Continued ASA and insulin sliding scale. She
very rarely required any insulin for as BG was generally < 150.
Thus, insulin was discontinued at discharge.
# Asthma - Continued albuterol, Dulera, montelukast
# GERD Continued PPI
# Gout - Decreased dose of allopurinol given ESRD.
> 30 minutes were spent on discharge planning and care
coordination.
TRANSITIONAL ISSUES:
- Patient should have ID and rheumatology ___ for
continued workup of extensive lymphadenopathy
- pathology sample to be sent for molecular beacon testing by
ID, no empiric treatment of TB recommended at this time
- insulin sliding scale discontinued as patient did not require
insulin during hospitalization
- consider outpatient Holder monitor to evaluate for paroxysmal
atrial fibrillation as patient had limited episodes during
hospitalization
- pending labs at discharge: ACE level, C4, C4, vitamin D, and
RF
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
2. Alendronate Sodium 35 mg PO QWED
3. Allopurinol ___ mg PO DAILY
4. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes
5. Aspirin EC 325 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares
7. Furosemide 80 mg PO BID
8. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain
9. Losartan Potassium 100 mg PO 4X/WEEK (___)
10. Montelukast 10 mg PO DAILY
11. NIFEdipine CR 90 mg PO DAILY
12. Omeprazole 20 mg PO BID
13. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral TID
14. LOPERamide 2 mg PO QID:PRN diarrhea
15. Metoprolol Succinate XL 200 mg PO DAILY
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
17. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY
18. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
19. Dulera (mometasone-formoterol) 200-5 mcg/actuation
inhalation BID
20. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
21. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN
pruritis
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Benzonatate 100 mg PO TID
3. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN sore throat
4. Docusate Sodium 100 mg PO BID
5. GuaiFENesin ___ mL PO Q6H
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
8. Alendronate Sodium 35 mg PO QWED
9. Allopurinol ___ mg PO DAILY
10. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes
11. Aspirin EC 325 mg PO DAILY
12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral TID
13. Dulera (mometasone-formoterol) 200-5 mcg/actuation
inhalation BID
14. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares
15. Furosemide 80 mg PO BID
16. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain
17. LOPERamide 2 mg PO QID:PRN diarrhea
18. Losartan Potassium 100 mg PO 4X/WEEK (___)
19. Metoprolol Succinate XL 200 mg PO DAILY
20. Montelukast 10 mg PO DAILY
21. NIFEdipine CR 90 mg PO DAILY
22. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
23. Omeprazole 20 mg PO BID
24. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN
pruritis
25. Triphrocaps (B complex with C#20-folic acid) 1 mg oral
DAILY
26. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Lymphadenopathy
# latent tuberculosis
# Colonic abnormality
# Acute blood loss Anemia
# Fall with Head trauma/laceration
# Hypertension
# Urinary Tract Infection
# Cervical Anterolisthesis
# Osteoporosis
# end stage renal disease
# Diabetes type 2
# Asthma
# GERD
# Dementia - high risk for delirium
# Gout
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___:
It was a pleasure caring for you at ___. You were admitted
with a fall and a large cut on your forehead. On a CAT scan you
were found to have enlarged lymph nodes ___ your abdomen. You
underwent a biopsy that showed granulomas. We performed multiple
tests and determined you do not have cancer. We are not sure
what is causing these large lymph nodes. It may due to TB (an
infection), but testing is currently pending. You should
___ with the infectious disease and rheumatology doctors
to determine what is causing your lymph nodes to be large.
You are now ready for discharge to rehab. Please take care,
Your ___ Team
Followup Instructions:
___
|
10035780-DS-17 | 10,035,780 | 27,291,894 | DS | 17 | 2133-02-01 00:00:00 | 2133-02-02 17:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / lisinopril / metformin / amlodipine
Attending: ___
___ Complaint:
Hypotension and ?Altered Mental Status during dialysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ only; History obtained from
chart, nephew/niece over phone call, and with the assistance of
language line interpreter):
Ms. ___ is a ___ year old ___ and ___ speaking woman
with a history of extrapulmonary TB (lymphadenitis) on RIPE
since ___, UTI treated on recent admission (___), DM2,
ESRD on HD (MWF), chronic HBV/HCV, HTN, and CAD who presented
with confusion and transient hypotension (SBPs to ___ during
dialysis.
Approximately one week prior to admission, the patient's
daughter noted foul smelling urine that was very dark in color,
and per the daughter, the patient experienced some dysuria. The
patient endorsed "feeling drunk" at this time along with several
episodes of vomiting, though both resolved at the time of
admission. She also endorsed weakness; at baseline, she
ambulates with the occasional assistance of a cane at home, and
she noted that she has had to use the cane in the days leading
up to admission due to this weakness and "shakiness" in the
legs.
Per ED note, the patient presented to her regular hemodialysis
yesterday (___) and was noted to have transient hypotension to
the ___ which corrected with administration of IV fluids. She
was then transferred to the ___ ED.
Notably, per chart review, she was recently hospitalized at the
___ from ___ to ___nd head strike with no
traumatic injury identified on CT Head but extrapulmonary TB
found incidentally on CT Torso after workup for lymphadenopathy;
three induced sputa with concentrated smears were negative for
TB and NAAT testing was negative. Urinalysis and urine culture
were positive for E. coli on admission and she completed 5 days
of IV ceftriaxone. She was discharged to ___ rehab on
___ and initiated RIPE on ___. She was discharged from
___ on ___.
Regarding her baseline status, her niece, ___, last saw her at
___, but spoke with a cousin who last saw her
approximately 5 days prior to admission. She noted that the
patient seemed well this week: alert, attentive, and able to
engage in conversation. She did note that the patient does not
leave the home very often and it is very possible she is not
aware of the date at baseline. Notably, the patient never
learned how to read and has poor eyesight.
Past Medical History:
- DMII
- ESRD on HD MWF, LUE AVG ___
- HTN
- osteoarthritis
- osteoporosis
- HLD
- asthma
- anemia
- HBV
- HCV
- gout
- GERD
- s/p lap cholecystectomy in ___
- h/o C diff
Social History:
___
Family History:
She is widowed and has 7 children, all in apparently good
health. No notable family hx.
Physical Exam:
==============
ADMISSION EXAM
==============
Vital Signs: T 98.3 BP 179/106 HR 78 RR 16 O2 Sat 99RA
General: Alert, oriented to person (gives last name only), place
(initially says home but acknowledges when prompted with
hospital), but not time ___ no acute distress
HEENT: Cutaneous horn noted below left eye. Sclerae anicteric,
MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not
elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact.
==============
DISCHARGE EXAM
==============
Vitals: T 97.9 BP 178/77 P 69 RR 18 O2 Sat 96RA
General: Alert, oriented to person and place, date ___ no
acute distress
HEENT: Cutaneous horn noted below left eye. Sclerae anicteric,
MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not
elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact.
Pertinent Results:
ADMISSION LABS
==============
___ 08:20PM BLOOD cTropnT-0.04*
___ 07:00AM BLOOD cTropnT-0.09*
___ 07:00AM BLOOD cTropnT-0.09*
___ 03:40PM BLOOD cTropnT-0.08*
___ 07:50AM BLOOD CK-MB-3
___ 03:40PM BLOOD CK-MB-3
___ 10:52PM BLOOD WBC-13.7*# RBC-3.34*# Hgb-11.4# Hct-34.9#
MCV-105*# MCH-34.1* MCHC-32.7 RDW-16.3* RDWSD-61.8* Plt ___
___ 10:52PM BLOOD Neuts-87.6* Lymphs-4.3* Monos-6.6
Eos-0.1* Baso-0.7 Im ___ AbsNeut-11.98*# AbsLymp-0.59*
AbsMono-0.90* AbsEos-0.01* AbsBaso-0.09*
___ 08:20PM BLOOD Glucose-88 UreaN-9 Creat-2.0* Na-137
K-3.2* Cl-92* HCO3-23 AnGap-25*
___ 03:40PM BLOOD Glucose-99 UreaN-18 Creat-3.2*# Na-138
K-4.2 Cl-97 HCO3-24 AnGap-21*
___ 03:40PM BLOOD Calcium-8.3* Phos-3.9 Mg-1.8
___ 08:20PM BLOOD ALT-20 AST-54* AlkPhos-100 TotBili-0.2
___ 08:20PM BLOOD Albumin-3.7
___ 08:20PM BLOOD Lipase-29
DISCHARGE LABS
==============
___ 06:00AM BLOOD WBC-6.2# RBC-2.99* Hgb-10.2* Hct-30.4*
MCV-102* MCH-34.1* MCHC-33.6 RDW-16.0* RDWSD-59.1* Plt ___
___ 06:00AM BLOOD Glucose-97 UreaN-29* Creat-3.7* Na-137
K-3.9 Cl-97 HCO3-25 AnGap-19
___ 06:00AM BLOOD Calcium-8.5 Phos-4.2 Mg-1.8
___ 03:11AM URINE RBC-1 WBC-17* Bacteri-FEW Yeast-NONE
Epi-0
___ 03:11AM URINE Blood-TR Nitrite-NEG Protein->300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-7.5 Leuks-NEG
___ 03:11AM URINE Color-Yellow Appear-Clear Sp ___
IMAGING/STUDIES
===============
___ (PA & LAT)
Chronic findings as noted above. No evidence of mass,
hemorrhage or
infarction.
___ CHEST/ABD/PELVIS W/O
1. No acute abnormality within the chest, abdomen, or pelvis.
2. Stable lymphadenopathy of mediastinal and porta hepatis lymph
nodes remains unclear in etiology.
___ HEAD W/O CONTRAST
Chronic findings as noted above. No evidence of mass,
hemorrhage or
infarction.
Brief Hospital Course:
___ ___ speaking ONLY) with DM2, ESRD on HD
(MWF), chronic HCV/HBV, HTN, extrapulmonary TB (lymphadenitis)
on RIPE who presented from HD with hypotension and recent UTI.
#Foul-smelling urine/ recent UTI: Started 5-day course of
ciprofloxacin by PCP ___ ___ for symptomatic complaints,
consistent with UTI. Received dose of ceftriaxone in ED on
___, to complete 5-day course of antibiotics. Afebrile, no
chills or flank pain or CVA tenderness, not complaining of
dysuria or other urinary symptoms, urine was not foul-smelling
during admission. U/A was negative for leukocyte esterase and
nitrites, few bacteria, 17 WBC, >300 mg/dL protein; the
proteinuria is her baseline. Notably, she has had recurrent
UTIs, several of which were cipro-resistant bacteria. Given
entire picture, decided to hold further antibiotics. Pt was
discharged prior to urine culture resulting; when culture
finalized on ___, patient and PCP were contacted to inform
them that the urine culture was negative and no further
intervention was required.
#Transient Hypotension in dialysis, elevated troponins:
No records from dialysis, note indicates SBPs to ___ but unclear
duration. Normotensive upon arrival to ___ ED. Pt had troponin
leak (peak 0.09 with subsequent downtrend) w/ transient ST
segment depressions in V5/6 on initial EKG that resolved on
subsequent EKGs. Pt denied cardiac or pulmonary complaints.
Unclear whether hypotension preceded troponin leak or vice
versa. Suspect that hypotension occurred in the setting of UTI
and poor PO intake preceding HD session on ___, which led her to
become hypotensive while undergoing ultrafiltration. Troponin
elevation was likely in the setting of demand ischemia, which
improved with resolution of hypotensive episode.
#Hypertension: SBPs in 170s-180s;asymptomatic. Did not receive
home anti-hypertensives for >24 hours in ED. Restarted on all
home antihypertensives with improvement of BP to 160s.
#Altered Mental Status: Per son, who lives with patient, that
patient was at her baseline mental status. Patient has a history
of dementia noted during previous admission, but further details
are unclear and family does not seem to be aware. Alert and
oriented to person and place, and able to relate recent history
clearly with no fluctuating consciousness. CT Head negative for
acute changes, demonstrates chronic atrophic changes and white
matter hypodensities.
#Osteoporosis: Alendronate held at previous admission given
ESRD, deferred to PCP ___: restarting. Continued to hold
alendronate during admission.
#ESRD on HD: has HD on ___ - did not require dialysis while
admitted. Continued Calcium and Vit D.
#DM2: blood glucose 99 at admission. Did not require insulin for
glucose management during admission.
#Asthma: Continued albuterol, montelukast. Given advair 250/50
instead of dulera; will restart Dulera as outpatient
#GERD: Continued PPI
#Gout: continued allopurinol, changed dosing to HD dosing, 150
mg after HD
TRANSITIONAL ISSUES
===================
[x] inpatient team will follow-up the result of urine culture
and contact one of the ___ relatives ___,
___. ___, niece, ___ for any
interventions that need to take place pending the results of the
culture -- this was completed prior to completion of this
discharge summary. Culture was negative; pt and PCP contacted,
no antibiotics required.
[ ] close follow-up of blood pressure with primary care
physician
___ than 30 minutes was spent on this patient's discharge
day management.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
2. Allopurinol ___ mg PO DAILY
3. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes
4. Aspirin EC 325 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares
6. Furosemide 80 mg PO BID
7. Losartan Potassium 100 mg PO 4X/WEEK (___)
8. Metoprolol Succinate XL 200 mg PO DAILY
9. Montelukast 10 mg PO DAILY
10. NIFEdipine CR 90 mg PO DAILY
11. Omeprazole 20 mg PO BID
12. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
13. Benzonatate 100 mg PO TID
14. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN sore throat
15. Docusate Sodium 100 mg PO BID
16. Dulera (mometasone-formoterol) 200-5 mcg/actuation
inhalation BID
17. Alendronate Sodium 35 mg PO QWED
18. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral TID
19. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain
20. LOPERamide 2 mg PO QID:PRN diarrhea
21. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
22. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN
pruritis
23. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY
24. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
25. Polyethylene Glycol 17 g PO DAILY:PRN constipation
26. GuaiFENesin ___ mL PO Q6H
27. Rifampin 900 mg PO 3X/WEEK (___)
28. Isoniazid ___ mg PO 3X/WEEK (___)
29. Pyrazinamide ___ mg PO 3X/WEEK (___)
30. Ethambutol HCl 1200 mg PO 3X/WEEK (___)
31. Pyridoxine 50 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO 3X/WEEK (___)
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
4. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes
5. Aspirin EC 325 mg PO DAILY
6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral TID
7. Docusate Sodium 100 mg PO BID
8. Dulera (mometasone-formoterol) 200-5 mcg/actuation
inhalation BID
9. Ethambutol HCl 1200 mg PO 3X/WEEK (___)
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares
11. Furosemide 80 mg PO BID
12. Isoniazid ___ mg PO 3X/WEEK (___)
13. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain
14. LOPERamide 2 mg PO QID:PRN diarrhea
15. Losartan Potassium 100 mg PO 4X/WEEK (___)
16. Metoprolol Succinate XL 200 mg PO DAILY
17. Montelukast 10 mg PO DAILY
18. NIFEdipine CR 90 mg PO DAILY
19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
20. Omeprazole 20 mg PO BID
21. Polyethylene Glycol 17 g PO DAILY:PRN constipation
22. Pyrazinamide ___ mg PO 3X/WEEK (___)
23. Pyridoxine 50 mg PO DAILY
24. Rifampin 900 mg PO 3X/WEEK (___)
25. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN
pruritis
26. Triphrocaps (B complex with C#20-folic acid) 1 mg oral
DAILY
27. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
28. HELD- Alendronate Sodium 35 mg PO QWED This medication was
held. Do not restart Alendronate Sodium until another physician
tells you to start taking this again.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Hypotension during hemodialysis
Demand ischemia
Secondary diagnoses:
End stage renal disease on hemodialysis
Hypertension
Diabetes
Asthma
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 ___ from
___ to ___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- Your blood pressure was quite low during dialysis.
- There was concern that you were confused and may have a
urinary tract infection (UTI).
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- Your blood pressure was monitored overnight; it remained high,
instead of low. We gave you all of your home medications to
control your blood pressure.
- We tested your urine - it showed no signs of infection.
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
- Continue to take all of your medicines, as prescribed.
- We will follow the results of your urine study to ensure that
no bacteria grow. If any bacteria does grow, and we need to
treat you for a urinary tract infection, we will call both you
and your primary care doctor, Dr ___, so we can
prescribe you an antibiotic.
- You should follow-up with your primary care doctor, Dr ___
___, some time this week to check-in.
We wish you the best with your health going forward. If you have
any further questions regarding your care here, please do not
hesitate to contact us at ___ ___ 7 front desk).
Your ___ Medicine Team
Followup Instructions:
___
|
10035780-DS-18 | 10,035,780 | 23,172,477 | DS | 18 | 2135-07-22 00:00:00 | 2135-07-22 18:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / lisinopril / metformin / amlodipine
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
AV fistula thrombectomy
History of Present Illness:
Ms ___ is a ___ y/o ___ speaking patient with PMH
significant for Alzheimer's dementia, HTN, HLD, ESRD (on ___
HD),
who originally presented to ___
thrombectomy, but was determined to not have capacity to consent
to procedure, and ___ was unable to get consent from HCP, thus
was
sent to the ED.
Patient presented to the ED from ___ after
she
was unable to provide consent for planned thrombectomy for
clotted left fistula. They attempted to contact the patient's
healthcare proxy multiple times but were unable to reach her.
The ED was also unable to reach her.
In the ED, the patient is mildly confused, which appears to be
her baseline. She notes mild abdominal pain but no other
symptoms.
In the ED...
- Initial vitals: 97.9 76 180/79 16 97% RA
- Labs/studies notable for: Cr > 9, K 5.0
- Patient was given: 10 IV labetalol
Past Medical History:
- DMII
- ESRD on HD ___, LUE AVG ___
- HTN
- osteoarthritis
- osteoporosis
- HLD
- asthma
- anemia
- HBV
- HCV
- gout
- GERD
- s/p lap cholecystectomy in ___
- h/o C diff
Social History:
___
Family History:
She is widowed and has 7 children, all in apparently good
health. No notable family hx.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
___ 2340 Temp: 98.1 PO BP: 190/95 HR: 81 RR: 18 Dyspnea: 0
RASS: 0 Pain Score: ___
GEN: Chronically ill appearing, NAD
HEENT: Conjunctiva clear, PERRL, MMM
NECK: No JVD.
LUNGS: CTAB
HEART: RRR, nl S1, S2. No m/r/g.
ABD: Mild epigastric tenderness normal bowel sounds.
EXTREMITIES: No edema. WWP. Left AV fistula.
SKIN: No rashes.
NEURO: Alert, unable to establish orientation.
DISCHARGE PHYSICAL EXAM:
===========================
24 HR Data (last updated ___ @ 1234)
Temp: 98.0 (Tm 98.1), BP: 172/84 (154-179/68-84), HR: 78
(70-78), RR: 18 (___), O2 sat: 100% (97-100), O2 delivery: Ra,
Wt: 95.46 lb/43.3 kg
GEN: NAD
HEENT: Jaundice, Normocephalic, atraumatic
NECK: No JVD.
LUNGS: CTAB
HEART: RRR, nl S1, S2. No m/r/g.
ABD: normal bowel sounds.
EXTREMITIES: No edema. WWP. Left AV fistula with some bruising.
Good thrill/bruit.
SKIN: No rashes.
NEURO: Alert, unable to establish orientation.
Pertinent Results:
Pertinent Results:
ADMISSION LABS
==============
___ 03:20PM BLOOD WBC-8.7 RBC-3.00* Hgb-10.1* Hct-31.5*
MCV-105* MCH-33.7* MCHC-32.1 RDW-14.2 RDWSD-53.3* Plt ___
___ 03:20PM BLOOD Plt ___
___ 03:20PM BLOOD Glucose-94 UreaN-53* Creat-9.4*# Na-135
K-5.0 Cl-94* HCO3-24 AnGap-17
RELEVANT LABS:
==============
___ 09:29AM BLOOD WBC-9.0 RBC-2.96* Hgb-10.1* Hct-30.9*
MCV-104* MCH-34.1* MCHC-32.7 RDW-14.8 RDWSD-54.6* Plt ___
___ 05:08AM BLOOD WBC-7.9 RBC-2.93* Hgb-10.0* Hct-30.7*
MCV-105* MCH-34.1* MCHC-32.6 RDW-15.2 RDWSD-57.1* Plt ___
___ 05:34AM BLOOD WBC-4.0 RBC-2.34* Hgb-7.9* Hct-25.4*
MCV-109* MCH-33.8* MCHC-31.1* RDW-15.9* RDWSD-62.4* Plt Ct-71*
___ 06:03AM BLOOD WBC-4.5 RBC-2.13* Hgb-7.3* Hct-22.7*
MCV-107* MCH-34.3* MCHC-32.2 RDW-15.6* RDWSD-61.2* Plt Ct-67*
___ 05:31AM BLOOD WBC-3.8* RBC-1.94* Hgb-6.6* Hct-21.3*
MCV-110* MCH-34.0* MCHC-31.0* RDW-15.5 RDWSD-62.4* Plt Ct-56*
___ 05:00PM BLOOD WBC-5.5 RBC-2.90* Hgb-9.5* Hct-30.5*
MCV-105* MCH-32.8* MCHC-31.1* RDW-18.7* RDWSD-72.4* Plt Ct-70*
___ 07:05AM BLOOD WBC-4.7 RBC-2.67* Hgb-8.7* Hct-27.6*
MCV-103* MCH-32.6* MCHC-31.5* RDW-18.5* RDWSD-70.4* Plt Ct-70*
___ 05:25AM BLOOD WBC-4.6 RBC-2.63* Hgb-8.6* Hct-27.9*
MCV-106* MCH-32.7* MCHC-30.8* RDW-17.5* RDWSD-69.1* Plt Ct-60*
___ 07:05AM BLOOD Neuts-62.1 ___ Monos-9.6 Eos-5.4
Baso-0.4 Im ___ AbsNeut-2.90 AbsLymp-1.03* AbsMono-0.45
AbsEos-0.25 AbsBaso-0.02
___ 09:29AM BLOOD Plt ___
___ 07:37AM BLOOD Plt ___
___ 05:32AM BLOOD Plt ___
___ 05:34AM BLOOD Plt Smr-VERY LOW* Plt Ct-71*
___ 06:03AM BLOOD Plt Ct-67*
___ 05:31AM BLOOD Plt Ct-56*
___ 06:48AM BLOOD ___ PTT-29.1 ___
___ 05:00PM BLOOD Plt Ct-70*
___ 07:05AM BLOOD Plt Ct-70*
___ 05:25AM BLOOD Plt Ct-60*
___ 08:00AM BLOOD Plt Ct-71*
___ 06:48AM BLOOD ___
___ 06:03AM BLOOD Ret Aut-4.5* Abs Ret-0.10
___ 05:31AM BLOOD Ret Aut-4.4* Abs Ret-0.09
___ 09:19PM BLOOD HIT Ab-NEG HIT ___
___ 09:29AM BLOOD Glucose-81 UreaN-58* Creat-10.4* Na-135
K-5.3 Cl-93* HCO3-25 AnGap-17
___ 08:21PM BLOOD Glucose-197* UreaN-67* Creat-12.1*
Na-132* K-4.9 Cl-91* HCO3-23 AnGap-18
___ 05:32AM BLOOD Glucose-98 UreaN-18 Creat-5.2* Na-142
K-3.7 Cl-100 HCO3-27 AnGap-15
___ 06:03AM BLOOD Glucose-112* UreaN-30* Creat-8.4*# Na-140
K-4.6 Cl-99 HCO3-21* AnGap-20*
___ 05:25AM BLOOD Glucose-89 UreaN-10 Creat-3.3*# Na-141
K-4.3 Cl-100 HCO3-31 AnGap-10
___ 08:00AM BLOOD Glucose-94 UreaN-27* Creat-4.8*# Na-140
K-4.3 Cl-101 HCO3-29 AnGap-10
___ 05:34AM BLOOD ALT-12 LD(LDH)-202 AlkPhos-53 TotBili-0.5
___ 06:03AM BLOOD ALT-13 AST-32 LD(LDH)-344* AlkPhos-46
TotBili-0.5
___ 09:29AM BLOOD Calcium-8.8 Phos-6.2* Mg-2.2
___ 08:21PM BLOOD Calcium-9.9 Phos-5.9* Mg-2.2
___ 02:18AM BLOOD Calcium-8.0* Phos-4.2 Mg-2.0
___ 06:03AM BLOOD Calcium-8.6 Phos-7.6* Mg-2.0
___ 07:05AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.0
___ 08:00AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.1
___ 06:03AM BLOOD Hapto-<10*
___ 05:31AM BLOOD Hapto-12*
___ 07:37AM BLOOD VitB12-1069*
___ 05:08AM BLOOD VitB12-1280* Folate->20
___ 09:29AM BLOOD %HbA1c-4.2 eAG-74
___ 05:31AM BLOOD TSH-2.4
___ 09:29AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS*
___ 08:00AM BLOOD IgM HBc-PND
___ 07:05AM BLOOD CMV IgG-PND CMV IgM-PND CMVI-PND EBV
IgG-PND EBNA-PND EBV IgM-PND EBVI-PND
___ 05:00PM BLOOD HCV VL-NOT DETECT
___ 07:05AM BLOOD HCV VL-NOT DETECT
___ 07:05AM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG & IGM)-PND
MICROBIOLOGY
============
___ 5:00 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending): No growth to date.
IMAGING
=======
___ Imaging AV FISTULOGRAM SCH
IMPRESSION:
Satisfactory restoration of flow following chemical and
mechanical
thrombolysis with a good angiographic and clinical result.
___ Imaging ART DUP EXT UP UNI OR L
IMPRESSION:
Small pseudoaneurysm immediately anterior to the AV fistula in
the left
antecubital fossa.
DISCHARGE LABS:
===============
___ 08:00AM BLOOD WBC-5.0 RBC-2.60* Hgb-8.5* Hct-27.3*
MCV-105* MCH-32.7* MCHC-31.1* RDW-17.5* RDWSD-67.6* Plt Ct-71*
___ 08:00AM BLOOD Plt Ct-71*
___ 08:00AM BLOOD Glucose-94 UreaN-27* Creat-4.8*# Na-140
K-4.3 Cl-101 HCO3-29 AnGap-10
___ 08:00AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.1
Brief Hospital Course:
Ms ___ is a ___ y/o ___ speaking patient with PMH
significant for Alzheimer's dementia, ESRD, and HTN, who
presented for thrombectomy, but was determined to not have
capacity to consent to procedure, and ___ was unable to get
consent, thus admitted for ___ procedure and dialysis. On ___,
Ms. ___ received a temp. line and recieved HD given worsening of
her condition. Eventually, HCP was contacted and She had a AVF
thrombectomy on ___. Her course was complicated by pancytopenia
requiring 1u pRBCs with improvement in cell counts prior to
discharge.
ACUTE ISSUES:
# Thrombosed Fistula- Resolved
Patient was originally transferred from nursing home for ___
intervention on clotted left AV fistula. She was unable to
consent for the procedure and was admitted to medicine service.
She had a temporary HD line placed to get HD while awaiting
consent from HCP. Consent was obtained and she underwent
thrombectomy on ___. She had HD successfully with her fistula
after thrombectomy. She had temporary HD line removed
afterwards.
#Pancytopenia
Patient was noted to have new onset pancytopenia during her
hospitalization. Etiology was unclear and felt to likely be
related to either viral infection or dysplastic bone marrow.
Hematology was consulted and assisted in infectious work up
which was unremarkable at time of discharge. Work up was notable
for negative HIT antibodies, mild evidence of hemolysis that
improved, normal bilirubin, normal B12 and folate, negative ___,
and HCV VL not detected. Pending work up included CMV IgG Ab,
CMV IgM Ab, EBV Ab Panel, HBC-IGM, and parvovirus B19
antibodies. Hgb nadir was 6.6 for which the patient received 1u
of PRBCs. Her discharge Hgb was 8.5. Platelets nadir of 60 with
discharge platelet count of 71. She required no platelet
transfusions during her hospitalization. Patient should have
repeat CBC at HD on ___. Could consider outpatient hematology
follow up if pancytopenia does not improve.
# ESRD
On MWF dialysis. As noted above, had temporary HD line placed
for HD that was removed after fistula was fixed. Last HD session
on ___. Will need HD on ___. Continue home calcium with meals,
sevelamer with meals.
# HTN
Patient was persistently hypertensive during her
hospitalization. Her losartan was increased from non-HD days to
daily and she remained on her home metoprolol succinate. Could
consider adding hydralazine as outpatient if BP remains
elevated.
CHRONIC/STABLE ISSUES:
#Dementia
Mental status was trended throughout her hospitalization and was
felt to be at baseline.
# COPD
- Hold home dulera (NF), duonebs q6hr prn
- Continue home montelukast
# GERD
- Continue ranitidine
# Hx Hep C
S/p treatment in ___.
# CODE STATUS: DNR/DNI per MOLST on file.
Transitional Issues:
===============================
[ ] Recheck CBC on ___ with HD
[ ] Consider hematology follow up if persistently pancytopenic
[ ] Follow up infectious work up: CMV IgG Ab, CMV IgM Ab, EBV Ab
Panel, HBC-IGM, and parvovirus B19 antibodies
[ ] Consider addition of hydralazine if BP remains elevated
[ ] Discontinued aspirin for primary prevention
[ ] Consider a family meeting regarding proxy - daughter hoping
to transition HCP to son
Patient seen and examined on day of discharge. Stable for
discharge to facility. >30 minutes on discharge activities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranitidine 150 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Allopurinol ___ mg PO BID
4. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation
BID
5. Loratadine 10 mg PO DAILY
6. Alendronate Sodium 35 mg PO QFRI
7. Losartan Potassium 100 mg PO 4X/WEEK (___)
8. Terazosin 2 mg PO QHS
9. Metoprolol Succinate XL 200 mg PO DAILY
10. Montelukast 10 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. LOPERamide 2 mg PO QID:PRN diarrhea
13. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
14. Calcium Acetate 667 mg PO TID W/MEALS
15. Ferric Citrate 210 mg PO TID W/MEALS
16. sevelamer CARBONATE 800 mg PO TID W/MEALS
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
2. Losartan Potassium 100 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Alendronate Sodium 35 mg PO QFRI
5. Allopurinol ___ mg PO BID
6. Calcium Acetate 667 mg PO TID W/MEALS
7. Dulera (mometasone-formoterol) 200-5 mcg/actuation
inhalation BID
8. Ferric Citrate 210 mg PO TID W/MEALS
Administer with food. Separate administration of other
medications by at least 2 hours.
9. LOPERamide 2 mg PO QID:PRN diarrhea
10. Loratadine 10 mg PO DAILY
11. Metoprolol Succinate XL 200 mg PO DAILY
12. Montelukast 10 mg PO DAILY
13. Ranitidine 150 mg PO DAILY
14. sevelamer CARBONATE 800 mg PO TID W/MEALS
15. Terazosin 2 mg PO QHS
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#Thrombocytopenia
#Thrombosed Fistula
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
======================
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 needed your fistula
fixed.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had your fistula fixed so you could get dialysis.
- You had low red blood cell counts and platelets. You were
given one unit of red blood cells with improvement in your blood
counts.
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:
___
|
10035844-DS-12 | 10,035,844 | 27,129,365 | DS | 12 | 2143-08-20 00:00:00 | 2143-08-24 09:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
oxycodone
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
Admission Labs
------------------
___ 01:22PM BLOOD WBC-11.5* RBC-4.96 Hgb-15.1 Hct-47.0*
MCV-95 MCH-30.4 MCHC-32.1 RDW-13.4 RDWSD-47.3* Plt ___
___ 01:22PM BLOOD Neuts-84.1* Lymphs-10.4* Monos-4.3*
Eos-0.1* Baso-0.6 Im ___ AbsNeut-9.68* AbsLymp-1.20
AbsMono-0.49 AbsEos-0.01* AbsBaso-0.07
___ 01:22PM BLOOD Plt ___
___ 01:22PM BLOOD Glucose-263* UreaN-17 Creat-0.9 Na-134*
K-5.5* Cl-102 HCO3-21* AnGap-11
___ 01:22PM BLOOD CK(CPK)-216*
___ 06:01AM BLOOD ALT-27 AST-45* AlkPhos-144* TotBili-0.8
___ 01:22PM BLOOD cTropnT-<0.01
___ 07:12AM BLOOD CK-MB-3 cTropnT-0.01
___ 07:12AM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.3 Mg-2.0
Cholest-155
___ 07:57AM BLOOD %HbA1c-7.1* eAG-157*
___ 07:12AM BLOOD HDL-34* CHOL/HD-4.6
___ 06:01AM BLOOD Cortsol-16.5
___ 01:22PM BLOOD TSH-2.2
___ 01:22PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
Discharge Labs
-------------------
___ 09:10AM BLOOD WBC-8.0 RBC-4.74 Hgb-14.5 Hct-45.3*
MCV-96 MCH-30.6 MCHC-32.0 RDW-13.2 RDWSD-46.6* Plt ___
___ 09:10AM BLOOD Plt ___
___ 09:10AM BLOOD Glucose-231* UreaN-12 Creat-0.8 Na-139
K-4.4 Cl-100 HCO3-24 AnGap-15
___ 09:10AM BLOOD ALT-30 AST-43*
___ 09:10AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.7
Imaging
------------------
CTA HEAD AND NECK
IMPRESSION:
1. Head CT: Images degraded by motion artifact. Within this
confine: No
definite acute territorial infarct, intracranial hemorrhage,
mass or mass
effect.
2. Head CTA: Patent circle of ___ without evidence of
stenosis,occlusion,or
aneurysm. Mild atherosclerotic calcifications of the bilateral
carotid
siphons.
3. Neck CTA: Images degraded by motion artifact. Within these
confines:
Linear filling defect within the proximal right internal carotid
artery
(3:157) is felt to reflect artifact related to patient motion.
There is
approximately 20% stenosis of the left proximal internal carotid
artery by
NASCET criteria. Otherwise, patent bilateral cervical carotid
and vertebral
arteries without evidence of stenosis, occlusion,or dissection.
CAROTID U/S
IMPRESSION:
Right ICA <40% stenosis.
Left ICA <40% stenosis.
MRI
IMPRESSION:
1. No acute intracranial abnormality. No evidence of acute or
subacute
infarct.
2. Mild nonspecific white matter signal changes most likely
reflecting chronic
small vessel disease in this age group
Brief Hospital Course:
___ is a ___ female with a history of
hypertension, diabetes on insulin who presented as a transfer
from ___ with hypoglycemia secondary to overinsulinization
found to have post-hypoglycemic tonic-clonic seizure complicated
by ___ paralysis with normal neurologic imaging and mental
status returning back to baseline. Her insulin regimen was
adjusted by the ___ diabetes team with education provided by
the diabetes educator.
TRANSITIONAL ISSUES:
====================
[] Ensure ___ follow up, patient given contact
information
[] Would benefit from Dexcom glucose monitor
[] Neuro follow up with seizure clinics
[] Needs a Basqimi (intransal glucagon) prescription upon follow
up
ACUTE ISSUES:
=============
#Hypoglycemic Seizure
#Left common carotid artery calcification
Patient presented to ___ with a tonic-clonic seizure that
was likely precipitated by a hypoglycemic episode with residual
right-sided hemiparesis secondary to a postictal state
precipitated by an overly aggressive home insulin sliding scale.
Work-up for her seizure was unremarkable with no signs of
infectious, toxic or Metabolic processes. Neurological imaging
with an CTA of the head and MRI was also unremarkable. She had
no further episodes of seizures while she was admitted here. She
will need follow up in the ___ seizure clinic for a routine
outpatient sleep deprived extended EEG as an outpatient.
#T2DM with repeated hypoglycemia
Her home insulin regimen consisted of 50 units of Lantus in the
AM
followed by 'carb counting' resulting in ___ units of Novolog
which was an overly aggressive insulin regimen. Her A1c during
this admission was 7.1 She was evaluated by the ___ team and
transition to a simpler insulin regimen of lantus 35u qAM with
sliding scale humalog with meals. She also met with the diabetes
nurse educator for further education.
CHRONIC ISSUES:
===============
#Hypothyroidism
Her TSH level was 2.2. Continued home levothyroxine 275mcg
daily.
#Depression
Continued her home sertraline 100mg daily
#HTN
Continued her home lisinopril
#Hyperlipidemia
Continued her home simvastatin.
CORE MEASURES
=============
#CODE: full confirmed
#CONTACT: ___, husband. ___: ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Sertraline 100 mg PO DAILY
2. Simvastatin 20 mg PO QPM
3. Lisinopril 20 mg PO DAILY
4. Glargine 50 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Levothyroxine Sodium 275 mcg PO DAILY
Discharge Medications:
1. Baqsimi (glucagon) 3 mg/actuation nasal PRN hypoglycemia
RX *glucagon [Baqsimi] 3 mg/actuation 1 spray nasal PRN Disp #*3
Spray Refills:*0
2. Glargine 35 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Levothyroxine Sodium 275 mcg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Sertraline 100 mg PO DAILY
6. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
==========
Hypoglycemic Seizure
Insulin depending diabetes mellitus
Secondary
==========
Hypothyroidism
Depression
Hypertension
Hyperlipedmia
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 admission to ___.
Below you will find information regarding your stay.
WHY WAS I ADMITTED TO THE HOSPITAL?
-You were admitted to the hospital because you had a seizure due
to low blood sugars.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-While you are in the hospital you received a number of imaging
diagnostic test to evaluate for causes of your seizure. These
tests all came back normal. Additionally, you also met with the
diabetes doctors as ___ as diabetes educator to work on a more
stable insulin regimen.
WHAT SHOULD I DO WHEN I GO HOME?
-Take your medications as prescribed and attend your follow up
appointments as scheduled.
-Please call ___ on ___ and request a "hospital
transition
appointment" within ___s a Dietician appointment on
the same day.
Thank you for letting us be a part of your care!
Your ___ Care Team
Followup Instructions:
___
|
10036086-DS-22 | 10,036,086 | 27,288,283 | DS | 22 | 2200-11-09 00:00:00 | 2200-11-10 14:57:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
Erythromycin Base / Biaxin / Ciprofloxacin
Attending: ___.
Chief Complaint:
left flank pain
Major Surgical or Invasive Procedure:
Cystoscopy left ureteral stent placement
History of Present Illness:
___ w hx of HIV, DM, CKD with 5 days of left flank pain. The
pain began this past ___ and was initially located in the
periumbilical region. It gradually moved to the left flank over
the following day. He describes the pain as sharp in nature and
nonradiating. The pain has been constant but waxing and waning
in
intensity, ranging from ___. He has been taking ibuprofen
twice a day for pain control. His PO intake has been minimal and
reports low grade fever to 100 and chills. He denies nausea and
vomiting. He denies dysuria, urinary frequency, urgency, or
hematuria. He has one prior kidney stone episode which passed
without instrumentation, he is unsure of when this occurred
Past Medical History:
PMHx/PSHx:
1. HIV, currently well controlled on antiretroviral therapy.
2. Prior hepatitis B.
3. Status post septic shock requiring Xigris with Strep
viridans
bacteremia.
4. Acute kidney injury and CVVH in the setting of severe
sepsis.
5. Chronic kidney disease, stage III.
6. History of splenic abscess status post splenectomy in ___
secondary to salmonella abscess.
7. Type 2 diabetes mellitus.
8. Obesity.
9. Hyperlipidemia.
10. Asthma.
11. Right medial meniscus tear.
12. History of severe bronchitis.
13. History of MRSA colonization.
Social History:
___
Family History:
Fam Hx: NC
Physical Exam:
AVSS
NAD
WWP
unlabored breathing
abd soft, NT, ND
Pertinent Results:
___ 04:25PM BLOOD WBC-10.2# RBC-4.72 Hgb-14.8 Hct-46.0
MCV-98 MCH-31.3 MCHC-32.2 RDW-14.0 Plt ___
___ 04:39AM BLOOD Glucose-92 UreaN-29* Creat-2.4* Na-141
K-4.7 Cl-108 HCO3-23 AnGap-15
___ 08:45PM BLOOD Glucose-63* UreaN-29* Creat-2.5* Na-140
K-4.6 Cl-106 HCO3-23 AnGap-16
___ 04:25PM BLOOD Glucose-82 UreaN-29* Creat-2.7*# Na-142
K-5.3* Cl-104 HCO3-24 AnGap-19
Brief Hospital Course:
The patient was admitted to the Urology Service under Dr.
___. On HD1 he underwent a left ureteral stent placement.
Please see the dictated note for further operative details. The
case was uncomplicated and he tolerated the procedure well. He
was discharged on HD1 after the procedure. He will follow up
with Dr. ___ in 2 weeks for discussion of definitive stone
management. He will see his nephrologist on ___ for repeat
creatinine draw. On discharge his pain was well controlled, he
was tolerating a diet, and voiding without issues.
Medications on Admission:
ALBUTEROL SULFATE - albuterol sulfate HFA 90 mcg/actuation
Aerosol Inhaler. 2 puffs(s) oral as needed - (Prescribed by
Other Provider)
ATORVASTATIN [LIPITOR] - Lipitor 40 mg tablet. one Tablet(s) by
mouth dialy - (Prescribed by Other Provider)
EFAVIRENZ [SUSTIVA] - Sustiva 600 mg tablet. 1 Tablet(s) by
mouth
daily - (Prescribed by Other Provider)
EMTRICITABINE [EMTRIVA] - Emtriva 200 mg capsule. one Capsule(s)
by mouth daily - (Prescribed by Other Provider)
EXENATIDE [BYETTA] - Byetta 10 mcg/0.04 mL per dose Sub-Q Pen
Injector. one syringe subcutaneous twice daily - (Prescribed by
Other Provider)
FENOFIBRATE MICRONIZED - fenofibrate micronized 134 mg capsule.
one capsule(s) by mouth daily - (Prescribed by Other Provider)
INSULIN GLARGINE [LANTUS SOLOSTAR] - Lantus Solostar 100 unit/mL
(3 mL) Sub-Q Insulin Pen. 75 u daily in AM - (Prescribed by
Other Provider)
LISINOPRIL - lisinopril 20 mg tablet. 1 tablet(s) by mouth daily
RALTEGRAVIR [ISENTRESS] - Isentress 400 mg tablet. one Tablet(s)
by mouth twice a day - (Prescribed by Other Provider)
SUPER IMMUNE - . 4 a day (super immune/nutrion brand)
TRAMADOL - tramadol 50 mg tablet. 1 tablet(s) by mouth TWICE
daily as needed for pain.
Medications - OTC
ASPIRIN [ADULT LOW DOSE ASPIRIN] - Adult Low Dose Aspirin 81 mg
tablet,delayed release. 1 Tablet(s) by mouth daily On Hold -
(Prescribed by Other Provider)
CHONDROITIN SULFATE A [CHONDROITIN SULFATE] - Chondroitin
Sulfate
250 mg capsule. 5 Capsule(s) by mouth daily 1200 mg dose, not
___. - (OTC)
COENZYME Q10 - Dosage uncertain - (Prescribed by Other
Provider)
GLUCOSAMINE SULFATE 2KCL - glucosamine sulfate dipotassium
chloride 500 mg capsule. 3 Capsule(s) by mouth daily -
(Prescribed by Other Provider)
MULTIVITAMIN - Dosage uncertain - (Prescribed by Other
Provider)
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - Fish Oil 1,000 mg
capsule. 2 Capsule(s) by mouth twice a day - (Prescribed by
Other Provider)
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Capsule Refills:*0
2. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth ___
hours Disp #*30 Tablet Refills:*0
3. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin 0.4 mg 1 capsule,extended release 24hr(s) by
mouth at bedtime Disp #*30 Capsule Refills:*0
Patient instructed to restart all home meds
Discharge Disposition:
Home
Discharge Diagnosis:
Left ureteral stone, acute on chronic renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume all of your pre-admission medications, except HOLD
aspirin until you see your urologist in follow-up
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place.
Followup Instructions:
___
|
10036086-DS-24 | 10,036,086 | 22,023,413 | DS | 24 | 2203-12-04 00:00:00 | 2203-12-04 18:19:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / Biaxin / Ciprofloxacin
Attending: ___
Chief Complaint:
Left arm pain
Major Surgical or Invasive Procedure:
Coronary Anatomy
Right dominant, heart rotated to the left.
LM: No significant disease.
LAD: Proximal 40% smooth disease. Mid vessel 90% stenosis after
large diag.
LCx: Luminal irregularities.
RCA: Luminal irregularities. 60% ostial PDA lesion.
Interventional Details
We proceeded with PCI of the mid LAD. XBLAD 3.5 guide. Vessel
wired with a Runthrough wire.
Angioplasty of the vessel followed by placement of a 3.0 x 18 mm
Xience DES, post dilated with a 3.5
and 3.75 NC balloon at high pressure. TIMI III flow, 0%
residual.
Impressions:
Successful PCI of severe mid LAD stenosis with single DES.
Recommendations
ASA for life, clopidogrel 75 daily x 3 months minimum
History of Present Illness:
Mr. ___ is a ___ year old male with PMH notable for HIV on
HAART therapy, T2IDDM, HTN, HLD, obesity, CKD who presents with
left arm pain. He was in his usual state of health until ___
when he was on the train when he noted severe dull left arm
pain. These symptoms lasted for approx. 5 minutes and improved.
Over the next few hours, he noted intermittent dull left arm
pain that felt very similar to that same episode. He then
presented to his PCP who referred him to the ED. Trops negative.
Nuclear stress test completed on ___ showed reversible
perfusion defect in the LAD territory. Since being here he has
had intermittent arm pain that can range in severity from a 2 to
an 8. Episodes of severe pain have been between 5 to 30 minutes.
He slept in a recliner last night as he feels his pain is less
when sitting upright.
At baseline, he is typically very sedentary as he had been
unemployed for 8 months. In ___, pt. began a new job and has
been walking approximately 1.3 miles a day. When he goes a
certain distance, he feels fatigued and short of breath which
causes him to stop. Additionally, when he goes up a flight a
steps, he feels very short of breath and can only do one flight
at a time. He denies a history of chest, arm, jaw, or back pain,
lightheadedness, dizziness, pre-syncope, syncope, worsening of
his chronic ___ edema, orthopnea, PND, or palpitations.
In the ED, pt. received crestor, losartan, fenofibrate, HAART
therapy, Tylenol, and insulin.
Past Medical History:
PMHx/PSHx:
1. HIV (VL ___, CD4 490 in ___ on antiretroviral therapy
2. Prior hepatitis B.
3. Status post septic shock requiring Xigris with Strep
viridans bacteremia.
4. Acute kidney injury and CVVH in the setting of severe
sepsis.
5. Chronic kidney disease, stage III.
6. History of splenic abscess status post splenectomy in ___
secondary to salmonella abscess.
7. Type 2 diabetes mellitus on insulin
8. Morbid obesity.
9. Hyperlipidemia.
10. Asthma.
11. Right medial meniscus tear.
12. History of severe bronchitis.
13. History of MRSA colonization.
Social History:
___
Family History:
nc
Physical Exam:
Physical Exam:
Gen: Alert, no acute distress, sitting comfortably in recliner
Neuro: Oriented x 3, speech clear, appropriate and
comprehensible, Follows commands appropriately, MAE, mood and
affect appropriate
CV: Regular rate/rhythm
Chest: Lungs clear bilaterally, diminished at bases, breathing
non-labored
ABD: Soft, non-tender, +bs
Extr: BLE warm/well-perfused, ___ pulses
Skin: Warm and dry
Pertinent Results:
___ 05:00AM BLOOD WBC-8.8 RBC-4.93 Hgb-14.9 Hct-47.3 MCV-96
MCH-30.2 MCHC-31.5* RDW-17.3* RDWSD-59.3* Plt ___
___ 05:50PM BLOOD WBC-9.4 RBC-5.39# Hgb-16.1# Hct-51.2*#
MCV-95 MCH-29.9 MCHC-31.4* RDW-17.3* RDWSD-58.6* Plt ___
___ 05:50PM BLOOD Neuts-62.6 ___ Monos-9.3 Eos-1.2
Baso-0.5 Im ___ AbsNeut-5.89 AbsLymp-2.43 AbsMono-0.87*
AbsEos-0.11 AbsBaso-0.05
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD ___ PTT-34.3 ___
___ 09:39PM BLOOD PTT-31.1
___ 12:45PM BLOOD ___ PTT-28.7 ___
___ 05:50PM BLOOD Plt ___
___ 05:00AM BLOOD Glucose-135* UreaN-26* Creat-1.3* Na-141
K-4.6 Cl-102 HCO3-27 AnGap-17
___ 05:50PM BLOOD Glucose-126* UreaN-27* Creat-1.4* Na-142
K-4.8 Cl-99 HCO3-29 AnGap-19
___ 11:35AM BLOOD cTropnT-<0.01
___ 12:45PM BLOOD cTropnT-<0.01
___ 12:00AM BLOOD cTropnT-<0.01
___ 05:50PM BLOOD cTropnT-<0.01
___ 05:50PM BLOOD proBNP-118
Brief Hospital Course:
Mr. ___ is a ___ year old man with a PMH notable for HIV on
HAART therapy, T2IDDM, hypertension, hyperlipidemia, obesity,
CKD who presented to the ED with left arm pain relieved with
nitroglycerin. He underwent a stress test, which was notable for
reversible ischemia in the LAD territory. He was started on
heparin and nitro gtts pre-cath and underwent a cardiac
catheterization on ___ and was found to have a severe mid
LAD stenosis and one DES was placed via a right radial approach.
his access site is clean without bleeding or hematoma. His CSM
is normal. His left arm pain never resolved and continues
despite coronary revascularization. He will be referred to his
PCP to have outpatient work-up for other non-cardiac cause. He
was started on ASA, Plavix and increased his dose of Crestor. He
will follow-up with Dr. ___ long term cardiology care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO DAILY
2. Fish Oil (Omega 3) ___ mg PO BID
3. Fenofibrate 134 mg PO DAILY
4. rilpivirine 25 mg oral DAILY
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO Q48H
6. RiTONAvir 100 mg PO DAILY
7. Rosuvastatin Calcium 20 mg PO QPM
8. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY
9. Glargine 60 Units Breakfast
10. Multivitamins 1 TAB PO DAILY
11. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Darunavir 800 mg PO DAILY
4. Glargine 60 Units Breakfast
5. Rosuvastatin Calcium 40 mg PO QPM
6. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
7. Emtricitabine-Tenofovir (Truvada) 1 TAB PO Q48H
8. Fenofibrate 134 mg PO DAILY
9. Fish Oil (Omega 3) ___ mg PO BID
10. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY
11. Losartan Potassium 50 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. rilpivirine 25 mg oral DAILY
14. RiTONAvir 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
CAD s/p DES to mid LAD
Discharge Condition:
Mr. ___ is a ___ year old man with a PMH notable for HIV on
HAART therapy, T2IDDM, hypertension, hyperlipidemia, obesity,
CKD who presented to the ED with left arm pain relieved with
nitroglycerin. He underwent a stress test, which was notable for
reversible ischemia in the LAD territory. He was started on
heparin and nitro gtts and which were stopped after his cardiac
catheterization. He is now s/p cardiac catheterization and DES
to LAD:
# Angina: fairly constant left arm discomfort since arrival to
___ on ___, worst was ___, currently ___, states has not
been ___ since his arrival. Now s/p cardiac catheterization
with PCI of severe mid LAD stenosis with ___ 1:
-NTG gtt stopped post-cath
-Heparin gtt stopped post-cath
-ASA 81mg po daily lifelong
-Start Plavix 75mg daily x minimum 3 months
-Referral to cardiac rehab upon discharge
-Follow-up with Dr. ___ for ___ cardiologist per
patient request.
# DM
-continue Lantus
-(takes victoza at home; may resume upon discharge,
non-formulary here) monitor ___, ISS PRN
-carb consistent diet
# Hypertension: BP stable 120s/70s
-Losartan held for cath (cr 1.4, now 1.3)
-___ resume post discharge
# Hyperlipidemia
-Increase Crestor to 40 mg
-cont Fenofibrate
# CKD stage III GFR 51 Creat 1.4
-pre and post IV hydration
-Holding Losartan for procedure; may resume upon discharge
-Renal function labs on ___
#. HIV
-cont home med regimen
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with left arm pain and were worked up
for a cardiac source. You had an abnormal stress test followed
by a cardiac catheterization. You were found to have a blockage
in your left anterior descending artery and a drug coated stent
was placed to improve blood flow to the heart. You will take
Aspirin 81mg daily for life and Plavix 75mg daily. These will
prevent a clot from forming in your stent. Do not stop taking
either of these unless your cardiologist instructs you to do so.
Stopping either of these will put you at risk for a life
threatening heart attack. We also recommend that you consider
attending a cardiac rehab program. A referral has been provided
with your discharge paperwork. Care of your right wrist access
site will be provided in your discharge instructions.
We are providing you with a lab slip to get your kidney function
tests checked on ___. We will request that
the results be sent to your PCP.
Your arm pain has not resolved despite your improved blood flow
to the heart muscle. We recommend that you follow-up with your
PCP to be worked up outpatient for other non-cardiac related
sources.
It has been a pleasure caring for you at ___!
Followup Instructions:
___
|
10036086-DS-25 | 10,036,086 | 25,086,233 | DS | 25 | 2206-01-30 00:00:00 | 2206-01-30 19:30:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / Biaxin / Ciprofloxacin
Attending: ___
Chief Complaint:
PE
Major Surgical or Invasive Procedure:
TEE/DCCV ___
History of Present Illness:
___ y/o male with hx of HIV on HAART therapy, prostate cancer s/p
brachytherapy, T2IDDM, HTN, HLD, obesity, CKD, presents w
tachycardia and dyspnea on exertion. Patient went to PCP today
for bilateral lower ext edema but was found to have a a heart
rate of 130s so sent here. He states that for the past few weeks
he has had progressive dyspnea with exertion and b/l swelling.
No
history of blood clot. No chest pain. no fevers. no abdominal
pain, n/v, cough or congestion. has had increased erythema over
the left lower ext medial mal with pain progressively worsening.
In the ED, initial vitals were:
HR 132 BP 152/88 RR 18 O2 95
- Exam notable for:
RLE swelling, erythema over bilat malls abrasions over the
anterior shin. full ROM of all joint.
- Labs notable for:
134 100 40 AGap=11
------------<295
9.1 23 1.5
Repeat whole K: 4.5
proBNP: 843
Trop-T: 0.04
Lactate:3.1-->3.5
- Imaging was notable for:
CTA
1. Pulmonary emboli extending from the distal right main
pulmonary artery to segmental level in right upper and middle
lobes and subsegmental level in right lower lobe. No left-sided
pulmonary emboli. Difficult to exclude right heart strain.
Echocardiogram would further assess.
2. No focal consolidation.
3. Mild nodular contour of the liver raise concern for
cirrhosis.
Correlation with liver function test is recommended for further
evaluation.
4. Status post splenectomy.
___ on right
There is non-occlusive deep vein thrombus of a right posterior
tibial vein.
- Patient was given:
___
___ 13:41 IV Piperacillin-Tazobactam
___ 13:41 IVF NS
___ 14:52 IV Vancomycin 1500mg
___ 17:33 IV Heparin 6500 UNIT ___
___ 18:41 IVF NS ___ Started
Upon arrival to the ICU, patient reports feeling fine without
sx.
Review of systems was negative except as detailed above.
Past Medical History:
PMHx/PSHx:
1. HIV (VL ___, CD4 490 in ___ on antiretroviral therapy
2. Prior hepatitis B.
3. Status post septic shock requiring Xigris with Strep
viridans bacteremia.
4. Acute kidney injury and CVVH in the setting of severe
sepsis.
5. Chronic kidney disease, stage III.
6. History of splenic abscess status post splenectomy in ___
secondary to salmonella abscess.
7. Type 2 diabetes mellitus on insulin
8. Morbid obesity.
9. Hyperlipidemia.
10. Asthma.
11. Right medial meniscus tear.
12. History of severe bronchitis.
13. History of MRSA colonization.
Social History:
___
Family History:
nc
Physical Exam:
ADMISSION EXAM:
===============
GENERAL: well-appearing sitting in bed with no distress
HEENT: NCAT
CARDIAC: RRR, no mgr.
PULMONARY: Lungs clear to auscultation b/l. No wheezing.
CHEST: no tenderness to palpation
ABDOMEN: soft and non-distended. Non-tender to palpation.
EXTREMITIES: RLE swelling, erythema over bilat malleoli w
abrasions over the anterior shin. full ROM of all joints.
SKIN: Abrasions over the anterior shin.
NEURO: A&Ox3. Motor and sensory exam grossly normal.
DISCHARGE EXAM:
===============
GENERAL: Well appearing male in no acute distress. Comfortable.
HEENT: NCAT. EOMI. MMM.
CARDIAC: Rapid rate, regular rhythm. Distant heart sounds. No
appreciable murmurs.
PULMONARY: Clear to auscultation bilaterally. Breathing
comfortably on nasal cannula.
ABDOMEN: Soft, non-tender, non-distended. No hepatosplenomegaly.
EXTREMITIES: Warm, well perfused, 1+ ___ on R>L. Right leg with
multiple healing ulcers. Diffuse erythema around right ankle,
tender, warm, no clear border between erythema and normal skin.
NEURO: AAOx3. CNII-XII grossly intact. Moving all four
extremities with purpose.
Pertinent Results:
ADMISSION LABS:
===============
___ 01:32PM BLOOD WBC-11.8* RBC-4.78 Hgb-15.8 Hct-47.6
MCV-100* MCH-33.1* MCHC-33.2 RDW-15.3 RDWSD-56.4* Plt ___
___ 01:32PM BLOOD Neuts-78.8* Lymphs-11.6* Monos-7.4
Eos-0.1* Baso-0.2 NRBC-0.2* Im ___ AbsNeut-9.27*
AbsLymp-1.37 AbsMono-0.87* AbsEos-0.01* AbsBaso-0.02
___ 01:32PM BLOOD ___ PTT-22.6* ___
___ 01:32PM BLOOD Plt ___
___ 01:32PM BLOOD Glucose-295* UreaN-40* Creat-1.5* Na-134*
K-9.1* Cl-100 HCO3-23 AnGap-11
___ 01:32PM BLOOD ALT-<5 AST-168* AlkPhos-41 TotBili-0.5
___ 01:32PM BLOOD proBNP-843*
___ 01:32PM BLOOD cTropnT-0.04*
___ 01:32PM BLOOD Albumin-3.4* Calcium-9.4 Phos-4.1 Mg-2.1
___ 04:58AM BLOOD PSA-<0.03
___ 11:13PM BLOOD ___ Temp-36.8 pO2-60* pCO2-39
pH-7.43 calTCO2-27 Base XS-1 Intubat-NOT INTUBA
___ 01:51PM BLOOD Lactate-3.1*
___ 03:00PM BLOOD LMWH-1.01
DISCHARGE LABS:
===============
___ 06:51AM BLOOD WBC-10.1* RBC-4.32* Hgb-14.2 Hct-44.2
MCV-102* MCH-32.9* MCHC-32.1 RDW-15.6* RDWSD-59.1* Plt ___
___ 06:51AM BLOOD Glucose-151* UreaN-42* Creat-1.2 Na-147
K-4.9 Cl-107 HCO3-25 AnGap-15
___ 04:58AM BLOOD AST-20 AlkPhos-53 TotBili-0.4
___ 06:51AM BLOOD Calcium-9.6 Phos-3.2 Mg-2.3
PERTINENT STUDIES:
==================
TEE ___
There is no spontaneous echo contrast or thrombus in the body of
the left atrium/left atrial appendage. The left atrial appendage
ejection velocity is normal. The interatrial septum is dynamic,
but not frankly aneurysmal. There is no evidence for an atrial
septal defect by 2D/color Doppler though evaluation was limited
by tachycardia and limited images obtained. Overall left
ventricular systolic function is at least mildly depressed with
beat-to-beat variability in the left ventricular contractility
due to the irregular rhythm. The right ventricle has moderate
global free wall hypokinesis. There are simple atheroma in the
descending aorta to from the incisors. The aortic valve leaflets
(3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. No abscess is seen.
There is trace aortic regurgitation. The mitral valve leaflets
appear structurally normal with no mitral valve prolapse. No
masses or vegetations are seen on the mitral valve. No abscess
is seen. There is mild to moderate [___] mitral regurgitation.
The tricuspid valve leaflets appear structurally normal. No
mass/vegetation are seen on the tricuspid valve. No abscess is
seen. There is tricuspid regurgitation present (could not be
qualified).
IMPRESSION: No vegetations or intracardiac thrombus seen. Mild
global biventricular systolic dysfunction. Mild to moderate
mitral regurgitation.
CTA Chest ___
IMPRESSION:
1. Pulmonary emboli extending from the distal right main
pulmonary artery to segmental level in right upper and middle
lobes and subsegmental level in right lower lobe. No left-sided
pulmonary emboli. Difficult to exclude right heart strain.
Echocardiogram would further assess.
2. No focal consolidation.
3. Mild nodular contour of the liver raise concern for
cirrhosis.
Correlation with liver function test is recommended for further
evaluation.
4. Status post splenectomy.
U/S of ___ ___
IMPRESSION:
Non-occlusive deep vein thrombus of one right posterior tibial
vein.
Brief Hospital Course:
___ man with history of CAD s/p DES to LAD (___),
HIV
on HAART, HTN, HLD, diabetes, prostate cancer s/p brachytherapy,
CKD, salmonella splenic abscess s/p splenectomy (___), and
prior
hepatitis B infection admitted w/ submassive PE and AF w/ RVR.
ACUTE ISSUES
============
# SUBMASSIVE PULMONARY EMBOLISM
# RIGHT LOWER EXTREMITY DVT
Notable for TTE with evidence of right heart strain as well as
mild troponin elevation. Never hypotensive, initiated on heparin
gtt upon arrival, quickly weaned to RA. Appears unprovoked at
this time: no signs of active malignancy,
immobilization (although obese, not active), operations, or
family history. Transitioned to warfarin, discharged on ___
bridge.
# ATRIAL FIBRILLATION W/ RVR
No prior records of Afib. Likely provoked ___ PE. Had rates
difficult to control despite escalating doses of metoprolol and
initiation of PO amiodarone. Hence, he had TEE and DCCV ___,
successful, remained in sinus at time of discharge.
Anticoagulation as above. Restarted on home dose metop succinate
25mg daily after DCCV, continued on PO amiodarone.
# Acute on Chronic HFpEF:
TTE this admission w/ poor image quality, noted depressed
systolic function but could not determine EF. If EF was
decreased, likely rate related I/s/o Afib w/ RVR. Mildly volume
overloaded on exam initially, responded well to low dose IV
diuresis, did not require PO diuretic at time of discharge.
# RLE Cellulitis: noted upon arrival, nonpurulent, started on
cephalexin for ___ORONARY ARTERY DISEASE
s/p DES to LAD (___). Mild troponin elevation likely
reflective of right heart strain from acute PE. Chest pain free.
Continued ASA, statin, ___, and BB as above. D/c'd Plavix given
initiation of AC, and > ___ year since stent placement.
# RADIOGRAPHIC LIVER ABNORMALITY
Mild nodular contour of the liver raises concern for cirrhosis.
Consider. outpatient Fibroscan and possibly hepatology referral.
CORE MEASURES:
=================================
# HIV
Most recent VL undetectable. CD4 of 500. Continued home HAART
regimen (Darunavir 800 mg PO QHS, Cobicistat 150 mg PO QHS,
Odefsey 200-25-25 mg oral QHS)
# HYPERLIPIDEMIA: Fenofibrate 145 mg PO DAILY in addition to
statin (both home meds)
# DIABETES: held PO meds, placed on insulin sliding scale.
TRANSITIONAL ISSUES
===================
[] given unprovoked PE, ensure age appropriate malignancy
screening has been done. if unremarkable, consider
hypercoagulability w/u.
[] currently on lovenox bridge until warfarin therapeutic.
Increased warfarin dose to 10mg daily on day of discharge. Will
need close monitoring and titration of warfarin dose, d/c
lovenox when INR > 2.
[] ___ of Hearts monitor at time of discharge
[] PO amiodarone started I/s/o difficult to control AF w/ RVR.
Please re-evaluate its need moving forward.
[] cephalexin for RLE cellulitis for 7 day course. Please
re-evaluate leg. pt diabetic and high risk for PVD, consider
noninvasive flow studies.
[] repeat TTE in several weeks to eval interval change from
prior, define EF, ensure not newly reduced
[] monitor for signs of increased volume, start diuretic as
necessary
[] outpatient Fibroscan and possibly hepatology referral given
liver appearance on imaging, high risk for NASH
[] on ASA/Plavix upon arrival for DES in ___. Given > ___ year,
and placed on warfarin, d/c'd Plavix use.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fenofibrate 145 mg PO DAILY
2. Rosuvastatin Calcium 40 mg PO QPM
3. Losartan Potassium 50 mg PO DAILY
4. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID
5. Clopidogrel 75 mg PO DAILY
6. Odefsey (emtricitab-rilpivir-tenofo ala) 200-25-25 mg oral
DAILY
7. Darunavir 800 mg PO DAILY
8. Cobicistat 150 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO TID
2. Cephalexin 500 mg PO Q6H Duration: 4 Days
3. Enoxaparin Sodium 120 mg SC BID
4. Warfarin 10 mg PO DAILY16
5. Glargine 60 Units Breakfast
6. Aspirin 81 mg PO DAILY
7. Cobicistat 150 mg PO DAILY
8. Darunavir 800 mg PO DAILY
9. Fenofibrate 145 mg PO DAILY
10. Losartan Potassium 50 mg PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Odefsey (emtricitab-rilpivir-tenofo ala) 200-25-25 mg oral
DAILY
13. Rosuvastatin Calcium 40 mg PO QPM
14. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID
15.Outpatient Lab Work
Please obtain an INR ___
ICD-9 Code: ___
Contact: ___ Phone: ___ Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Pulmonary Embolism
Right Lower Extremity Deep Vein Thrombosis
Atrial Fibrillation with rapid ventricular response
Acute on Chronic Heart Failure with preserved ejection fraction
SECONDARY DIAGNOSIS
===================
Coronary Artery Disease
HIV
Diabetes Mellitus II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___!
WHY WERE YOU ADMITTED
=====================
You were admitted after we found blood clots in your lungs and
legs. You were also in an abnormal heart rhythm.
WHAT DID WE DO FOR YOU HERE
===========================
We started you on blood thinners for the clots. We then shocked
your heart back into a normal rhythm.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE
=====================================
- It is really important that you take your blood thinner
(warfarin) as prescribed. You need to have regular blood checks
to make sure the blood thinner is at a good level (INR between 2
and 3).
- You need to see a cardiologist (heart doctor) after you leave
the hospital.
- You were discharged on an event monitor that will record your
heart rhythm if it is triggered. If you feel palpitations,
trigger the monitor so your cardiologist can see if your heart
goes back into an abnormal rhythm.
- Please weigh yourself every morning. If your weight increases
by more than 3lbs in one day or 5 lbs in one week, please call
your cardiologist to consider adding a medicine that will keep
the extra fluid out of your body.
We wish you the best of health,
Your ___ Care Team
Followup Instructions:
___
|
10036086-DS-26 | 10,036,086 | 24,186,608 | DS | 26 | 2206-03-20 00:00:00 | 2206-03-20 19:46:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / Biaxin / Ciprofloxacin
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
___ catheter insertion
___ filter placement
___ with duodenal ulcer clipping
History of Present Illness:
Mr. ___ is a ___ man with a history of CAD s/p DES
to LAD (___), HIV on HAART, HTN, HLD, diabetes, prostate
cancer s/p brachytherapy, CKD, salmonella splenic abscess s/p
splenectomy (___), and prior hepatitis B infection who was
admitted with a submassive PE and AF with RVR on ___ until
___ at ___. He is now presenting with dyspnea in the
setting of being off anticoagulation since ___ in the setting
of GI and RP bleeding.
Of note patient was recently admitted with submassive PE on
___. MASCOT was consulted and he was treated and discharged
on warfarin with a lovenox bridge. During that admission, he
also had a TEE/DCCV for new AF with RVR and started on
amiodarone PO.
After discharge on ___ patient was doing well until
___ when he developed severe abdominal pain and was
admitted to ___ with GI and RP bleeding. After
admission to the floor, his BP dropped to SBP ___, for which he
required norepinephrine and 4 units pRBCs.
Patient was then discharged to rehab on ___ off of all
anticoagulation. He was doing well until ___ when he
developed acute shortness of breath with mild activity getting
around and new swelling in both his legs and his right arm. He
had no chest pain, palpitations, lightheadedness,dizziness, or
syncope.
Given these symptoms he was sent from rehab to ___
where he was found to be hypoxemic and hypotensive to SBP ___. A
CT was performed showing a saddle PE, for which he was started
on heparin and transferred to ___.
Past Medical History:
PMHx/PSHx:
1. HIV (VL <20, CD4 500s in ___ on antiretroviral therapy
2. Prior hepatitis B.
3. Status post septic shock requiring Xigris with Strep
viridans bacteremia.
4. Acute kidney injury and CVVH in the setting of severe
sepsis.
5. Chronic kidney disease, stage III.
6. History of splenic abscess status post splenectomy in ___
secondary to salmonella abscess.
7. Type 2 diabetes mellitus on insulin
8. Morbid obesity.
9. Hyperlipidemia.
10. Asthma.
11. Right medial meniscus tear.
12. History of severe bronchitis.
13. History of MRSA colonization.
14. Submassive PE/DVT in ___
15. Retroperitoneal venous bleed in ___
16. Saddle PE/DVT in ___
17. Paroxysmal atrial fibrillation with h/o RVR
Social History:
___
Family History:
nc
Physical Exam:
Admission Physical Examination:
===============================
VS: T 96.9, BP 126/72, HR 98, Resp rate 28 O2Sa 91% on 6L NC
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: Supple. JVP not elevated.
CARDIAC: RRR no m/r/g
LUNGS: CTAB no r/r/w
ABDOMEN: Soft, NT, ND, +BS, scattered bruising.
EXTREMITIES: Bilateral leg edema R>L
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Discharge Physical Examination:
================================
VS: 24 HR Data (last updated ___ @ 509)
Temp: 97.5 (Tm 97.5), BP: 126/52 (115-126/52-62), HR: 71
(71-76),
RR: 18, O2 sat: 98% (93-98), O2 delivery: 2.5L (2L NC-3L), Wt:
552.47 lb/250.6 kg
Fluid Balance (last updated ___ @ 538)
Last 8 hours Total cumulative 1206ml
IN: Total 1256ml, PO Amt 400ml, IV Amt Infused 856ml
OUT: Total 50ml, Urine Amt 50ml
Last 24 hours Total cumulative 1206ml
IN: Total 1256ml, PO Amt 400ml, IV Amt Infused 856ml
OUT: Total 50ml, Urine Amt 50ml
(Multiple missed voids)
GEN: morbidly obese woman lying in bed in NAD
HEENT: NC/AT. PERRLA, EOMI, MMM.
NECK: supple
CV: RRR, no murmurs
PULM: CTAB no increased WOB
ABD: obese, soft, NT, ND, +BS
EXTR: WWP. No clubbing, cyanosis, or peripheral edema.
SKIN: no significant lesions or rashes.
PULSE: distal pulses palpable and symmetric.
NEURO: AOx3, grossly intact.
Pertinent Results:
Admission Labs:
===============
___ 05:03PM TYPE-ART PO2-64* PCO2-43 PH-7.40 TOTAL CO2-28
BASE XS-0
___ 04:44PM HGB-10.0* HCT-33.9*
___ 04:44PM PTT-60.9*
___ 04:44PM ___
___ 12:35PM TYPE-ART PO2-116* PCO2-58* PH-7.29* TOTAL
CO2-29 BASE XS-0
___ 12:00PM HGB-9.7* HCT-33.5*
___ 12:00PM ___
___ 10:17AM TYPE-ART PO2-149* PCO2-58* PH-7.27* TOTAL
CO2-28 BASE XS--1
___ 10:01AM WBC-9.1 RBC-3.03* HGB-9.8* HCT-33.4* MCV-110*
MCH-32.3* MCHC-29.3* RDW-19.1* RDWSD-75.8*
___ 10:01AM ___ PTT-47.1* ___
___ 10:01AM ___
___ 08:26AM TYPE-ART PO2-61* PCO2-51* PH-7.32* TOTAL
CO2-27 BASE XS-0
___ 08:26AM LACTATE-1.1
___ 06:58AM TYPE-ART PO2-103 PCO2-56* PH-7.25* TOTAL
CO2-26 BASE XS--3
___ 06:58AM LACTATE-1.2
___ 06:51AM GLUCOSE-227* UREA N-39* CREAT-1.3* SODIUM-141
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-22 ANION GAP-14
___ 06:51AM ALT(SGPT)-20 AST(SGOT)-26 LD(LDH)-720* ALK
PHOS-67 TOT BILI-1.0
___ 06:51AM ALBUMIN-2.8* CALCIUM-8.4 PHOSPHATE-5.3*
MAGNESIUM-1.8
___ 06:51AM WBC-9.5 RBC-3.26* HGB-10.4* HCT-35.9*
MCV-110* MCH-31.9 MCHC-29.0* RDW-19.1* RDWSD-76.0*
___ 06:51AM ANISOCYT-1+* POIKILOCY-1+* MACROCYT-1+*
POLYCHROM-1+* ECHINO-1+* RBCM-SLIDE REVI
___ 06:51AM PLT SMR-NORMAL PLT COUNT-272
___ 06:51AM ___ PTT-55.9* ___
___ 03:00AM %HbA1c-7.1* eAG-157*
___ 02:36AM ___ PTT-56.6* ___
___ 02:22AM ___ PO2-30* PCO2-51* PH-7.36 TOTAL
CO2-30 BASE XS-0
___ 02:22AM LACTATE-1.1
___ 02:22AM O2 SAT-50
___ 12:37AM VoidSpec-SPECIMEN S
___ 11:51PM GLUCOSE-167* UREA N-41* CREAT-1.2 SODIUM-141
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-11
___ 11:51PM estGFR-Using this
___ 11:51PM cTropnT-0.21* proBNP-5167*
___ 11:51PM WBC-9.9 RBC-3.32* HGB-10.7* HCT-36.3*
MCV-109* MCH-32.2* MCHC-29.5* RDW-18.9* RDWSD-73.7*
___ 11:51PM NEUTS-70.8 LYMPHS-17.5* MONOS-9.0 EOS-0.4*
BASOS-0.3 NUC RBCS-3.2* IM ___ AbsNeut-6.98* AbsLymp-1.73
AbsMono-0.89* AbsEos-0.04 AbsBaso-0.03
___ 11:51PM PLT COUNT-292
___ 11:51PM ___ PTT-76.6* ___
Pertinent Labs:
==================
___ 03:00AM BLOOD %HbA1c-7.1* eAG-157*
___ 05:29AM BLOOD VitB___ Folate-9
Pertinent Studies:
==================
CXR: ___
FINDINGS:
- Lung volumes are low bilaterally. There has been interval
placement of a right chest port with tip overlying the
cavoatrial junction. Streaky linear bibasilar opacities likely
represent atelectasis. There is no focal consolidation,
effusion, or pneumothorax. The cardiomediastinal silhouette is
likely mildly enlarged although this is likely exaggerated by
low lung volumes and the AP technique. No acute osseous
abnormalities are identified.
IMPRESSION:
1. Interval placement of a right chest port with tip overlying
the cavoatrial junction. No pneumothorax.
2. Redemonstration hypoinflated lungs with lower lobe volume
loss.
___ Pulmonary Arteriogram
COMPARISON: CTA Chest ___ from outside facility.
TECHNIQUE: Dr. ___ and Dr. ___
Interventional ___ and Dr. ___,
Interventional Radiology fellow performed the procedure.
ANESTHESIA: Mac sedation was provided by anesthesia.
MEDICATIONS: A total of 8 mg of tPA were infused during the
procedure.
CONTRAST: 60 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 21.7 minutes, 1122 mGy
PROCEDURE: 1. Right IJ central venous access under ultrasound
guidance.
2. Left pulmonary arteriogram.
3. Left pulmonary artery chemical thrombolysis.
4. Lysis catheter placement in the left lower lobe pulmonary
artery.
5. Right pulmonary arteriogram.
6. Right pulmonary artery mechanical and chemical thrombolysis.
7. Repeat right pulmonary arteriogram.
8. Lysis catheter placement in the right lower lobe pulmonary
artery.
PROCEDURE DETAILS: Following the discussion of the risks,
benefits and
alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the
angiography suite and placed supine on the exam table. A
pre-procedure time-out was performed per ___ protocol. The
neck and both groins were prepped and draped in the usual
sterile fashion.
Preliminary ultrasound images of the right IJ were stored. The
overlying skin was anesthetized with 1% lidocaine solution. A
21 gauge needle was advanced into the right IJ under ultrasound
guidance. A microwire was advanced through the needle into the
___. A small skin ___ was made at the needle insertion site.
The needle was exchanged for a micropuncture access sheath. The
wire and inner dilator were removed ___ wire was advanced
into the ___. The micro sheath was then exchanged for a 6
___ sheath. The inner dilator and ___ wire were then
removed.
A 5 ___ C2 Cobra glide catheter and Glidewire were then
advanced through the sheath and used to navigate into the left
pulmonary artery. The wire was removed. At this point, the
catheter was used to measure pulmonary artery pressures (the
left mean pulmonary artery pressure was 51). Contrast was
injected to confirm positioning. A digital was retracted left
pulmonary arteriogram was performed, demonstrating large filling
defect in the proximal pulmonary artery and a paucity of lower
lobe pulmonary artery branches. At this point, the patient's
hemodynamic status began to decline. 2 mg of diluted tPA were
injected directly into the proximal thrombus. A ___ wire was
then advanced through the Cobra catheter, which was subsequently
exchanged for a 6 cm EKOS infusion catheter.
A 21 gauge needle was advanced into the right IJ at a separate
access site under ultrasound guidance. A microwire was advanced
through the needle into the ___. A small skin ___ was made at
the needle insertion site. The needle was exchanged for a
micropuncture access sheath. The wire and inner dilator were
removed ___ wire was advanced into the ___. The micro
sheath was then exchanged for a 6 ___ sheath. The Cobra
catheter was advanced through the new sheath and navigated into
the right pulmonary artery with a Glidewire. Glidewire was
removed. Contrast was injected to confirm positioning. A
digitally subtracted right pulmonary arteriogram was performed,
demonstrating proximal thrombus and near complete occlusion of
the right lung sparing only 2 segments in the right upper lobe.
2 mg of dilute tPA were infused directly into the thrombus.
A ___ wire was advanced through the Cobra catheter. The Cobra
catheter was exchanged for a Omni flush catheter. The Omni
Flush catheter was used to perform mechanical thrombectomy as an
additional 4 mg of tPA were infused. The ___ wire was
injected advanced through the Omni Flush catheter. The Omni
Flush catheter was then removed. The 6 ___ sheath was
exchanged for an 8 ___ sheath. A penumbra aspiration
catheter was advanced over the ___ wire and into the right
pulmonary artery. The aspiration catheter was used for
thrombectomy transiently. Shortly after initiation of
thrombectomy, the patient's hemodynamic status significantly
improved. The aspiration catheter was then exchanged over a
___ wire for the Omni Flush catheter.
A repeat digitally subtracted right pulmonary arteriogram was
performed
demonstrating improved flow the right lung. The ___ wire was
then advanced through the Omni Flush catheter and positioned in
the right lung base. The Omni Flush catheter was then exchanged
for a 12 cm EKOS infusion catheter. Contrast was injected
through both EKOS catheters to confirm positioning. The coast
catheters were then assembled unattached to respective devices.
Both sheaths and infusion catheters were secured to the skin
with 0 silk suture. A sterile dressing was applied.
The patient tolerated the procedure well. There were no
immediate post-procedure complications. The patient was
transferred to the ICU in stable condition.
FINDINGS:
- Pulmonary arteriograms demonstrated extensive thrombosis
bilaterally.
- Local tPA was infused (total of 8 mg).
- Post thrombolysis/thrombectomy arteriogram showed improvement
in pulmonary arterial flow.
- Successful placement of bilateral pulmonary arterial EKOS
lysis catheters.
IMPRESSION:
- Successful pulmonary arterial thrombus debulking.
- Successful placement of bilateral pulmonary arterial EKOS
lysis catheters.
TTE ___
CONCLUSION:
There is mild symmetric left ventricular hypertrophy with a
normal cavity size. There is normal regional left ventricular
systolic function. Overall left ventricular systolic function is
normal. The visually estimated left ventricular ejection
fraction is 55-60%. Moderately dilated right ventricular cavity
with moderate global free wall hypokinesis. There is abnormal
interventricular septal motion c/w right ventricular pressure
overload. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. There is trace aortic
regurgitation. The tricuspid valve leaflets are mildly
thickened. There is mild [1+] tricuspid regurgitation. There is
moderate pulmonary artery systolic hypertension.
IMPRESSION: Dilated right ventricle with moderate global RV
systolic dysfunction. Moderate pulmonary hypertension.
___ IVC Filter Placement
Final Report
INDICATION: ___ year old man with DVT and history of bleeding
from
anticoagulation// IVC filter placement
COMPARISON: Lower extremity venous duplex dated ___
TECHNIQUE: Dr. ___ Interventional ___,
performed the procedure.
ANESTHESIA: 1% lidocaine was injected in the skin and
subcutaneous tissues
overlying the access site.
MEDICATIONS: 1% lidocaine
CONTRAST: 25 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 4.7, 484 mGy
PROCEDURE:
1. IVC venogram.
2. Infrarenal Denali IVC filter deployment.
3. Post-filter placement venogram.
PROCEDURE DETAILS: Following the discussion of the risks,
benefits and alternatives to the procedure, written informed
consent was obtained from the patient. The patient was then
brought to the angiography suite and placed supine on the exam
table. A pre-procedure time-out was performed per ___
protocol. the right neck was prepped and draped in the usual
sterile fashion.
An Amplatz wire was placed through the existing 8 ___ sheath.
The sheath was removed over the wire and a new 8 ___ sheath
was placed. The Amplatz wire was passed down into the distal
IVC and left iliac vein. Over the wire, a straight flush
catheter was placed. A inferior vena cava venogram was
performed. Based on the results of the venogram, detailed below,
a decision was made to place a Denali filter. The catheter and
sheath were removed over the wire and the sheath of a Denali
filter was advanced over the wire into the IVC past the take-off
of the renal vessels. An Denali vena cava filter was advanced
over the wire until the cranial tip was at the level of the
inferior margin of the lower renal vein. The sheath was then
withdrawn until the filter was deployed. The wire and loading
device were then removed through the sheath and a repeat
contrast injection was performed, confirming appropriate filter
positioning. The final image was stored on PACS.
The sheath was removed and pressure was held for 5 minutes,at
which point
hemostasis was achieved. A sterile dressing was applied. The
patient tolerated the procedure well and there were no immediate
post procedure complications.
FINDINGS:
1. Patent normal sized, non-duplicated IVC with single bilateral
renal veins and no evidence of a clot.
2. Successful deployment of an infra-renal Denali IVC filter.
___ CXR Portable
FINDINGS:
- There is no evidence of pneumoperitoneum, though detection is
severely limited given patient positioning. Lung volumes are
low bilaterally. No focal consolidation is seen. Blunting of
the left costophrenic angle is unchanged and likely secondary to
pericardial fat as demonstrated on CT from ___.
The right internal jugular central line has been removed.
IMPRESSION:
- No evidence of pneumoperitoneum, though detection severely
limited by patient positioning and portable technique.
___ EGD
1) Normal mucosa in the whole esophagus
2) Normal mucosa in the whole stomach
3) Oozing was noted upon entry into the duodenal bulb and
duodenal sweep. A single cratered 8mm ulcer was found in the
duodenal sweep. A visible vessel suggested recent bleeding. 2ml
epinephrine was successfully applied for hemostasis. One
endoclip was successfully applied for the purpose of hemostasis.
___ CXR for PICC Placement
TECHNIQUE: Dr. ___ radiology attending)
performed the procedure.
ANESTHESIA: 1% lidocaine was injected in the skin and
subcutaneous tissues
overlying the access site.
MEDICATIONS: None
CONTRAST: 0 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 1.1 minutes, 5.2 mGy
PROCEDURE: 1. Replacement of right PICC.
PROCEDURE DETAILS: Using sterile technique and local anesthesia,
the existing PICC line was aspirated and flushed and a Nitinol
guidewire was introduced into the superior vena cava (SVC). A
peel-away sheath was then placed over a guidewire. The guidewire
was then advanced into the superior vena cava. A double lumen
PIC line measuring 42 cm in length was then placed through the
peel-away sheath with its tip positioned in the distal SVC under
fluoroscopic guidance. Position of the catheter was confirmed by
a fluoroscopic spot film of the chest. The peel-away sheath and
guidewire were then removed. The catheter was secured to the
skin, flushed, and a sterile dressing applied. The patient
tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. Existing right arm approach PICC with tip in the axillary
vein replaced
with a new double lumen PIC line with tip in the distal SVC.
IMPRESSION:
Successful placement of a 42 cm right arm approach double lumen
PowerPICC with tip in the distal SVC. The line is ready to use.
Discharge Labs:
===============
___ 05:41AM BLOOD WBC-7.7 RBC-2.51* Hgb-8.4* Hct-28.7*
MCV-114* MCH-33.5* MCHC-29.3* RDW-24.0* RDWSD-96.6* Plt ___
___ 05:41AM BLOOD ___ PTT-24.8* ___
___ 06:01AM BLOOD Glucose-137* UreaN-31* Creat-1.2 Na-142
K-4.2 Cl-99 HCO3-31 AnGap-12
___ 06:01AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.1
___ 05:29AM BLOOD ALT-22 AST-20 LD(LDH)-551* AlkPhos-45
TotBili-0.5
Brief Hospital Course:
Summary:
=========
Mr. ___ is a ___ man with a history of CAD s/p DES
to LAD (___), HIV on HAART, HTN, HLD, diabetes, prostate
cancer s/p brachytherapy, CKD, salmonella splenic abscess s/p
splenectomy (___), and prior hepatitis B infection who was
recently admitted with a submassive PE from ___ until ___
at ___. He now represents with a saddle PE on CT with
hypoxemia and hypotension after a recent episode of
retroperitoneal hemorrhage leading to hemorrhagic shock and
withholding of all anticoagulation since ___.
#CORONARIES: s/p DES to LAD (___)
#PUMP: LVEF 55-60% (___)
#RHYTHM: Sinus
TRANSITIONAL ISSUES:
====================
Follow Ups:
[] PLEASE ENSURE PATIENT KEEPS HIS F/U ___ ON
___
[] ___ will set up a clinic appointment to assess for IVC filter
removal in ___ months.
Medications:
[] Patient started on Warfarin for treatment of massive PE, INR
GOAL: 1.8-2.4 given severe RP and GI bleeds on anticoagulation.
Bridge with enoxaparin 120 mg BID for INR < 1.8.
[] Patient will need long-term management of anticoagulation
with Warfarin, PCP ___ aware.
[] Discharged on PPI BID given GI bleed on anticoagulation.
Discontinue PO PPI in 8 weeks (___).
[] Glargine 60u at home, discharged on 50u given lower
requirements during hospitalization. Increase back prn.
Issues:
***For Rehab***
[] Please monitor the patient's weight and attempt to uptitrate
diuresis as needed to achieve his dry weight of 274lbs.
***For Cardiology***
[] PO amiodarone started I/s/o difficult to control AF w/ RVR.
Please re-evaluate its need moving forward.
[] Repeat TTE in 1 month to eval interval change from prior,
define EF, ensure not newly reduced
***For PCP***
[] Given unprovoked PE, ensure age appropriate malignancy
screening has been done. if unremarkable, consider
hypercoagulability w/u.
[] Mildly nodular contour seen on abdominal imaging. Consider
outpatient Fibroscan and possibly hepatology referral. Pt is
high risk for NASH
Data:
* Discharge Hb 8.4; no need to recheck if not having melena.
* DRY WT: ~274 lbs. Last pre-discharge 281.08lbs, bed weight (on
___.
CODE STATUS: FULL
ACUTE ISSUES:
=============
#Massive PULMONARY EMBOLISM
#Acute on chronic hypoxic respiratory failure
Patient recently admitted for submassive PE and discharged on
___ with warfarin and a lovenox bridge. Presented later
that month to ___ and was found to have GI bleeding as
well as a large RP bleed and the decision was made to stop his
anticoagulation. He was discharged to rehab and represented
___ with dyspnea found to have a mass PE initially
requiring pressor support. Immediately after arriving on the
floor patient was taken to ___ suite where two EKOS catheters
were placed for tPA administration. During procedure local tPA
boluses were administered to the clot and a catheter was used
break up the clot. The patient was started on a heparin drip.
EKOS catheters were removed later that day. Transthoracic echo
showed a dilated right ventricle associated with dysfunction.
Patient also had moderate pulmonary hypertension. Given his
edematous appearance, the patient was diuresed with IV Lasix and
eventually transitioned to PO Lasix 20mg daily. On ___,
patient had a IVC filter placed successfully. The patient was
continued on a heparin drip, and converted to warfarin. His INR
goal was determined to be 1.8-2.4 given high risk of major bleed
as well as high risk of life-threatening clot. On discharge INR
was 1.8.
#UGIB on AC
#S/p Clipping of duodenal ulcer
The patient was started on warfarin ___. Overnight on
___, the patient had multiple melanotic stools, with
associated hemoglobin drop from 8.7 to 7. The patient received
2 units of packed red blood cells with good response 9.1. He
was taken to endoscopy by gastroenterology, and had a duodenal
ulcer clipped with appropriate hemostasis. On discharge he was
having soft brown BMs. He will be continued on a PPI on
discharge for 8 weeks. Discharge hemoglobin was 8.4.
#ATRIAL FIBRILLATION W/ RVR
Had new onset afib with RVR during previous hospitalization to
submassive PE. Had DCCV ___, successful, remained in sinus at
time of discharge. Anticoagulation as above. His home
metoprolol was held in the setting of acute pulmonary embolus
associated with right ventricular dysfunction. His amiodarone
was adjusted to 200 mg twice daily, as he had already been
appropriately loaded with amiodarone on his prior
hospitalization. on discharge we continued him home metoprolol
succinate
#CORONARY ARTERY DISEASE
s/p DES to LAD (___). Mild troponin elevation likely
reflective of right heart strain from acute PE. He was chest
pain-free throughout the hospitalization. He was continued on
his home rosuvastatin and losartan. His metoprolol was held
during the admission in the setting of severe RV systolic
dysfunction as well as the UGIB. It was able to restarted on
discharge.
#Acute on Chronic HFpEF
The patient had increased volume on examination with a TTE
showing an LV EF of 55-60. He was volume overloaded on
examination and required Lasix 20 IV which had good effect. We
converted him to po Lasix regimen and would like his facility to
continue to monitor the patients weight with a plan to have him
lose another ___ pounds from his admission to the facility. He
should have daily weights at the facility.
CHRONIC ISSUES:
===============
#HIV
Most recent VL undetectable. CD4 of 500. Continue the patient
on his home darunavir/cobicistat and Odefsey.
#HYPERLIPIDEMIA
Continued Fenofibrate 145 mg PO DAILY in addition to statin
(both home meds)
#DIABETES:
Held PO meds and home liraglutide (as it was nonformulary),
placed on 40u glargine qAM (60u at home) as well as insulin
sliding scale instead in the setting of acute illness. On
discharge uptitrated glargine to 50u.
#RADIOGRAPHIC LIVER ABNORMALITY
Mild nodular contour of the liver raises concern for cirrhosis.
Consider outpatient Fibroscan and possibly hepatology referral.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Fenofibrate 145 mg PO DAILY
3. Rosuvastatin Calcium 40 mg PO QPM
4. Glargine 60 Units Breakfast
5. liraglutide 1.8 mg subcutaneous DAILY
6. Odefsey (emtricitab-rilpivir-tenofo ala) 200-25-25 mg oral
DAILY
7. Amiodarone 200 mg PO TID
8. Prezcobix (darunavir-cobicistat) 800-150 mg-mg oral DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY Duration: 14 Days
2. Aspirin 81 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. ___ MD to order daily dose PO DAILY16
6. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days
7. Amiodarone 200 mg PO DAILY
8. Glargine 50 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
9. Fenofibrate 145 mg PO DAILY
10. liraglutide 1.8 mg subcutaneous DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Odefsey (emtricitab-rilpivir-tenofo ala) 200-25-25 mg oral
DAILY
13. Prezcobix (darunavir-cobicistat) 800-150 mg-mg oral DAILY
14. Rosuvastatin Calcium 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
==================
1) Massive Pulmonary Embolism
2) Upper GI Bleeding s/p duodenal ulcer clipping
3) Acute on chronic hypoxic respiratory
4) Afib with RVR
5) Coronary Artery Disease .
6) Acute on Chronic Heart Failure with Preserved Ejection
Fraction
Secondary Diagnosis:
====================
1) HIV
2) Hyperlipidemia
3) Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
-You were admitted to the hospital because you had blood clots
in your lungs
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
-We gave you medications to break up the clots
We started you on a blood thinning medication
Unfortunately you had a small gastrointestinal bleed, which was
fixed by our gastroenterologist.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
-Take all of your medications as prescribed (listed below),
especially your warfarin
-Your goal INR is 1.8-2.4
-Follow up with your doctors as listed below
-Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs.
-___ medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10036821-DS-5 | 10,036,821 | 20,948,493 | DS | 5 | 2151-04-24 00:00:00 | 2151-04-24 17:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet / Ativan / latex
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o Hodgkin disease (Dx ___, s/p ABVD x6), newly
diagnosed gastric cancer (cT3N2M0 Stage III, Her-2 neg)
currently C1D7 ___ chemotherapy. He was referred in from home
today due to acute onset of severe abdominal pain starting this
morning sometime before lunch. States he ate breakfast and had
a bowel movement without any difficulty then pain later came on
spontaneously. He describes it as generalized abdominal pain
and "muscle cramping ". Currently ___ however was more severe
when he initially presented to ED and he received total of 1.5
mg Dilaudid with some relief but notes that when it wears off
the pain does return. Denies any bony or joint pain. Denies
nausea, vomiting, diarrhea. He was taking Zofran regularly
after his chemo cycle and did have some mild constipation but
does not feel this is the cause of his current pain. Has not
had any difficulty eating or drinking and does still have
appetite.
In the ED he also underwent abdominal CT which did not show any
acute pathology.
REVIEW OF SYSTEMS: No fevers, night sweats, or weight loss.
Appetite is good. No chest pain, shortness of breath, or cough.
No abdominal pain, nausea/vomiting, or diarrhea. No urinary
symptoms. No headaches, vision changes, or focal
numbness/weakness. No bone or back pain. A comprehensive
14-point review of systems was otherwise negative.
Past Medical History:
Hodgkin Lymphoma:
Mixed cellularity Hodgkin's Disease with mediastinal mass
diagnosed ___. PET shows disease limited to chest. No B
symptoms. Anemic (Hct 32) with MCV 76. Ferritin 403. BM biopsy
negative for involvement by HD. ABVD x6. Treated by Dr ___, ___.
Gastric Cancer:
- ___: presented with reflux symptoms
- ___: EGD showed an 8-10 cm mass in the body and fundus of
the stomach.
- ___: CT Torso showed no distant disease, but there
remains
a question of the etiology of several omental nodules and
non-regional lymph nodes.
- ___: EUS staging showed 4 suspicious lymph nodes, T3N2
disease. Gastric biopsy showed signet ring adenocarcinoma,
HER-2
negative (IHC 1+). Biopsy of a gastrohepatic lymph node was
positive.
- ___ - C1D1 ___ ___ + leucovorin, docetaxel, oxaliplatin)
+ neulasta
PMH/PSH:
Peripheral neuropathy
BPH
possible prostate nodule
DVT while on chemotherapy, treated with Lovenox for 3 months
? interstitial lung disease following bleomycin treatment
chronic lower back pain
s/p b/l IHR as a child ___ years old)
s/p R knee arthroscopy
Social History:
___
Family History:
Maternal side: uncle with lung cancer, uncle with prostate
cancer
Cancers in the family: no others known
Physical Exam:
___ 2149 Temp: 98.5 PO BP: 132/79 HR: 78 RR: 18 O2 sat: 95%
O2 delivery: RA
General appearance: Generally well appearing, comfortable
appearing and in no acute distress.
Head, eyes, ears, nose, and throat: Pupils round and equally
reactive to light. Oropharynx clear with moist mucous membranes.
Lymph: No palpable cervical or supraclavicular lymphadenopathy.
Cardiovascular: Regular rate and rhythm, S1, S2, no audible
murmurs.
Respiratory: Lungs clear to auscultation bilaterally.
Abdomen: Bowel sounds present, soft, nondistended. No palpable
hepatosplenomegaly. Trivial tenderness to deep palpation in the
RUQ and RLQ.
Extremities: Warm, without edema.
Neurologic: Alert and oriented. Grossly normal strength,
coordination, and gait. ___ strength in lower extremities.
Intact and symmetric fine touch sensation on abdominal wall and
in lower extremities. 2+ and symmetric patellar reflexes.
Skin: No rashes.
Pertinent Results:
LABS:
___ 03:42AM BLOOD WBC-9.3 RBC-4.89 Hgb-11.8* Hct-36.5*
MCV-75* MCH-24.1* MCHC-32.3 RDW-17.0* RDWSD-45.1 Plt ___
___ 03:42AM BLOOD Neuts-60 Bands-6* ___ Monos-9 Eos-1
Baso-0 ___ Metas-2* Myelos-0 AbsNeut-6.14* AbsLymp-2.05
AbsMono-0.84* AbsEos-0.09 AbsBaso-0.00*
___ 03:42AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-3+* Polychr-NORMAL
___ 03:42AM BLOOD Glucose-81 UreaN-13 Creat-0.9 Na-138
K-4.1 Cl-98 HCO3-29 AnGap-11
___ 03:42AM BLOOD ALT-27 AST-15 AlkPhos-92 TotBili-0.5
___ 03:42AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.7
___ 04:12PM BLOOD Lactate-1.2
CT ABDOMEN/PELVIS W/ CONTRAST:
1. No pneumoperitoneum.
2. Upper abdominal lymphadenopathy is again seen, with some
unchanged in size, some with interval decrease in size, and
interval development of central necrosis in 1 lymph node.
Haziness of the left omentum is again seen.
CXR
No evidence of acute thoracic process. No free subdiaphragmatic
free air.
Brief Hospital Course:
___ w/ Hodgkin disease (Dx ___, s/p ABVD x6), newly diagnosed
gastric cancer (T3N2M0 Stage III, Her-2 neg; C1D7 ___ on
admission) who was admitted with acute-onset abdominal pain.
Exam by surgery and by the admitting and discharging medicine
physicians was unremarkable for any abdominal or neurological
pathology to explain the symptoms. His CT showed only known
pathology. LFTs and lipase also normal. He is far enough out
from his chemo that we cannot invoke oxaliplatin toxicity, and
he did not have bone pain consistent with a Neulasta side
effect.
His pain was initially ___ intensity, but subsided over about
12 hours and by the time of discharge he was fairly comfortable,
although still intermittently requiring oral opiate analgesics.
At discharge his PPI was empirically doubled to twice daily
dosing and he was given a seven day supply of oral dilaudid to
use as needed. He was instructed to return should his symptoms
evolve or worsen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Dexamethasone 4 mg PO Q12H
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
4. Omeprazole 20 mg PO DAILY
5. Tamsulosin 0.4 mg PO DAILY
Discharge Medications:
1. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every
four (4) hours Disp #*42 Tablet Refills:*0
2. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth BIDAC Disp #*60
Capsule Refills:*0
3. Dexamethasone 4 mg PO Q12H
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
6. Tamsulosin 0.4 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Gastric cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with sudden-onset of severe abdominal
pain. We remain unsure what caused this, but your CT scan, labs,
and exam were all very reassuring.
We are doubling your omeprazole to twice daily in case the pain
is from some sort of irritation in the stomach. We are also
giving you dilaudid pills that you can take as needed if the
pain continues.
If the pain keeps coming back in severe episodes, or worsens
progressively, please return to the ED for consideration of
further workup. With any more minor issues, or if you aren't
sure whether you should come in, call the ___ clinic at
___ and ask to speak to one of the nurses.
Followup Instructions:
___
|
10036821-DS-7 | 10,036,821 | 26,439,594 | DS | 7 | 2151-10-12 00:00:00 | 2151-10-12 15:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Percocet / Ativan / latex
Attending: ___.
Chief Complaint:
Abdominal pain following total gastrectomy with roux-en-y
esophagojejunostomy (___).
Major Surgical or Invasive Procedure:
Underwent drain repositioning with Interventional Radiology on
___.
History of Present Illness:
___ history of recurrent DVT on lovenox, Hodgkin's lymphoma
s/p chemotherapy, pT3N3aM0 gastric cancer s/p neoadjuvant
chemotherapy, robotic total gastrectomy with roux-en-y
esophagojejunostomy (___) who presents with abdominal pain
after
recent discharge on ___. His post-operative course was
complicated by left gastrocnemius DVT for which he continues on
lovenox as well as an abscess adjacent to the
esophagojejunostomy
anastomosis, for which his surgical drain remains in place with
scant purulent output. He completed a course of oral
cipro/flagyl
at home as planned on ___. During his hospital stay, he was
unable to tolerate solids and was discharged to rehab on fulls
with J-tube feed supplementation. He recently underwent repeat
UGI on ___ after one episode of dysphagia showing a persistent
small leakage at the EJ anastomosis site. He presents today
complaining of acute onset of lower abdominal pain starting at
7pm tonight that has since worsened to a ___ in intensity. He
describes the pain as sharp and coming in waves. He was
discharged home on fulls and JTfeeds, which he has tolerated per
his baseline with occasional episodes of dry heaving but no
retching. He reports have normal bowel function with last BM and
flatus tonight and no constipation or diarrhea. No fevers or
chills. Reports persistent, scant purulent drainage from the
surgical drain. No dysuria. No prior similar episodes of pain.
Past Medical History:
Hodgkin Lymphoma:
Mixed cellularity Hodgkin's Disease with mediastinal mass
diagnosed ___. PET shows disease limited to chest. No B
symptoms. Anemic (Hct 32) with MCV 76. Ferritin 403. BM biopsy
negative for involvement by HD. ABVD x6. Treated by Dr ___, ___.
Gastric Cancer:
- ___: presented with reflux symptoms
- ___: EGD showed an 8-10 cm mass in the body and fundus of
the stomach.
- ___: CT Torso showed no distant disease, but there
remains
a question of the etiology of several omental nodules and
non-regional lymph nodes.
- ___: EUS staging showed 4 suspicious lymph nodes, T3N2
disease. Gastric biopsy showed signet ring adenocarcinoma,
HER-2
negative (IHC 1+). Biopsy of a gastrohepatic lymph node was
positive.
- ___ - C1D1 ___ ___ + leucovorin, docetaxel, oxaliplatin)
+ neulasta
PMH/PSH:
Peripheral neuropathy
BPH
possible prostate nodule
DVT while on chemotherapy, treated with Lovenox for 3 months
? interstitial lung disease following bleomycin treatment
chronic lower back pain
s/p b/l IHR as a child ___ years old)
s/p R knee arthroscopy
Social History:
___
Family History:
Maternal side: uncle with lung cancer, uncle with prostate
cancer
Cancers in the family: no others known
Physical Exam:
Admission Physical Exam
=======================
Vitals-98.4 68 138/72 16 100% RA
General- no acute distress, uncomfortable-appearing
HEENT- PERRL, EOMI, sclera anicteric, moist mucus membranes
Cardiac- RRR
Chest- no increased WOB on RA
Abdomen- soft, TTP in LLQ >RLQ with voluntary guarding, no
rebound, mildly distended. Incisions well-healed without
erythema
or drainage. Drain x1 with scant purulent output. Jtube site
c/d/I.
Ext- WWP, no notable edema or TTP, compression stockings in
place
b/l
Discharge Physical Exam
=======================
___ 0004 Temp: 99.1 PO BP: 110/67 R Lying HR: 66 RR: 18 O2
sat: 98% O2 delivery: Ra
General- no acute distress
HEENT- PERRL, EOMI, sclera anicteric, moist mucus membranes
Cardiac- Regular rate
Chest- no increased WOB on RA
Abdomen- soft, no tenderness to palpation, no rebound, minimally
distended. Incisions well-healed without erythema or drainage.
Drain x1 with scant serous output, bulb holding suction. Jtube
site without clinical signs of infection.
Ext- WWP
Pertinent Results:
Lab Results
===========
___ 12:00PM BLOOD WBC-7.1 RBC-3.81* Hgb-8.8* Hct-27.9*
MCV-73* MCH-23.1* MCHC-31.5* RDW-19.2* RDWSD-50.8* Plt ___
___ 05:06AM BLOOD WBC-4.0 RBC-3.88* Hgb-8.9* Hct-28.4*
MCV-73* MCH-22.9* MCHC-31.3* RDW-19.7* RDWSD-52.0* Plt ___
___ 01:55AM BLOOD WBC-5.1 RBC-3.75* Hgb-8.6* Hct-27.5*
MCV-73* MCH-22.9* MCHC-31.3* RDW-20.0* RDWSD-52.3* Plt ___
___ 01:55AM BLOOD Neuts-40.6 ___ Monos-7.4 Eos-3.3
Baso-0.4 Im ___ AbsNeut-2.07 AbsLymp-2.46 AbsMono-0.38
AbsEos-0.17 AbsBaso-0.02
___ 05:15AM BLOOD Glucose-95 UreaN-9 Creat-0.6 Na-139 K-4.2
Cl-95* HCO3-33* AnGap-11
___ 05:06AM BLOOD Glucose-66* UreaN-10 Creat-0.7 Na-138
K-4.5 Cl-97 HCO3-28 AnGap-13
___ 01:55AM BLOOD Glucose-89 UreaN-11 Creat-0.6 Na-137
K-4.4 Cl-99 HCO3-29 AnGap-9*
___ 01:55AM BLOOD ALT-42* AST-30 AlkPhos-95 TotBili-0.3
___ 01:55AM BLOOD Lipase-38
___ 05:15AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.9
___ 05:06AM BLOOD Calcium-9.4 Phos-4.3 Mg-1.5*
___ 01:55AM BLOOD Albumin-3.4*
Imaging
=======
DRAIN CATHETER MANIPULATION ___
IMPRESSION:
Successful fluoroscopy guided reposition of surgical drain with
tip now adjacent to the esophago-jejunal anastomosis.
CT abd/pelvis with IV/oral contrast (___):
1. Evaluation of the upper abdomen is slightly limited by
extensive streak artifact from dense contrast opacification of
the right colon. Within this limitation, no acute
intra-abdominal
process. Oral contrast extends at least to the level of the
transverse colon without evidence of extraluminal contrast. No
bowel obstruction.
2. Interval resolution of previously seen left subdiaphragmatic
fluid collection adjacent to the esophageal jejunal anastomosis.
3. Decreased size of now trace left pleural effusion.
4. Marked prostatomegaly.
UGI IMPRESSION ___:
1. Small leak at the esophagojejunostomy site tracking along
abdominal drain.
2. No overt abnormality of the jejunojejunostomy site.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain, in the
setting of recent total gastrectomy with roux-en-y
esophagojejunostomy (___). He was previously found to have an
abscess adjacent to the esophagojejunostomy anastomosis, and
within this admission underwent drain repositioning with
interventional radiology with placement confirmed by
fluoroscopy.
Throughout his stay, Mr. ___ remained nutritionally
supported with his home tube feeding regimen via his J-tube.
Nutrition services followed him within admission, and changed
the formulation of his tube feeds, which were better tolerated
by the patient, causing less diarrhea. At the time of discharge
his diet included full liquids, and tubefeeds of Jevity 1.2. 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 his usual
lovenox during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating his home
tube feeds, as well as diet as above per oral, ambulating,
voiding without assistance, and pain was well controlled. The
patient was discharged to rehab per ___ recommendations. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Enoxaparin Sodium 80 mg SC Q12H
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
3. Tamsulosin 0.8 mg PO QHS
4. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line
5. LOPERamide 2 mg PO BID:PRN loose stools
6. Simethicone 80 mg PO QID:PRN bloating/gas
7. Pyridoxine 100 mg PO DAILY
8. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Multivitamins 1 TAB PO DAILY
3. Pregabalin 50 mg PO DAILY
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
5. Docusate Sodium 100 mg PO BID
6. Simethicone 40-80 mg PO QID:PRN bloating/gas
7. Enoxaparin Sodium 80 mg SC Q12H
8. LOPERamide 2 mg PO BID:PRN loose stools
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Pyridoxine 100 mg PO DAILY
11. Tamsulosin 0.8 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
___ history of recurrent DVT on lovenox, Hodgkin's lymphoma s/p
chemotherapy, pT3N3aM0 gastric cancer s/p neoadjuvant therapy,
robotic total gastrectomy with roux-en-y esophagojejunostomy
(___) with resolving lower abdominal pain, now s/p drain
repositioning to address fluid collection adjacent to the
esophageal jejunal anastomosis.
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital for
abdominal pain following your total gastrectomy with roux-en-y
esophagojejunostomy (___). You were previously found to have
an abscess adjacent to your esophagojejunostomy anastomosis, and
underwent drain repositioning with interventional radiology.
The drain is functioning appropriately, and you have recovered
and are now ready to be discharged back to rehab. Please follow
the recommendations below to ensure a speedy and uneventful
recovery.
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may climb stairs.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- You may resume sexual activity unless your doctor has told
you otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
YOUR BOWELS:
- Constipation is a common side effect of medicine such as
Percocet or codeine. Diarrhea is a common side effect of tube
feeds. You were seen by nutrition at ___, and nutritionists
at your rehabilitation facility should be able to address either
of these issues for you.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon. If diarrhea does not
resolve, or is severe and you feel ill, please call your
surgeon.
PAIN MANAGEMENT:
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
- Take all the medicines you were on before the operation just
as you did before, unless you have been told differently.
- If you have any questions about what medicine to take or not
to take, please call your surgeon.
Followup Instructions:
___
|
10036942-DS-15 | 10,036,942 | 23,803,237 | DS | 15 | 2174-09-17 00:00:00 | 2174-09-19 12:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
TEE on ___
Midline placement ___
attach
Pertinent Results:
ADMISSION LABS:
================
___ 04:10PM BLOOD WBC-10.1* RBC-4.22* Hgb-12.7* Hct-38.3*
MCV-91 MCH-30.1 MCHC-33.2 RDW-12.7 RDWSD-41.7 Plt ___
___ 04:10PM BLOOD Neuts-76.8* Lymphs-15.1* Monos-6.6
Eos-0.8* Baso-0.3 Im ___ AbsNeut-7.75* AbsLymp-1.52
AbsMono-0.67 AbsEos-0.08 AbsBaso-0.03
___ 04:10PM BLOOD Glucose-99 UreaN-9 Creat-0.6 Na-135 K-4.0
Cl-97 HCO3-28 AnGap-10
___ 04:40AM BLOOD ALT-15 AST-14 AlkPhos-66 TotBili-0.7
___ 04:40AM BLOOD Albumin-3.6 Calcium-8.9 Phos-3.0 Mg-1.7
___ 04:40AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-POS*
___ 04:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 04:40AM BLOOD HCV Ab-NEG
___ 4:10 pm BLOOD CULTURE
**FINAL REPORT ___
STAPH AUREUS COAG +
| STAPH AUREUS COAG +
| |
CLINDAMYCIN-----------<=0.25 S <=0.25 S
ERYTHROMYCIN----------<=0.25 S <=0.25 S
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- 0.25 S <=0.12 S
OXACILLIN------------- 0.5 S 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S
___ 5:18 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
___ 6:25 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
___ 7:34 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
CXR ___
Borderline cardiac silhouette size, likely accentuated by AP
technique.
Otherwise, no definite acute intrathoracic process.
CT HEAD W/O CONTRAST ___
IMPRESSION: No acute intracranial process or fracture.
TTE
1) Possibly very small vegetation on the pulmonary valve. Image
quality is excellent. We seldomly see the pulmonary valve this
well depicted and therefore the nodularity could be part of a
normal variant including Lambl's exrescene. 2) Mitral valve
appears without vegetation. There is a very small mobile
structure on the atrial side , the differential is likely torn
mitral valve, beam hardening artifact, howver in this clinical
scenario vegetation (less likely) cannot be excluded.
CHEST CT W/ CONTRAST
1. Possible minimal bronchial inflammation. The lungs are
otherwise clear.
2. No evidence of rib fracture or other osseous or soft tissue
abnormality.
DISCHARGE LABS:
================
___ 07:50AM BLOOD WBC-9.0 RBC-4.38* Hgb-13.3* Hct-40.5
MCV-93 MCH-30.4 MCHC-32.8 RDW-12.1 RDWSD-41.3 Plt ___
___ 06:20AM BLOOD Neuts-52.6 ___ Monos-9.2 Eos-0.9*
Baso-0.6 Im ___ AbsNeut-3.42 AbsLymp-2.35 AbsMono-0.60
AbsEos-0.06 AbsBaso-0.04
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD Glucose-113* UreaN-9 Creat-0.6 Na-142
K-4.5 Cl-101 HCO3-24 AnGap-17
___ 07:50AM BLOOD ALT-20 AST-24 LD(LDH)-176 AlkPhos-71
TotBili-0.2
___ 07:50AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.9
___ 02:37PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-POS* oxycodn-NEG mthdone-POS*
___ 04:00PM URINE bnzodzp-NEG barbitr-NEG opiates-POS*
cocaine-NEG amphetm-POS* oxycodn-NEG mthdone-NEG
___ 11:25AM URINE AMPHETAMINES, LC/MS-PND
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
=======================
This is a ___ male patient with a history of IVDU w/ last use
of
heroin ___ who presents with 5 days of persistent exertional
chest pressure w/o radiation and dyspnea who was found to be
running a low grade fever, found to have MSSA bacteremia with
TEE without signs of endocarditis
TRANSITIONAL ISSUES:
=====================
[] Continue treatment with IV cefazolin for a total of 14 days
from first negative blood culture (until ___
[] Will need to ensure has established with a ___ clinic
on discharge
[] Needs to establish care with a PCP at discharge
[] Confirmatory testing for amphetamines on Utox was pending at
time of discharge
ACUTE ISSUES:
=============
#MSSA bacteremia
Bacteremia iso IVDU with last positive blood culture on ___.
TTE with question of vegetation on pulmonary valve but no
evidence of endocarditis on TEE. ID following with inpatient -
patient meets all criteria of uncomplicated MSSA bacteremia (TEE
negative, clearance of blood culture by 72h, defervescence
within 72 hrs of therapy, no evidence/sxs of metastatic
infection), will plan for 2 total weeks of therapy from first
negative blood culture (___). On cefazolin 2g q8hr until ___
with midline in place.
#Left costochondral pain
Focal pain on exam on the left concerning for septic
costochondritis vs abscess vs osteo given GPC bacteremia.
However, chest CT negative on ___ for soft tissue
abnormality/infectious process. In the hospital patient was
treated with IV ketorolac for 3 days then transitioned to PO
ibuprofen, which was alternated with Tylenol.
#Opioid use disorder
Uses heroin every day ___ times based on how he's feeling).
Last
treated for substance use in ___ with naltrexone
injections. Was previously on suboxone. Patient began to exhibit
sxs of withdrawal while inpatient, scoring >10 on ___ scale.
Patient seen by addiction psychiatry - stated that he is
interested in methadone maintenance therapy and feels that daily
___ clinic visits would be good for him to provide some
daily structure - wishes to receive methadone daily at ___ clinic
on ___. Started patient on 40mg methadone qd while
inpatient.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. CeFAZolin 2 g IV Q8H
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
4. Lidocaine 5% Patch 1 PTCH TD QPM upper back pain
5. Methadone 40 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
7. Ramelteon 8 mg PO QHS:PRN Insomia
Should be given 30 minutes before bedtime
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Staph aureus bacteremia
Opioid use disorder
Left costochondral pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital with 5 days of chest pain
and concern for an infection.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Your blood cultures grew a bacteria called staph aureus. We
started you on IV antibiotics for this
- We got a picture (called an echocardiogram) of your heart
which did not show any infection of your heart valves.
- You will continue on antibiotics for a total of 14 day, end
date ___.
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:
___
|
10037598-DS-15 | 10,037,598 | 24,022,026 | DS | 15 | 2162-03-17 00:00:00 | 2162-03-18 18:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a pmh of morbid obesity, HTN, DMII and OSA presenting
with worsening shortness of breath and bilateral lower extremity
swelling. Transferred from ___ due to lack of beds.
His main complaint is worsening b/l leg swelling over the last
two weeks that, as per pt, work-up has been unable to find an
explanation. States that his R leg was initially swollen, then
his L, and is now symmetrical and gradually worsening. Endorses
intermittent erythema, denies calf pain/leg pain. He endorses 20
pound weight gain in the last month and 50 pounds in the last
year. He also complains of SOB with exertion, worsening over the
last year, never at rest, walks about ___ block (5min) before
stopping. Denies PND (but wakes up due to his OSA), and sleeps
with three pillow orthopnea (45 degrees). Denies chronic cough.
Endorses nocturia (___). He denies fevers/chills. Denies
CP/syncope, diarrhea/constipation, n/v. Denies blood in his
stool, denies dysuria, HA.
In the ED, initial vs were 98.3 78 170/95 24 94% on 2L. He was
noted to have bibasilar rales and 2+ pitting edema to mid-thigh.
Troponin <0.01, BNP 614, D-dimer 1046. EKG: NS @ 77 bpm, LAD,
TWI I, aVL, no STE/STD. Unable to get a CTA due to weight (>500
pounds), admitted for V/Q scan. Started on Heparin IV drip.
Transfer VS 98.1 80 155/84 17 95% 4L.
On arrival to the floor, patient reports feeling better,
breathing comfortably on nasal cannula. Feels at ease being in
the hospital.
REVIEW OF SYSTEMS:
See HPI.
Past Medical History:
HTN, DMII, OSA, morbid obesity, depression.
Social History:
___
Family History:
Father was planned for CABG before he had a fall and passed
away, also with a h/o stroke, on HD. Mother with DM, CAD/MI,
deceased. One healthy daughter.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 98.3 150/dopp 74 20 94-95% 3L
GEN Alert, oriented, no acute distress, morbidly obese
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, unable to visualize JVD, no LAD
PULM Good air entry, no crackles, no wheezes
CV Distant heart sounds S1S2 RRR
ABD Soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c, significant
symmetrical b/l ___ edema to knee/hip, no erythema, no calf
tenderness
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
DRE occult negative brown stool
DISCHARGE PHYSICAL EXAM:
98.6 ___ 17 93-94%RA
GEN Alert, oriented, no acute distress, morbidly obese
HEENT MMM, PERRLA
NECK Supple, unable to visualize JVD, no LAD
PULM CTAB but difficult to assess
CV Distant heart sounds S1S2 RRR systolic murmur that is
difficult to characterize due to habitus
ABD Soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c, symmetrical b/l
___ edema to knee (1+) that improved with diuresis, no erythema,
no calf tenderness
NEURO Grossly nonfocal
SKIN No ulcers or lesions
Pertinent Results:
ADMISSION LABS:
___ 09:40AM BLOOD WBC-10.6 RBC-5.03 Hgb-13.6* Hct-43.2
MCV-86 MCH-27.0 MCHC-31.4 RDW-15.5 Plt ___
___ 09:40AM BLOOD Neuts-72.7* ___ Monos-4.1 Eos-3.4
Baso-0.3
___ 09:40AM BLOOD ___ PTT-30.9 ___
___ 09:40AM BLOOD Glucose-159* UreaN-12 Creat-0.8 Na-140
K-3.0* Cl-95* HCO3-34* AnGap-14
___ 09:40AM BLOOD proBNP-614*
___ 09:40AM BLOOD cTropnT-<0.01
___ 05:25AM BLOOD Calcium-9.2 Phos-4.7* Mg-2.2 Cholest-125
___ 10:53AM BLOOD D-Dimer-1046*
___ 05:25AM BLOOD Triglyc-106 HDL-30 CHOL/HD-4.2 LDLcalc-74
DISCHARGE LABS:
___ 05:45AM BLOOD Glucose-117* UreaN-10 Creat-0.8 Na-142
K-3.4 Cl-94* HCO3-34* AnGap-17
___ 05:45AM BLOOD Calcium-8.2* Phos-4.3 Mg-2.2
___ 05:25AM BLOOD %HbA1c-7.2* eAG-160*
IMAGING:
___ CXR
IMPRESSION: Findings compatible with pulmonary edema in the
setting of
mild-to-moderate cardiomegaly.
___ KNEE XR
IMPRESSION: Moderate degenerative changes. No evidence of
fracture or
dislocation.
___ ___ R
IMPRESSION:
1. No evidence of deep vein thrombosis in the right lower
extremity.
2. Moderate-sized complex right ___ cyst.
___ V/Q Scan
IMPRESSION: No evidence for acute pulmonary embolism. Limited
exam secondary to obesity.
EKG ___
Normal sinus rhythm with A-V conduction delay. Delayed R wave
progression
and intraventricular conduction defect.
MICRO: None
Brief Hospital Course:
___ with a past medical history of morbid obesity, HTN, DMII and
OSA presenting with worsening DOE and bilateral lower extremity
swelling.
#SOB/Hypoxia due to presumed acute diastolic CHF: Acute on
chronic CHF versus PE. H/o progressively worsening DOE over one
year, stable chronic orthopnea, and worsening b/l ___ edema over
last two weeks suggests chronicity, no acute change. On exam,
there was evidence of b/l symmetrical lower extremity edema with
clear lung fields on exam (although limited by habitus).
Initially admitted due to suspicion for PE, positive d-dimer and
negative R ___, started on heparin drip in ED. Unable to fit in
CT scan for a CTA, completed a limited V/Q scan (due to habitus)
which did not suggest PE. Given history and very low suspicion
for PE, heparin drip was d/c. Admission CXR read as pulmonary
edema, no evidence of crackles one exam, but with O2
requirement. Pro BNP slightly elevated but not significantly
elevated to suggest overwhelmingly a CHF exacerbation. H/o OSA
predisposes pt to R sided HF 2/t pul htn and his h/o HTN/morbid
obesity and possible underlying CAD given risk factors
predisposes him to L sided HF. Denies CP, and had a negative
trop x1 which makes MI unlikely as a cause for CHF. EKG also was
unremarkable. Bicarb of 34 suggests chronic CO2 retainer likely
from OSA. Pt was diuresed with 10mg IV Lasix over two days and
improved, weaning the O2 requirement. With diuresis, pt
ambulated on RA and saturations decreased to 88% but responded
back into the mid ___ with deep breaths. TTE was unable to be
done during the admission but it should be done as an outpt.
Patient was discharged on 20mg Lasix daily and 40meq potassium
daily with CLEAR instructions that he MUST f/u with PCP within ___
week for electrolytes/fluid status check, as well as to get him
set up with outpatient sleep study/TTE. Pt agreed with the plan.
#Lower Extremity Swelling: Symmetrical with no erythema. Likely
sxs of R sided CHF/venous insufficiency, due to OSA/pul htn or
new L sided CHF. R ___ negative. Improved with diuresis, likely
due to CHF.
#R Knee Pain: Negative Xrays. Large ___ cyst on ___ with no
signs of a DVT. Likely due to fall about a month ago. Received
Tylenol prn.
#DM2, controlled with complications: Holding oral
hyperglycemics, started on ISS. No Hgb A1C in system, ordered
while in house and it was 7.2%. Morbid obesity suggests possible
underlying uncontrolled DM.
#Obesity: ___ be related to depression, lipid panel and A1C done
during this admission. Being worked-up for possible gastric
bypass but pt would like to attempt weight loss first.
#HTN: Endorses a h/o HTN, hypertensive while in ED. CP free. BP
improved with reinitiation of home meds. Continue Metoprolol
XLl, Lisinopril, HCTZ, and Nifedipine.
#Depression: Recent stresses in life (i.e. homeless, deaths),
see HPI. Continued Paxil, Trazodone for sleep.
#OSA: Likely due to morbid obesity. Likely has pul htn. See
above for discussion. Monitored on tele. Continued on CPAP.
Sleep study as outpt.
TRANSITIONAL ISSUES:
-F/u with PCP, recheck ___ status as outpt since discharged
on Lasix
-Needs outpt TTE and sleep study
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 100 mg PO DAILY Start: In am
2. Lisinopril 40 mg PO DAILY Start: In am
3. GlipiZIDE XL 5 mg PO DAILY
4. Paroxetine 20 mg PO DAILY Start: In am
5. Hydrochlorothiazide 25 mg PO DAILY Start: In am
6. NIFEdipine CR 60 mg PO DAILY Start: In am
7. Aspirin 81 mg PO DAILY Start: In am
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. NIFEdipine CR 60 mg PO DAILY
6. Paroxetine 20 mg PO DAILY
7. GlipiZIDE XL 5 mg PO DAILY
8. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
9. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours
RX *potassium chloride 10 mEq 4 capsules by mouth daily Disp
#*56 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Heart Failure
Secondary: Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
for worsening lower leg swelling and worsening shortness of
breath with walking. We were concerned that you may have had a
clot travel to your lungs and you were started on a blood
thinner. Tests showed that you most likely did not have a lung
clot. The blood thinner medication was stopped. You most likely
have heart failure due to a combination of factors including
your obstructive sleep apnea, weight, and high blood pressure
given that these symptoms have been getting worse over the last
year to weeks. You were given a pill to help you urinate which
helped remove fluid from your lungs. You improved during your
stay: leg swelling improved, and you did not require oxygen at
time of discharge. You were sent home with this medication (to
help remove extra fluid) as well as potassium supplements.
Before you left, you noticed that the tops of your feet were
red. We were not concerned for infection and we encouraged you
to keep your feet elevated when sitting. Please bring this to
your PCP's attention if it has not resolved by the time of your
appointment.
NEW MEDICATIONS:
Lasix 20mg daily
Potassium chloride 40meq once daily
(But please be sure NOT to take one medication without the
other. If you do NOT take the lasix, do NOT take the potassium.
Please take both together.)
Followup Instructions:
___
|
10037602-DS-20 | 10,037,602 | 26,699,121 | DS | 20 | 2151-04-20 00:00:00 | 2151-04-20 17:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
quaternium 15 / potassium dichronate / balsam of ___ / nickel /
paraben / fragrances / glycerol monothiogylconate / tea tree oil
/ benzoyl peroxide
Attending: ___
___ Complaint:
Right knee osteoarthritis
Major Surgical or Invasive Procedure:
___: R TKR
History of Present Illness:
___ year old female with right knee osteoarthritis now s/p R TKR.
Past Medical History:
PMH: HLD, HTN, OA, Thyroid nodule, GERD, Depression
Shx: ___
Family History:
non-contributory
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Aquacel dressing with scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 06:30AM BLOOD WBC-12.3* RBC-3.33* Hgb-8.9* Hct-28.4*
MCV-85 MCH-26.7 MCHC-31.3* RDW-14.3 RDWSD-44.9 Plt ___
___ 05:40AM BLOOD WBC-12.3* RBC-3.53* Hgb-9.6* Hct-30.0*
MCV-85 MCH-27.2 MCHC-32.0 RDW-14.0 RDWSD-43.0 Plt ___
___ 06:06AM BLOOD WBC-11.0* RBC-3.73* Hgb-10.0*# Hct-31.9*#
MCV-86 MCH-26.8 MCHC-31.3* RDW-13.9 RDWSD-43.6 Plt ___
___ 06:30AM BLOOD Plt ___
___ 05:40AM BLOOD Plt ___
___ 06:06AM BLOOD Plt ___
___ 06:06AM BLOOD Glucose-124* UreaN-17 Creat-0.7 Na-138
K-4.2 Cl-100 HCO3-26 AnGap-12
___ 06:06AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.8
___ 11:00AM BLOOD HBsAg-NEG HBsAb-POS
___ 11:00AM BLOOD HIV Ab-NEG
___ 11:00AM BLOOD HCV Ab-NEG
___ 06:06AM BLOOD
___ 11:00AM BLOOD
Brief Hospital Course:
The patient was admitted to the orthopedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was unremarkable.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. The patient received Aspirin 325 mg twice
daily for DVT prophylaxis starting on the morning of POD#1. The
surgical dressing will remain on until POD#7 after surgery. The
patient was seen daily by physical therapy. Labs were checked
throughout the hospital course and repleted accordingly. At the
time of discharge the patient was tolerating a regular diet and
feeling well. The patient was afebrile with stable vital signs.
The patient's hematocrit was acceptable and pain was adequately
controlled on an oral regimen. The operative extremity was
neurovascularly intact and the dressing was intact.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity.
Ms. ___ is discharged to home with services in stable
condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 320 mg PO DAILY
2. betamethasone, augmented 0.05 % topical BID
3. Atorvastatin 20 mg PO QPM
4. Omeprazole 40 mg PO DAILY
5. Loratadine 10 mg PO DAILY
6. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 325 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 300 mg PO TID
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
6. Senna 8.6 mg PO BID
7. Atorvastatin 20 mg PO QPM
8. betamethasone, augmented 0.05 % topical BID
9. Loratadine 10 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Sertraline 50 mg PO DAILY
12. Valsartan 320 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right knee osteoarthritis
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:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment in three (3) weeks.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. You may wrap the knee with an ace bandage
for added compression. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
8. ANTICOAGULATION: Please continue your Aspirin 325 mg twice
daily with food for four (4) weeks to help prevent deep vein
thrombosis (blood clots). Continue Pantoprazole daily while on
Aspirin to prevent GI upset (x 4 weeks). If you were taking
Aspirin prior to your surgery, take it at 325 mg twice daily
until the end of the 4 weeks, then you can go back to your
normal dosing.
9. WOUND CARE: Please remove Aquacel dressing on POD#7 after
surgery. It is okay to shower after surgery after 5 days but no
tub baths, swimming, or submerging your incision until after
your four (4) week checkup. Please place a dry sterile dressing
on the wound after aqaucel is removed each day if there is
drainage, otherwise leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
Staples will be removed by your doctor at follow-up appointment
approximately 3 weeks after surgery.
10. ___ (once at home): Home ___, dressing changes as
instructed, and wound checks.
11. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Mobilize with assistive devices (___) if
needed. Range of motion at the knee as tolerated. No strenuous
exercise or heavy lifting until follow up appointment.
Physical Therapy:
Weight bearing as tolerated on the operative extremity. Mobilize
with assistive devices (___) if needed. Range of
motion at the knee as tolerated. No strenuous exercise or heavy
lifting until follow up appointment.
Treatments Frequency:
Remove aquacel POD#7 after surgery
apply dry sterile dressing daily if needed after aquacel
dressing is removed
wound checks daily after aquacel removed
staple removal and replace with steri-strips at follow up visit
in clinic
Followup Instructions:
___
|
10037818-DS-4 | 10,037,818 | 26,686,311 | DS | 4 | 2189-03-23 00:00:00 | 2189-03-23 17:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / iodine /
shellfish derived
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___, generally health presenting with acute pancreatitis.
2 days ago out of her normal state of health she noticed that
she was experiencing chills. One day ago at approximately 3 pm
she started to vomit which laster for about 3 hours. She has not
vomitted since yesterday, but she has had a dull ___ epigastric
constant pain since then radiating to her back. Lying on her
side make it feel worse, nothing makes it feel better. She has
not had any fever, shortness of breath, dysuria, hematuria,
vaginal bleeding or discharge.
On admission to ED VS: 14:56 7 98.0 93 116/85 18 98% ra, PE
notable for epigastric tenderness
Labs notable for lactate of 2.7, leukocytosis 13.2 neu 89%, Hct
51, mod pos UA with SG 1.031, lipase 651.
RUQ ultrasound - Mildly prominent pancreatic duct. In the
setting of an elevated lipase concerning for acute pancreatitis.
CXR - non acute.
.
She denies alcohol and smoking. She does not have any personal
of family history of gallstones. She denies any medications or
supplements except as below.
Past Medical History:
MIGRAINE HEADACHES
OSTEOPENIA
VITAMIN D DEFICIENCY
H/O ANGIOEDEMA
H/O IDIOPATHIC THROMBOCYTOPENIA PURPURA
H/O FIBROADENOMA
Social History:
Marital status: Married
Children: Yes, Description: 2
Lives with: ___ Children
Work: ___
Sexual activity: Past
Sexual orientation: Male
Domestic violence: Denies
Tobacco use: Never smoker
Alcohol use: Present
Alcohol use Holidays
comments:
Recreational drugs Denies
(marijuana, heroin,
crack pills or
other):
Depression: Patient does not report symptoms of
depression
Exercise: Activities
Exercise comments: walksdog
Diet: healthy
Seat belt/vehicle Always
restraint use:
Family History:
___ COLON CANCER
Physical Exam:
99.6 124/82 91 16 96RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, significant epigastric tenderness, 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 intact, motor function grossly normal
Pertinent Results:
___ 04:08PM BLOOD WBC-13.2*# RBC-5.11 Hgb-17.0* Hct-51.4*
MCV-101* MCH-33.3* MCHC-33.1 RDW-12.4 Plt ___
___ 04:08PM BLOOD Neuts-89.0* Lymphs-5.9* Monos-4.3 Eos-0.5
Baso-0.3
___ 04:08PM BLOOD Glucose-152* UreaN-21* Creat-0.9 Na-140
K-4.1 Cl-99 HCO3-30 AnGap-15
___ 04:08PM BLOOD ALT-19 AST-19 AlkPhos-95 TotBili-1.1
___ 04:08PM BLOOD Lipase-655*
___ 04:12PM BLOOD Lactate-2.7*
Prelim RUQ u/s: Mildly prominent pancreatic duct. In the
setting of an elevated lipase, these
findings are concerning for acute pancreatitis.
No evidence of cholecystitis. A small gallbladder polyp is noted
without
thickening of the gallbladder wall.
Brief Hospital Course:
___ generally healthy who presents with two days of epigastric
pain and vomiting with laboratory and ultrasonographic picture
concerning for acute pancreatitis.
Acute Pancreatitis
Initially patient was kept NPO and received IV narcotics. On
HD#2 she was feeling better and able to transition to PO pain
medications (which she took very rarely) and a clear diet. She
was discharged home able to tolerate POs.
There was no clear etiology of her pancreatitis. She denied any
Etoh use and her RUQ ultrasound was unremarkable. Triglycerides
and calcium were normal. A follow-up appointment was made with
the pancreatic clinic at ___ to see if further work-up is
necesssary and whether there is any role of cholecystectomy
after this first time unexplained pancreatitis episode.
Possible UTI
She had some WBC in her urine and culture grew group b strep.
Though she was relatively asx (she reported some blood in
urine), I chose to treat with ciprofloxacin x 3 days for
uncomplicated UTI (pen allergic).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Loratadine 10 mg PO DAILY:PRN allergy/sinusitis
2. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q12H
RX *ciprofloxacin [Cipro] 250 mg 1 tablet(s) by mouth twice a
day Disp #*6 Tablet Refills:*0
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every six
(6) hours Disp #*10 Tablet Refills:*0
3. Loratadine 10 mg PO DAILY:PRN allergy/sinusitis
4. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis, UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for pancreatitis. Why you developed
pancreatitis is unclear. As we discussed in some cases, the
cause is unknown.
Followup Instructions:
___
|
10037928-DS-13 | 10,037,928 | 22,490,490 | DS | 13 | 2177-07-24 00:00:00 | 2177-07-24 19:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Sulfasalazine / Lisinopril / Codeine
Attending: ___.
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female Spanishh speaking with a history of Type 2DM
on insulin (Detemir BID and Glipizide BID and metformin) who
presents with malaise x 5 days "not feeling herself" per her
daughter. ___ any cough, fever, no nausea vomitting,
abdominal pain. No dysuria. Her daughter notes that she is
concerned that her mother ___ know how to take her meds at
home (she lives alone) and she also takes ambien every day which
makes her have MS changes and makes her forgetful. Daughter
called EMS today after seeing her mother "not act herself" she
was oriented but her house was messy which is not like her. EMS
found her to have profound hyperglycemia in ED (Gluc 996),
transferred to ___ for HHS on Insulin gtt.
She denies chest pain, shortness of breath, nausea, vomiting,
diarrhea, dysuria. No other localizing symptoms of infection.
In the ED, Tmax 98.2 HR ___, 110s-120s/40s-50s 96%RA. FSBG
Crit High, Glucose on chem panel 996, Na 126 (144 corrected), K
5.3, AG 14, BUN 36, Cr 1.9. Given Insulin 5 SQ then 10IV(bolus),
then started on Insulin gtt, initially at 3u/hr, then increased
to 5/hr. Received total of 3L NS. She was mentating well, and
was able to ambulate to the bathroom on her own.
Also, in ED noted to have Guaiac positive stool (checked in
setting of Hct 26, previous in our system was 36 9mo ago).
On arrival to the MICU, she is no apparant distress, daughter
says that her mental status is at her baseline. Pt feels hungry
Past Medical History:
DM2, HTN, Hyperlipidemia, Depression, Anxiety, Iron Deficiency
Anemia, GERD, Chronic Back Pain, Insomnia.
Tongue cancer, sees specialist at ___, chronic anemia (per pt
she has had since she was a little girl, h/o stomach ulcers
years ago.
Social History:
___
Family History:
She had brother with lung CA, daughter with endometrial cancer
Physical Exam:
On admission:
VS: Please see Metavision
General: Well appearing female in no acute distress
HEENT: Mucous membs moist
Neck: JVP nonelevated
CV: Regular Rate and Rhythm, no murmurs/gallops appreciated
Lungs: Crackles at the bases
Abdomen: Soft, nontender, normoactive bowel sounds
GU: Ulcer about 2cm left labia majora, appears to be adhesions,
labia minor are very small and not seen very well, very narrow
vaginal entroitis, and it is difficult to see the urethra
Ext: Warm/no peripheral edema, peripheral pulses 2+ ___
Neuro: strength ___ all ext
On discharge:
Physical Exam:
Vitals: Tm 100.5 T: 98.4 BP: 114/43 HR 83 RR 20 99%RA
24hr Glucose Range: 60, 214, 368, 372, 196, 295, 185
General: Well appearing elderly/female in no acute distress
CV: RRR no murmurs/gallops appreciated
Lungs: clear bilaterally no w/r
Abdomen: Soft, nontender, normoactive bowel sounds
Ext: Warm/no peripheral edema
Neuro: alert, answering questions appropriately in ___
Pertinent Results:
On admission:
___ 03:15PM BLOOD WBC-4.4 RBC-3.63* Hgb-7.0*# Hct-26.8*
MCV-74* MCH-19.4*# MCHC-26.2*# RDW-17.3* Plt ___
___ 03:15PM BLOOD Neuts-78* Lymphs-13* Monos-9 Eos-0 Baso-0
___ 03:15PM BLOOD ___ PTT-23.7* ___
___ 03:15PM BLOOD Glucose-996* UreaN-36* Creat-1.9* Na-126*
K-5.3* Cl-88* HCO3-24 AnGap-19
___ 03:15PM BLOOD cTropnT-<0.01
___ 03:15PM BLOOD Calcium-10.5* Phos-5.5* Mg-2.2
___ 06:39PM BLOOD Comment-GREEN TOP
___ 03:26PM BLOOD Glucose-GREATER TH Na-130* K-5.2* Cl-88*
calHCO3-27
___ 03:26PM BLOOD Hgb-7.8* calcHCT-23
___ 09:20PM BLOOD freeCa-1.16
Microbiology:
BCx x2 (___): Pending
Imaging:
CXR PA/lateral (___): No acute cardiopulmonary process.
___ 05:40AM BLOOD WBC-6.9 RBC-3.45* Hgb-8.0* Hct-26.3*
MCV-76* MCH-23.2* MCHC-30.3* RDW-23.0* Plt ___
___ 09:19AM BLOOD Neuts-64.5 ___ Monos-5.9 Eos-1.6
Baso-0.2
___ 05:40AM BLOOD Plt ___
___ 05:40AM BLOOD Glucose-275* UreaN-26* Creat-1.3* Na-136
K-4.6 Cl-101 HCO3-27 AnGap-13
___ 05:40AM BLOOD Calcium-8.9 Phos-4.8* Mg-1.6
SPEP and UPEP negative
Brief Hospital Course:
Ms. ___ is a ___ with type 2 diabetes mellitus who presents in
a hyperosmolar, hyperglycemic state in the setting of poor
medication compliance.
# Type II diabetes, uncontrolled with hyperosmolarity/HHS -
diagnosed by Serum Glucose > 600(996), HCO3 > 15(24), no
ketonuria,no ketonemia . This is most likely from med non
compliance as daughter has worries about this and patient notes
there are times she forgets to take her insulin. No signs of
infection though she does have a labial ulcer but it is not
erythematous or painful. She was intially on an insulin drip and
was weaned off, given long acting insulin and her BG levels
returned to the 100s. Her MS was at baseline by the time she
reached the MICU. ___ was consulted for recommendations on
control of her BG levels. Her K was repleted. She received 4 L
of NS in ER and ICU. At discharge glucose remained labile but
was in the range of 150-300 the day prior to discharge. Insulin
regimen was limited by the pateint's schedule (she often sleeps
until ___ and does not eat until noon) and the fact that her
family can only administer insulin early in the morning and in
the evening. Given these limitations, she was discharged on a
regimen of Lantus 38 units in the morning and ___ 30 units at
dinner. She was advised to continue to check her blood sugar 4
times daily. She has a follow up appointment scheduled in the
___ on ___.
# Elevated Lactate - 4.9 on arrival and went down to 1.9. Likely
related to hypovolemia, and/ or metformin in setting of poor
GFR. Lactate resolved
# Met Acidosis with AG: AG initially 19 (from lactate), improved
with HHS rx as above
# Microcytic Anemia with low MCV elev RDW. Differential includes
iron deficiency (guaiac pos brown stool, h.o ulcer in the past
per daughter though not ___ in records) vs thallasemia
(per pt she has been anemic all her life). Also on differential
is MM in setting of renal failure. SPEP and UPEP were checked
and were negative. Labs showed more of iron deficiency picture
though it is possible she also has thallasemia. In setting of
guaiac pos brown stool, history of angioectasisas seen on ___
and ___ ulcers pt should follow up with GI. H. pylori testing
was positive, and patient should discuss with PCP and GI in
follow up next week whether to treat for this.
# Acute on chronic kidney disease: Initial Cr 1.9, likely due to
hypovolemia in the setting of hyperglycemia. Improved to 1.3 on
discharge.
#Urinary tract infection:
Complaints of urinary frequency- UA was positive and culture was
positive for pan sensitive E. Coli. She was treated with oral
ciprofloxacin and will complete a 7 day course. Of note, she did
have a low grade fever the day prior to discharge. She had no
new symptoms of infection and WBC count was not elevated
therefore no further infectious work up was pursued.
# Gyn: pt with labia majora ulcer and vaginal atrophy possible
lichen sclerosis atrophicus. Could not insert foley because
entroitus was so narrowed. Started on topical steroids and
estrogen for atrophic vaginitis v. lichen. Will need gyn f/u.
CHRONIC ISSUES
#HTN:
continued hctz, losartan, propanolol
#Depression: continued buspirone and paroxitene
Transitional issues:
#Anemia
Consistent with iron deficiency- started on PO Iron but needs
outpatient evaluation with Colonoscopy/EGD. Also H. Pylori
antigen positive. Treatment not started in house.
#Vaginal atrophy
Needs GYN follow up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Hydrocortisone Cream 2.5% 1 Appl TP 3X/WEEK (___)
3. BusPIRone 10 mg PO TID
4. Zolpidem Tartrate 10 mg PO HS
5. Fluconazole 150 mg PO BID
6. Clotrimazole Cream 1 Appl TP DAILY
7. Propranolol 20 mg PO BID
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Amlodipine 10 mg PO DAILY
10. Atorvastatin 20 mg PO DAILY
11. Detemir 30 Units Breakfast
Detemir 30 Units Bedtime
12. Ferrous Sulfate 325 mg PO DAILY
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H:PRN
pain
15. Omeprazole 40 mg PO DAILY
16. Paroxetine 40 mg PO DAILY
17. GlipiZIDE 10 mg PO BID
18. Hydrochlorothiazide 25 mg PO DAILY
19. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY
2. BusPIRone 10 mg PO TID
3. Ferrous Sulfate 325 mg PO DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Losartan Potassium 100 mg PO DAILY
7. Paroxetine 40 mg PO DAILY
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
10. Amlodipine 10 mg PO DAILY
11. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H:PRN
pain
12. Hydrocortisone Cream 2.5% 1 Appl TP 3X/WEEK (___)
13. Omeprazole 40 mg PO DAILY
14. Propranolol 20 mg PO BID
15. Docusate Sodium (Liquid) 100 mg PO BID
You can buy this over the counter if needed.
16. Estrogens Conjugated 1 gm VG DAILY Duration: 3 Weeks
17. Clotrimazole Cream 1 Appl TP DAILY
18. Glargine 38 Units Breakfast
Humalog ___ 30 Units Dinner
RX *insulin lispro protam & lispro [Humalog Mix ___ KwikPen]
100 unit/mL (75-25) ___ Units before dinner Disp #*1
Box Refills:*3
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) ___ Units before Breakfast Disp #*1 Box Refills:*3
19. Ciprofloxacin HCl 500 mg PO Q12H
Last day ___
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*5 Tablet Refills:*0
20. linagliptin *NF* 5 mg Oral daily
RX *linagliptin [Tradjenta] 5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diabetes mellitus, type II, poorly controlled with complications
Acute renal failure
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted due to dangerously high blood sugars. You
required a continuous infusion of insulin when your first
arrived. This was changed back to your usual insulin and the
dose was adjusted with the help of the ___ Diabetes
specialists.
You should continue to follow a diabetic diet. You need to check
your sugars in the morning when you wake up and before every
meal.
This is very important to regulate your sugars so you do not
need to go to the ICU again. You will also need to take insulin
twice daily.
Stop taking Glipizide, Determir
Start Linagliptin 5mg daily for diabetes
Start Lantus (Glargine) 38 units in the morning and ___ 30
units in the evening
Start Ciprofloxacin 500mg twice daily- last dose is ___
Followup Instructions:
___
|
10037928-DS-15 | 10,037,928 | 22,326,517 | DS | 15 | 2177-12-23 00:00:00 | 2177-12-23 19:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Sulfasalazine / Lisinopril / Codeine
Attending: ___.
Chief Complaint:
#Cough
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ with DM2 on insulin who presents with cough for 3d. Reports
sore throat, productive cough with green sputum. Denies f/c, cp,
n/v. Normal po intake. Per report she did not take her insulin
today because she wasnt feeling well. Her symptoms remind her of
when she has PNA in the beginnign of ___.
In the ED intial vitals were: 98.7 108 151/55 22 98%
Labs notable for BG 667 Cr 1.6 (baseline 1.2-1.5) anion gap =15
VBG pH 7.39 pCO2 52 pO2
CXR showed Streaky bibasilar opacities most likely reflective of
atelectasis
she was given albuterol nebs, 10 of humalog
plan to admit pt for cough and hyperglycemia
On the floor she says she feels better but still has a cough
Past Medical History:
DM2, HTN, Hyperlipidemia, Depression, Anxiety, Iron Deficiency
Anemia, GERD, Chronic Back Pain, Insomnia.
Tongue cancer, sees specialist at ___, chronic anemia (per pt
she has had since she was a little girl, h/o stomach ulcers
years ago.
Social History:
___
Family History:
She had brother with lung CA, daughter with endometrial cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 100.3 141/43 105 16 97%RA
General- Alert, oriented, coughing
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- lots of cough on exam, slightly decr breath sounds no
wheeze or crackles
CV- slightly tachycardic low 100s Regular rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM:
Vitals- Tm 98.8 130s-140s/40s-60s HR ___ RR ___ Sa02
97% r/a
General- Alert, oriented, coughing
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- minimal cough today, minimal scattered coarse breath
sounds and no crackles
CV- RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
___ 06:25PM BLOOD WBC-10.7# RBC-4.04* Hgb-12.3 Hct-40.2
MCV-100*# MCH-30.5 MCHC-30.6* RDW-13.3 Plt ___
___ 06:25PM BLOOD Neuts-78.1* Lymphs-12.2* Monos-8.9
Eos-0.4 Baso-0.4
___ 06:25PM BLOOD Glucose-677* UreaN-23* Creat-1.6* Na-130*
K-4.5 Cl-91* HCO3-25 AnGap-19
___ 06:36PM BLOOD ___ pO2-33* pCO2-52* pH-7.39
calTCO2-33* Base XS-4
==========================================================
DISCHARGE LABS
___ 06:10AM BLOOD WBC-12.2* RBC-4.00* Hgb-12.2 Hct-39.0
MCV-97 MCH-30.5 MCHC-31.3 RDW-13.4 Plt ___
___ 06:10AM BLOOD Glucose-165* UreaN-17 Creat-1.0 Na-139
K-4.5 Cl-102 HCO3-23 AnGap-19
==========================================================
IMAGING:
___ CXR
HISTORY: Cough and dyspnea.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS: The cardiac, mediastinal and hilar contours are within
normal limits. The pulmonary vasculature is normal. Streaky
opacities in the lung bases likely reflect atelectasis, and no
focal consolidation is demonstrated. There is no pleural
effusion or pneumothorax. There is evidence of prior
vertebroplasty within a total body at the thoracolumbar
junction.
IMPRESSION:
Streaky bibasilar opacities most likely reflective of
atelectasis.
----------
EKG:
Sinus tachycardia. Left atrial abnormality. Baseline artifact.
Diffuse
non-specific ST-T wave changes, new as compared to the previous
tracing
of ___, while the rate has increased. Clinical correlation
is suggested.
Brief Hospital Course:
___ F h/o IDDM presents with cough for 3 days, sore throat, and
found to be hyperglycemic to 600s in the ER with ___.
#Acute bronchitis versus community acquired pneumonia:
Initially, thought to be acute viral bronchitis based on
symptoms, lack of CXR findings consistent with PNA. However,
gven that she was initially hypovolemic at the time of her CXR,
we thought it possible that a consolidation had not
radiographically developed yet. Her initial pneumonia severity
index was intermediate with inpatient stay being appropriate.
Because the risk of not treating a possible pneumonia seemed
quite high, she was treated with azithromycin with a planned 5
day course. Sputum gram stain showed 4+ GPCs and some GNC/GNRs
as well. Culture preliminarily showed commensal respiratory
flora. She had significant cough, wheezing, and dyspnea without
hypoxemia requiring scheduled q6 hour nebulizers. She improved
significantly by ___ AM from a respiratory status standpoint
and was felt to be safe to discharge home with antibiotic course
ending ___.
Given that this is her second admission for respiratory
infection this year without a history of COPD, smoking, or
fibrotic lung disease, there was some suspicion that she may
have developed a chronic underlying process such as
bronchiectasis that predisposes to infection. This requires
ongoing outpatient evaluation potentially with PFTs vs chest CT
at some point if she were to have ongoing respiratory
complaints. She was prescribed a spacer to help optimize her
outpatient MDI.
#Acute Kidney Injury: Cr 1.6 on admission from a baseline of
~1.2. This is most likely pre-renal azotemia in the setting of
poor PO intake, osmotic diuresis from hyperglycemia, and
insensible losses with fever. Her sCr improved to baseline with
IV fluids.
#Diabetes/Hyperglycemia: In the ER BS in the 600s. There was no
elevated anion gap on labs. This was thought to be due to not
taking her insulin the day of admission because she was feeling
sick. While an inpatient her blood sugars were extremely hard to
control. She varied between hypoglycemic to hyperglycemic
throughout the day on her home regimen. Her outpatient HgbA1c
has reflected poorly controlled diabetes. This may be due to
labile blood sugars on her insulin regimen, not medication
non-compliance, given that she was difficult to control while
here. She was seen by ___ and ___ diabetic education RN. She
had follow up appointments scheduled for ___. She was
discharged on her outpatient Lantus and Humalog sliding scale.
Chronic Issues
--------------
# HTN: Losartan was held in the setting of ___, but was
restarted at the time of discharge. HCTZ and Propranolol were
continued.
# Hyperlipidemia: Atorvastatin was continued
# Depression and Anxiety: Paroxetine and Buspirone were
continued
# GERD: Ranitidine was continued
TRANSITIONAL ISSUES:
-Outpatient titration of her insulin regimen
-Monitoring of respiratory complaints with further workup if
frequent, recurrent lower respiratory tract infections.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH HS asthma
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. BusPIRone 10 mg PO TID
5. Cyanocobalamin 1000 mcg PO DAILY
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Hydrochlorothiazide 25 mg PO DAILY
9. Losartan Potassium 100 mg PO DAILY
10. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit Oral
BID
11. Paroxetine 40 mg PO DAILY
12. Propranolol 20 mg PO BID
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Glargine 36 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
15. Furosemide 10 mg PO DAILY
16. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH HS asthma
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. BusPIRone 10 mg PO TID
5. Cyanocobalamin 1000 mcg PO DAILY
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Hydrochlorothiazide 25 mg PO DAILY
9. Paroxetine 40 mg PO DAILY
10. Ranitidine 150 mg PO DAILY
11. Propranolol 20 mg PO BID
12. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit Oral
BID
13. Ferrous Sulfate 325 mg PO DAILY
14. Furosemide 10 mg PO DAILY
15. Losartan Potassium 100 mg PO DAILY
16. Multivitamins W/minerals 1 TAB PO DAILY
17. Glargine 36 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
18. Azithromycin 250 mg PO Q24H Duration: 2 Days
final day of 5 day course is ___
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
19. Omeprazole 20 mg PO DAILY
20. Spacer for metered dose inhaler
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
#Acute bronchitis versus community acquired pneumonia
#Hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___, it was a pleasure to be part of your care at
___. You were admitted for concern for pneumonia and for very
high blood sugar. We suspect that your cough and shortness of
breath is due to an infection of the lungs. A sputum culture
grew a few types of bacteria, so this may represent a pneumonia.
You were treated with antibiotics (azithromycin) and will
continue to take this medication through ___. We gave you
breathing treatments with nebulizers to help open your airways
and improve your breathing. At home, you will continue to use
albuterol as needed with a spacer which we showed you how to use
in the hospital.
Also, when you were admitted your blood sugar was dangerously
high, likely because of a missed insulin dose, but severe
illness can raise blood sugars too. We think high sugars and
your respiratory infection caused you to become dehydrated. We
gave you IV fluids to improve your hydration. We had doctors
___ come see you to discuss your diabetes because
your blood sugars were very high and very low during this
admission. They would like you to follow up in clinic (SEE
BELOW).
Followup Instructions:
___
|
10037928-DS-16 | 10,037,928 | 24,225,421 | DS | 16 | 2178-10-02 00:00:00 | 2178-10-03 06:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Sulfasalazine / Lisinopril / Codeine
Attending: ___.
Chief Complaint:
Right ear pain and drainage
Major Surgical or Invasive Procedure:
ENT fiberoptic scope
Cleaning of right external ear canal and wick placement
History of Present Illness:
Ms. ___ is a ___ year old woman with a past medical history of
Type 2 Diabetes Mellitus (insulin-controlled), hypertension,
GERD, depression, and tongue cancer, who presented with 1 day of
ear pain and serosanguinous drainage and subjective
fevers/chills following URI. According to her family, her BP had
been somewhat elevated and she had missed some medication doses,
her blood sugars at home had been in the 300s, and she had been
incontinent of urine.
In the ED initial vitals were: 97.6 96 121/65 16 94%. Labs were
significant for leukocytosis, normal bicarb, elevated creatinine
(baseline 1.4), elevated glucose, and UA concerning for UTI. CXR
was normal and ear drainage was sent for cultures. She received
insulin and IV cefepime was administered to cover pseudomonas.
She was started on ciproflaxacin and dexamethasone drops for
otitis externa. ESR was elevated raising concern for for
malignant otitis externa. She was admitted to the floor for
further workup of otitis, blood sugar and UTI management.
On admission to the floor, patient remained afebrile with stable
vitals. She noted very mild right ear pain but denied chest
pain, shortness of breath, abdominal pain, nausea, vomiting,
diarrhea, dysuria or increased urinary frequency. ROS was
otherwise negative.
Past Medical History:
DM2, HTN, Hyperlipidemia, Depression, Anxiety, Iron Deficiency
Anemia, GERD, Chronic Back Pain, Insomnia.
Tongue cancer, sees specialist at ___, chronic anemia (per pt
she has had since she was a little girl, h/o stomach ulcers
years ago.
Social History:
___
Family History:
She had brother with lung CA, daughter with endometrial cancer
Physical Exam:
ON ADMISSION:
Vitals - T: 98.3 BP: 173/74 to 162/64 HR: 100 RR: 22 02 sat:
95%RA
GENERAL: Well and comfortable appearing woman lying in bed in
NAD
HEENT: AT/NC, EOMI, PERRL, MMM. No tenderness, swelling,
erythema, or rash over R mastoid. Ruptured R TM with small
amount of serous fluid present in auditory canal, minimal
erythema. L TM intact, nonbulging, no erythema.
NECK: no LAD
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, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
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
ON DISCHARGE:
PE: 97.7 131/53 ___ 18 100% on RA
Gen: Alert and responsive, NAD sitting up on bed
Chest: Sparse crackles at lung bases, no rhonchi or wheezes
CV: RRR, no murmurs, rubs, and gallops
HEENT: R ear clean, no active drainage, wick removed
Pertinent Results:
ON ADMISSION:
___ 08:45PM WBC-16.7*# RBC-4.37 HGB-14.3 HCT-44.1
MCV-101* MCH-32.8* MCHC-32.5 RDW-12.3
___ 08:45PM NEUTS-86* BANDS-1 LYMPHS-4* MONOS-9 EOS-0
BASOS-0 ___ MYELOS-0 NUC RBCS-1*
___ 08:45PM PLT COUNT-357
___ 08:45PM SED RATE-65*
___ 10:05PM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 10:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 10:05PM URINE RBC-1 WBC->182* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 10:05PM URINE MUCOUS-RARE
___ 09:25PM ___ PO2-36* PCO2-51* PH-7.40 TOTAL
CO2-33* BASE XS-4
___ 08:55PM LACTATE-2.0
___ 08:45PM GLUCOSE-529* UREA N-23* CREAT-1.6*
SODIUM-132* POTASSIUM-5.0 CHLORIDE-89* TOTAL CO2-29 ANION GAP-19
MICRO:
___ 10:05 pm URINE
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Time Taken
WOUND CULTURE (Final ___:
BETA STREPTOCOCCUS GROUP A. HEAVY GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
ON DISCHARGE:
___ 04:55AM BLOOD WBC-9.9 RBC-3.93* Hgb-12.8 Hct-39.4
MCV-100* MCH-32.6* MCHC-32.5 RDW-12.4 Plt ___
___ 04:55AM BLOOD Glucose-91 UreaN-20 Creat-1.1 Na-141
K-3.5 Cl-102 HCO3-27 AnGap-16
___ 04:55AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.8
REPORTS:
CT TEMPORAL BONE ___. Soft tissue density in the right external auditory canal and
middle ear with inflammatory changes extending into the soft
tissues, findings are concerning for malignant otitis externa,
recommend skullbase MRI for further assessment. No bony
destruction identified.
2. Asymmetric fullness of the ___ fossa on the right,
new from
___, could be secondary to inflammation in this region
however,
underlying mass is a concern, recommend direct visualization.
This finding can also be assessed on a contrast enhanced
skullbase MRI.
Brief Hospital Course:
Ms. ___ is an ___ year old woman with Type II Diabetes Mellitus,
hypertension, GERD, depression and tongue cancer who was
admitted with right ear pain.
ACUTE MEDICAL ISSUES:
#Otitis externa: Pt presented with one day of ear pain and
serosanguineous drainage. Given recent history of poorly
controlled Type II diabetes, leukocytosis and elevated ESR, this
raised concerns for malignant otitis externa, although there was
no granulation tissue on exam by ENT. This was further evaluated
with CT, which showed soft tissue involvement and inflammation
but no bony involvement, and also raised question of possible
mass which may have represented inflammation from her current
infection. Pt was treated for pseudomonas coverage with
cefepime, PO cipro and cipro ear drops. Pt's wound culture then
grew group A strep and she was narrowed to ceftriaxone per
Infectious Disease recommendations. Both ENT and Infectious
Disease consultants did not feel the patients presentation
represented malignant otitis externa given her physical exam and
culture data. MRI was considered as inpatient for further
evaluation of questionable mass seen on CT, but patient was
clinically improved with no pain or drainage, and the decision
was made to follow up as outpatient with ENT in 1 week. She was
discharged on 4 days Augmentin to complete antibiotic course as
well as cipro ear drops.
#DM: Pt was hyperglycemic >500 upon arrival with concern that
she might not have been taking all of her medication at home.
Given her infections, the goal was for tight glucose control.
Her home glipizide, liraglutide were discontinued and she was
started on sliding scale standing insulin (which she also
self-administers at home) and Glargine (on Levemir at home),
with input from ___. With this regimen, the pt's blood
glucose decreased to 100s-200s. On discharge, pt will resume her
levemir pen and humalog, with adjustments to sliding scale.
Family has been provided with copy of sliding scale regimen and
the pt is already trained to administer insulin at home via pen
mechanism.
#UTI: Pt presented with reports of urinary incontinence and
dysuria and her UA was grossly positive. Urine culures grew E.
coli. On discharge, patient reports some ongoing burning on
urination, but no other urinary symptoms and she is afebrile.
She will be covered with Augmentin to finish course.
___: On admission, had rise in Creatinine to 1.6 from baseline
(1.3-1.5). This resolved to baseline with fluids and reached 1.1
on discharge day, suggesting hypovolemia likely from
dehydration. Pt's lasix and losartan were held
CHRONIC MEDICAL ISSUES:
#HLD: Pt was continued on home atorvastatin
#GERD: Pt was continued home ranitidine, omeprazole
#Depression/anxiety: Pt was continued home paroxetine,
buspirone
#HTN: Pt was continued home amlodipine and propanolol.
Losartan-HCTZ and lasix were held given ___, however creatinine
improved by discharge day, thus losartan-HCTZ was resumed as
outpatient. Given her decreased PO intake and lack of volume
overload, her lasix was held and can be restarted as an
outpatient.
TRANSITIONAL ISSUES
[] Complete 4 more days of PO augmentin (last day ___
[] Pt to follow up with ENT
[] Pt to continue cipro ear drops until she is seen by ENT
[] Pt's CT temporal bone showed questionable mass. She will
follow up with ENT regarding if further imaging with outpatient
MRI is necessary
[] Pt to follow up in ___ given her poorly
controlled diabetes
[] Pt discharged on 33 units Levamir at night and humalog
sliding scale
[] Pt noted to be dehydrated with ___ on admission. Lasix 20 mg
held on discharge and to be restarted as needed by PCP
___ on ___:
The Preadmission Medication list is accurate and complete.
1. losartan-hydrochlorothiazide 100-25 mg oral daily
2. Clobetasol Propionate 0.05% Ointment 1 Appl TP HS
3. BusPIRone 10 mg PO TID
4. Propranolol 20 mg PO BID
5. Amlodipine 10 mg PO DAILY
6. Estrogens Conjugated 1 gm VG DAILY
7. Ranitidine 150 mg PO DAILY
8. Atorvastatin 20 mg PO HS
9. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous daily
10. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous
QAC
11. Ferrous Sulfate 325 mg PO DAILY
12. Furosemide 20 mg PO DAILY
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Omeprazole 40 mg PO DAILY
15. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral BID
16. Paroxetine 40 mg PO DAILY
17. Cyanocobalamin 1000 mcg PO DAILY
18. GlipiZIDE XL 10 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Atorvastatin 20 mg PO HS
3. BusPIRone 10 mg PO TID
4. Cyanocobalamin 1000 mcg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Paroxetine 40 mg PO DAILY
8. Propranolol 20 mg PO BID
9. Ranitidine 150 mg PO DAILY
10. Ciprofloxacin 0.3% Ophth Soln 3 DROP RIGHT EAR TID
RX *ofloxacin 0.3 % 3 drops ear three times per day Disp #*1
Bottle Refills:*1
11. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral BID
12. Clobetasol Propionate 0.05% Ointment 1 Appl TP HS
13. Estrogens Conjugated 1 gm VG DAILY
14. Omeprazole 40 mg PO DAILY
15. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 4 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every 12 hours Disp #*8 Tablet Refills:*0
16. Levemir Flexpen (insulin detemir) 100 unit/mL (3 mL)
subcutaneous daily
33 units daily
RX *insulin detemir [Levemir] 100 unit/mL 33 units SC daily Disp
#*10 Vial Refills:*0
17. losartan-hydrochlorothiazide 100-25 mg oral daily
18. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous
QAC
RX *insulin lispro [Humalog KwikPen] 100 unit/mL per sliding
scale with meals Disp #*15 Syringe Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. acute otitis externa
Secondary:
2. Urinary tract infection
3. acute kidney injury, likely due to hypovolemia
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted for right ear pain and drainage. You
were seen by the Ear, Nose, and Throat doctor and the Infectious
___ doctors to ___ up with a plan. You were treated with
antibiotics for an infection of your external ear canal.
During this hospitalization you were also seen by the diabetes
doctors who ___ your doses of insulin and you were treated
for a bladder infection.
Sincerely,
Your team at ___
Followup Instructions:
___
|
10037928-DS-18 | 10,037,928 | 23,721,604 | DS | 18 | 2179-04-04 00:00:00 | 2179-04-07 08:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Sulfasalazine / Lisinopril / Codeine
Attending: ___.
Chief Complaint:
Diarrhea, Cough, Decreased Appetite, Weakness
Major Surgical or Invasive Procedure:
___: Flexible bronchoscopy
History of Present Illness:
___ pmh HTN, HLD, DMII, and h/o tongue cancer who p/w 1 day of
diarrhea, weakness, and a non productive cough. Pt reports that
she developed diarrhea yesterday, non bloody or non melena, and
had about 10 BMs, did not allow her to sleep. She denies n/v,
f/c, lightheadedness/dizzines. She also reports dysuria (which
appears chronic per documentation), denies back pain. She
completed a 14d course of Nitrofurantoin per PCP (cx appears to
have been resistant). She also reports weakness for 3 days
associated with poor PO intake. BS this AM was in the 200s. She
also reports a cough which has gone from non productive to
productive recently, present for a week. No SOB, no CP. No HA,
no neck pain.
In the ED, initial vitals: 99.8 97 176/86 32 88% RA
Labs were significant for +UA, hemolyzed chem 7 with
hyponatremia, normal K and a cr of 1.3 (slightly above baseline
of 1.2-1.3. No CBC sent.
Imaging w/ normal CXR.
Given Ceftriaxone x1.
Blood and urine cxs sent. Negative flu.
Vitals prior to transfer: 97.8 93 155/65 16 96% NC
Currently, feels tired, coughing but has not had a BM today.
Endorses dysuria as well.
Past Medical History:
DM2
HTN
Hyperlipidemia
Depression
Anxiety
Iron deficiency anemia
GERD
Chronic back pain
Insomnia
Tongue cancer, sees specialist at ___
H/o stomach ulcers
Social History:
___
Family History:
She had brother with lung CA, daughter with endometrial cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 99.5 162/53 95 22 95%4L
GEN: Sleepy, laying in bed, calm
HEENT: MMM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD or JVD
PULM: Bibasilar crackles that seem atelactic in nature
COR: RRR (+)S1/S2 no m/r/g but heart sounds are distant
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal,
AAOx3
GYN: Erythematous labia majora and minora with white discharge
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 99.9 98.0 116-157/50-64 ___ 99% RA
GEN: Awake sitting up in bed, no acute distress, on RA
HEENT: MMM, anicteric sclerae, no conjunctival pallor
PULM: B/l crackles diffusely. Stable from yesterday.
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended, +BS
EXTREM: Warm, well-perfused. Erythema, swelling and tender (less
so today) area on the L radial aspect of wrist.
NEURO: Alert and interactive. Grossly intact.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:46PM BLOOD WBC-8.3 RBC-4.77 Hgb-14.9 Hct-45.1 MCV-94
MCH-31.2 MCHC-33.0 RDW-13.9 Plt ___
___ 09:46PM BLOOD Neuts-77* Bands-5 Lymphs-8* Monos-9 Eos-0
Baso-0 ___ Metas-1* Myelos-0
___ 09:46PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 09:46PM BLOOD ___ PTT-26.1 ___
___ 09:46PM BLOOD Plt Smr-NORMAL Plt ___
___ 02:34PM BLOOD Glucose-433* UreaN-33* Creat-1.4* Na-132*
K-4.1 Cl-93* HCO3-22 AnGap-21*
___ 02:34PM BLOOD ALT-23 AST-46* LD(LDH)-456* AlkPhos-84
TotBili-0.3
___ 02:34PM BLOOD Albumin-4.0
___ 09:46PM BLOOD Calcium-8.9 Phos-3.5 Mg-1.2*
___ 02:41PM BLOOD Lactate-1.4
___ 05:33PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:33PM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 05:33PM URINE RBC->182* WBC->182* Bacteri-FEW
Yeast-MANY Epi-0
PERTINENT LABS:
===============
___ 06:45AM BLOOD ALT-19 AST-29 LD(___)-288* AlkPhos-66
Amylase-65 TotBili-0.2
___ 06:45AM BLOOD proBNP-1003*
___ 10:44AM BLOOD Type-ART Temp-36.7 pO2-64* pCO2-33*
pH-7.46* calTCO2-24 Base XS-0
___ 03:20PM BLOOD HIV Ab-NEGATIVE
DISCHARGE LABS:
===============
___ 07:10AM BLOOD WBC-11.6*# RBC-3.88* Hgb-12.2 Hct-36.9
MCV-95 MCH-31.5 MCHC-33.1 RDW-13.1 Plt ___
___ 07:10AM BLOOD Neuts-73.4* Lymphs-17.8* Monos-8.2
Eos-0.4 Baso-0.3
___ 07:10AM BLOOD Plt ___
___ 07:10AM BLOOD Glucose-152* UreaN-12 Creat-1.2* Na-136
K-4.4 Cl-98 HCO3-26 AnGap-16
___ 07:10AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.6
MICROBIOLOGY:
=============
___ BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 9:04 pm STOOL
C. difficile DNA amplification assay (Final ___:
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.
___ URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
___ RML BRONCHIAL LAVAGE.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary): NO GROWTH, <1000
CFU/ml.
FUNGAL CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ RUL BRONCHIAL LAVAGE.
Respiratory Viral Antigen Screen (Final ___:
COMBINED WITH SPECIMEN #___ ___.
Positive for Respiratory viral antigens.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Respiratory Virus Identification (Final ___:
Reported to and read back by ___. ___ 15:43
___.
POSITIVE FOR INFLUENZA A VIRAL ANTIGEN.
Viral antigen identified by immunofluorescence.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary): NO GROWTH, <1000
CFU/ml.
FUNGAL CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
IMAGING:
========
CXR (___): No acute cardiopulmonary abnormality.
CXR (___): Cardiomediastinal silhouette is normal. There are
no signs for focal consolidation or overt pulmonary edema. There
are no pleural effusions or pneumothoraces.
CXR (___): No relevant change. No pneumonia. No pulmonary
edema. Normal size of the cardiac silhouette. No pleural
effusions. The lateral radiograph reveals a status post
vertebroplasty.
ECHO (___): The left atrium is normal in size. The estimated
right atrial pressure is ___ mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). 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. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild aortic regurgitation. Normal estimated RV/LV
filling pressures.
CT CHEST W/O CONTRAST (___): Combination of ground-glass
opacities, solid nodules and solid/ground-glass nodules within
hello might be consistent with diffuse infectious process.
Alternatively atypical mycobacterial infection, hypersensitivity
reaction, aspiration or vasculitis would be a possibility.
Neoplasm is substantially
less likely. Cryptogenic organizing pneumonia is another less
likely
possibility.
Diffuse bronchial wall thickening and endobronchial secretions
might reflect part of the in infection/inflammatory process.
Irregularity of the upper trachea with be beneficial to proceed
with direct evaluation.
PROCEDURES:
===========
BRONCHOSCOPY ___: The bronchoscope was passed through the
mouth and the into the oropharynx where the cords were
visualized and appeared normal. The cords were anesthatized with
topical lidocaine. The bronchoscope was then passed through the
cords and into the trachea. Thick, yellow, adherent mucous was
noted on the posterior segment of the trachea. This did not
clear with suctioning or with instilled saline. The bronchoscope
was then passed into the right mainstem and into the RUL where
lavage was performed in the anterior segment of the RUL. The
bronchoscope was then withdrawn and passed into the BI and into
the RML where another lavage was performed. The remained of the
bilateral bronchi were inspected and patent. A cytorush was used
to brush the upper airway adherent mucous. The airways appeared
edemetous and hyperemic throughout.
Impression: Diffuse parenchymal lung disease
Recommendations: ___ microbiology, cytology and pathology
Followup cytology
Brief Hospital Course:
___ F PMhx HTN, DMII on insulin, recent UTI status post ___ of
nitrofurantoin, admitted ___ w hypoxiam, cough and
diarrhea, found to have Cdiff colitis, initially flu negative on
admission, subsequently undergoing CT chest with concerning
features and bronchoscopy with a viral culture demonstrating
influenza A as well as evidence of pneumonia, started on
antibiotics, discharged home
#) Hypoxic Respiratory Failure / Acute Influenza A Infection /
Community Acquired Pneumonia - Patient admitted with hypoxia and
cough, initially presumed PNA and placed on
azithromycin/ceftriaxone, which was subsequently discontinued
when no infiltrates were seen on CXR. Given persistant systems,
CT chest was obtained and showed "combination of ground-glass
opacities, solid nodules and solid/ground-glass
nodules". Pulmonary consult recommended Bronchoscopy, which
showed "diffuse parenchymal lung disease", and possible concern
for residual PNA. She was started on levofloxacin (7-day course,
day 1 = ___ for CAP. In addition, viral studies sent from
bronchoscopy returned positive for influenza A prompting
initiation of oseltamivir (5-day course, day 1 = ___. Her
saturation normalized and she was discharged home with PCP and
___.
#) C. DIFF INFECTION/DIARRHEA: Stool positive for C. diff.
Thought to be secondary to recent outpatient course of
nitrofurantoin. Patient treated with PO vancomycin. She was
having 10 BMs/day on admission, and by the day of discharge
these had reduced to 3 loose stools/day. This should be
continued for 14 days after completion of Levofloxacin course as
above.
#) CELLULITIS: Pt developed L hand cellulitis at site of prior
phlebotomy. This was clinically improving on the day of
discharge, on levofloxacin for her pneumonia would also cover
cellulitis. PCP should ___ for improvement.
#) DM TYPE II: Uncontrolled with renal complications
(Proteinuria), last A1C 11.6. Levemir was uptitrated to 31units
from 25units
#) YEAST INFECTION: On presentation, patient found to have yeast
infection, thought to be secondary to recent antibiotics.
Resolved with fluconazole q72hr. Nystatin cream was also used to
groin area.
#) HYPERTENSION: Continued home amlodipine, held Losartan-HCTZ
given mild ___ and infections. This should be restarted per PCP.
#) HLD: Continued home atorvastatin.
#) ANXIETY: Continued home Buspar, paroxetine.
#) GERD: Continued PPI, held H2 blocker.
TRANSITIONAL ISSUES:
[] Will need to follow up with Pulmonology and obtain PFTs as an
outpatient (scheduled)
[] F/u resolution of yeast infection
[] Levofloxacin course for 8 days (d1 = ___
[] Tamiflu course for 5 days (d1 = ___
[] Vancomycin course to end on ___ (2 weeks after
Levofloxacin ends)
[] We have held her ___ and ___ HCTZ. Please resume at PCP's
discretion.
[] Patient has uncontrolled diabetes. Please evaluate home
medication regimen and patient compliance. Uptitrated insulin.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. BusPIRone 10 mg PO TID
4. Levemir 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. losartan-hydrochlorothiazide 100-25 mg oral daily
6. Omeprazole 40 mg PO DAILY
7. Paroxetine 40 mg PO DAILY
8. Propranolol 20 mg PO BID
9. Ranitidine 150 mg PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
11. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral BID
12. Ferrous Sulfate 325 mg PO DAILY
13. Docusate Sodium 100 mg PO BID:PRN constipation
14. Estrogens Conjugated 1 gm VG WEEKLY
15. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 18 Days
RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp
#*72 Capsule Refills:*0
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. BusPIRone 10 mg PO TID
5. Levemir 31 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Omeprazole 40 mg PO DAILY
7. Paroxetine 40 mg PO DAILY
8. Propranolol 20 mg PO BID
9. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*0
10. Levofloxacin 500 mg PO Q48H Duration: 2 Doses
RX *levofloxacin 500 mg 1 tablet(s) by mouth every 48 hours Disp
#*3 Tablet Refills:*0
11. Nystatin Cream 1 Appl TP BID
RX *nystatin 100,000 unit/gram apply to groin rash twice a day
Refills:*0
12. OSELTAMivir 75 mg PO Q24H
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth daily Disp
#*3 Capsule Refills:*0
13. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral BID
14. Cyanocobalamin 1000 mcg PO DAILY
15. Docusate Sodium 100 mg PO BID:PRN constipation
16. Estrogens Conjugated 1 gm VG WEEKLY
17. Ferrous Sulfate 325 mg PO DAILY
18. Multivitamins W/minerals 1 TAB PO DAILY
19. Ranitidine 150 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Influenza A
Community-acquired pneumonia
Clostridium difficile infection
Yeast infection
Secondary diagnoses: Type II diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on ___ for a cough, weakness, and
diarrhea. You tested negative for influenza in the emergency
department. We initially treated you for pneumonia, but because
you also had a concurrent Clostridium difficile (C. diff)
infection causing your diarrhea, when it was clear on imaging
and in your bloodwork that you did not have a pneumonia, we
stopped the antibiotics, treating only your C. diff infection
with an antibiotic. It was also thought that you had a urinary
tract infection, given your report of discomfort with urination,
but with your concurrent yeast infection, it was decided to
treat that, and your symptoms improved.
Your diarrhea was still occurring on the day of discharge, but
it was significantly improved from your arrival.
Unfortunately, your oxygen levels remained low despite our
initial treatment. A picture of your heart was normal. We
obtained a CT scan of your lungs, which was concerning was for a
widespread lung infection or a medication-related insult to your
lungs, possibly related to the treatment of your previous
urinary tract infection. You were seen by our Pulmonology
Fellow, who recommended that we use a scope to look inside your
lungs and obtain fluid for analysis (bronchoscopy). While many
of the results of this study have not yet returned, it was
determined that you were positive for influenza and you were
started on an antiviral medication called oseltamivir.
Additionally, we decided to treat you with a full course of
antibiotics in case you had a pneumonia that had only partially
resolved. Throughout this time, your breathing was slowly
improving, and you did not require extra oxygen for the last few
days of your admission.
You will follow up with Pulmonology as an outpatient. Thank you
for allowing us to take part in your care.
___ MDs
Followup Instructions:
___
|
10038141-DS-21 | 10,038,141 | 21,658,233 | DS | 21 | 2170-10-30 00:00:00 | 2170-10-31 14:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
alendronate sodium
Attending: ___.
Chief Complaint:
Disinhibited conduct, progressively worsening gait, and large
volume urinary incontinence.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ yo woman with medical history of HTN, GERD,
and recent personality changes presenting to the ED sent from
her
assisted living facility with ___ weeks of disinhibited conduct,
progressively worsening gait, and large volume urinary
incontinence.
Per discussion with her son she has been in ___
___ with subtle cognitive decline. She had been doing well
there until the end of ___, however he reports in the last ___
weeks she has shown significant personality changes including
disinhibition, aggression (yelling/hitting staff), and becoming
very confrontational which is out of her character. He also
complains she has developed gait instability, initially
requiring
a walker and much worse in the last week to the point that she
is
unable to stand on her own and has been requiring a wheelchair
to
get around. She also has large volume urinary incontinence
during
the same period which is new for her.
Per her PCP ___ (___) she was initially
evaluated in ___. At the time she was having mild
psychiatric issues which she describes as hallucinations and
flight of ideas. She was started on Seroquel bid with
significant
improvement. At the time she was described as "verbose but
appropriate". She was seen again by Dr. ___ ___ weeks ago for
evaluation of falls up to three times per day. She was also
acting inappropriately disrobing herself in her living facility.
At the time the case was discussed with a neurologist at
___ which thought she may have "frontal lobe syndrome".
MRI/MRA was performed which per report showed lacunar infarcts,
moderate atrophy, and small vessel ischemic disease.
At some point during the last ___ weeks he was admitted to a
psych facility and started on Zoloft, Remeron, and Seroquel. Her
son reports she takes Ativan 1mg TID for many decades for
anxiety.
On arrival to the ED she was agitated requiring lorazepam 2mg PO
total, Seroquel 25mg PO x1, and home Depakote 125 mg. Psychiatry
evaluated and confirmed ___. Recommended Thiamine
supplementation due to concerns for Wernike's.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies focal muscle weakness, numbness, parasthesia.
Denies loss of sensation. Reports bladder incontinence. Firmly
denies difficulty with gait.
On general review of systems, the patient denies chest pain,
palpitations, dyspnea, or cough. Denies nausea, vomiting,
diarrhea, constipation, or abdominal pain.
Past Medical History:
HTN
GERD
LT radial fracture with hardware in place
Recently seen by neurologist at ___ w/"frontal lobe
syndrome"
Per psych note: "No psych history prior ___ who is sent via
___ from her assisted living facility for significantly
worsening aggression, impulsivity, and gait disturbance over the
last two months".
Social History:
___
Family History:
Mother: died of possible MI at ___ yo
Dad: died at age ___ of unknown causes
Son: Healthy
Physical ___:
==============
ADMISSION EXAM
==============
Vitals:
98.1
74
137/81
16
99% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
MS: Awake, alert, oriented x 3. Able to relate history with
difficulty as rationalizes her gait issues by saying her socks
are sticky, her shoes were tight, or her toenails were too long.
Inattentive, unable to name ___ backwards as she writes them
down
FWD and then reads them in BW order. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Content of speech bizarre as describes formed hallucinations
("when I close my eyes I see a bunny"). Mood is labile. Able to
follow both midline and appendicular commands.
Cranial Nerves: PERRL 4-3mm brisk. EOMI, no nystagmus. V1-V3
without deficits to light touch bilaterally. No facial movement
asymmetry. Hearing intact to finger rub bilaterally. Palate
elevation symmetric. SCM/Trapezius strength ___ bilaterally.
Tongue midline.
Motor - Normal bulk and tone. No drift. No tremor or asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 4+ 5 5 5 5 5
R 5 ___ ___ 4+ 5 5 5 5 5
- Sensory - No deficits to light touch, but patient would not
allow us to touch her feet any further to assess for
proprioception
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 1
R 3 3 3 3 1
Plantar response upgoing bilaterally. Unable to test for jaw
jerk
due to poor cooperation.
Coordination: No dysmetria with finger to nose testing
bilaterally.
Gait testing attempted but patient with broad base stance and
significant retropulsion, unable to stand unassisted.
==============
DISCHARGE EXAM
==============
Essentially unchanged.
-VS: T:98.___.5 BP: 145-153/79-84 HR: ___ RR: 18 O2: 97% RA
-GEN: Awake in bed, NAD
-HEENT: NC/AT
-NECK: Supple
-CV: warm, well perfused
-PULM: normal inspiratory effort
-ABD: Soft, NT/ND.
-EXT: No clubbing, cyanosis, or edema.
-MS: Alert, oriented x3. Verbally combative throughout exam.
Unable to perform luria sequence. States MOYF and MOYB. ___
recall ___ with categories. Spontaneously repeated the 3 words
correctly ~10 minutes later. Naming intact. Repetition and
comprehension intact. Able to read and write. Follows commands,
but perseverates on prior task.
-CN: PERRL ___. Limited upgaze, otherwise EOMI. Face symmetric.
Tongue midline. Intact sensation in V1-V3.
-Motor: Mildly increased tone. Postural tremor L>R. ___
bilateral
delt/bic/tri, 4+ IP b/l, giveway weakness bilateral quad/ham,
___
bilateral TA/Gas
-DTR: R toe down. L toe mute. (+)palmar-mental reflex R>L, (-)
glabellar reflex. (+) jaw jerk
Bi Tri ___ Pat Ach
L 3 3 3 3 1
R 3 3 3 3 1
-Sensory: Intact to light touch throughout.
-Coordination: Intact finger to nose, mild postural tremor
bilaterally. Finger tapping more clumsy on L.
-Gait: Requires assistance to sit at the edge of bed,
retropulses
when attempts to stand. Requires two-person assist to stand
upright.
Pertinent Results:
====
LABS
====
___ 06:24PM BLOOD WBC-10.8* RBC-4.64 Hgb-12.9 Hct-41.1
MCV-89 MCH-27.8 MCHC-31.4* RDW-14.3 RDWSD-46.1 Plt ___
___ 06:24PM BLOOD Neuts-74.9* Lymphs-14.7* Monos-6.5
Eos-3.0 Baso-0.4 Im ___ AbsNeut-8.13* AbsLymp-1.59
AbsMono-0.71 AbsEos-0.32 AbsBaso-0.04
___ 05:00AM BLOOD WBC-8.2 RBC-4.39 Hgb-12.3 Hct-39.7 MCV-90
MCH-28.0 MCHC-31.0* RDW-14.3 RDWSD-47.6* Plt ___
___ 05:00AM BLOOD ___ PTT-31.7 ___
___ 06:24PM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-140 K-3.7
Cl-101 HCO3-25 AnGap-18
___ 05:00AM BLOOD Glucose-84 UreaN-8 Creat-0.6 Na-143 K-3.8
Cl-104 HCO3-28 AnGap-15
___ 06:24PM BLOOD ALT-8 AST-13 AlkPhos-114* TotBili-0.3
___ 05:00AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.1
___ 05:00AM BLOOD VitB12-580 Folate-10
___ 05:00AM BLOOD TSH-1.0
___ 06:24PM BLOOD Valproa-23*
___ 06:24PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:22AM URINE Color-Straw Appear-Hazy Sp ___
___ 12:22AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
- CSF
___ 04:07PM CEREBROSPINAL FLUID (CSF)
WBC-2 RBC-94* Polys-5 ___ Monos-24 Eos-1
TotProt-55* Glucose-54
FLUID CULTURE-PRELIMINARY; ACID FAST CULTURE-PRELIMINARY NEG
- Micro
SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-PENDING
Blood (LYME) Lyme IgG-PENDING; Lyme IgM-PENDING
URINE CULTURE-NEGATIVE
=======
IMAGING
=======
- ___ CT Head
1. No evidence of acute intracranial abnormalities.
Specifically, no evidence for normal pressure hydrocephalus.
2. Age related global atrophy and chronic microangiopathy.
3. Mild left sphenoid sinus disease.
Brief Hospital Course:
Ms. ___ is a ___ yo woman with medical history of HTN,
GERD, and progressive personality changes presenting to the ED
sent from her assisted living facility with ___ weeks of
worsening disinhibited conduct, worsening gait, and large volume
urinary incontinence, diagnosed with Fronto-Temporal Dementia.
Neurologic exam is limited by labile mood but notable for
numerous frontal signs including inattention, disinhibition,
inability to perform Luria sequence, brisk but symmetric
reflexes, and significant retropulsion with attempted gait
assessment. NCHCT with evidence of atrophy (especially
frontally) and small vessel ischemic disease. History, exam, and
imaging most consistent with fronto-temporal dementia, likely
exacerbated by chronic vascular dementia. CSF studies were
normal and showed no evidence of infection or inflammatory
process. Opening pressure was slightly elevated at 21cm, however
this done in ___ with the patient supine rather in flexed lateral
position and likely represents false elevation. Suspicion was
low for NPH. She is medically cleared for discharge. Studies for
Lyme and syphilis are pending, but these are sufficiently
unlikely given the overall clinical presentation that their
pending status should not be a barrier to discharge to an
appropriate care facility.
She was evaluated by psychiatry who assessed the determined her
to meet ___ for inability to care for self in the
community, absence of insight into her care needs or
presentation, and that she would benefit from an admission to a
___ facility (see note from Dr. ___,
___.
# Dementia: Likely frontotemporal dementia.
- Continue divalproex ___ TID. Consider increasing if LFTs
stable.
- Stop memantine.
- Continue quetiapine 25mg QHS PRN.
- Continue lorazepam taper to discontinuation. Currently 0.5mg
BID (home 1mg TID). Contributing to disinhibition.
CV:
# Hypertension:
- Continue atenolol 25mg BID. Consider resumption of home 50mg
dose, or switch to agent with more CNS effects, such as
propranolol.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Sertraline 50 mg PO DAILY
3. QUEtiapine Fumarate 25 mg PO BID
4. Atenolol 50 mg PO BID
5. Divalproex (DELayed Release) 125 mg PO TID
6. Mirtazapine 7.5 mg PO QHS
7. LORazepam 1 mg PO TID
8. Vitamin D 1000 UNIT PO DAILY
9. Cyanocobalamin 100 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Divalproex Sod. Sprinkles 125 mg PO TID
3. Docusate Sodium 100 mg PO BID
4. Heparin 5000 UNIT SC BID
5. Senna 17.2 mg PO HS
6. Thiamine 100 mg PO DAILY
7. Atenolol 25 mg PO BID
8. LORazepam 0.5 mg PO BID
9. QUEtiapine Fumarate 25 mg PO QHS:PRN agitation
10. Cyanocobalamin 100 mcg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Sertraline 50 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Frontotemporal Dementia
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:
Ms. ___,
You were admitted for symptoms of disinhibited conduct,
including physical aggression, and worsening gait. Upon
evaluation, you did not have evidence for any infectious,
inflammatory, or other treatable cause for these symptoms. You
showed neuropsychiatric signs consistent with a form of dementia
that initially affects executive function (inhibition and
planning). You will be referred to a care facility that
specializes in this and similar conditions, and they will be
best able to care for you.
We made the following changes to your medications:
- Weaning your Ativan (lorazepam). This worsens cognitive
function and disinhibition.
- STOP Remeron (mirtazapine). As it did not be appear to be
having any effect and in order to simplify your medication
regimen.
- REDUCE Seroquel (quetiapine) from 25mg TWICE PER DAY to 25mg
AT NIGHT IF NEEDED. This medicine is for agitation - which was
not prominent during your stay - and can be used for now only
when needed, in order to avoid excessive sedation.
Thank you,
Your ___ Neurology Team
Followup Instructions:
___
|
10038332-DS-22 | 10,038,332 | 22,514,900 | DS | 22 | 2172-11-24 00:00:00 | 2172-11-24 15:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
CC: ___, Wound Eval
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo man with h/o T10 paraplegia and recurrent
UTIs, who presents via own wheelchair to the ___ ED with
multiple concerns including "bed sores", new UTI and fever, as
well as wanting detox from heroin.
On review of the record, the patient was last seen in clinic by
Dr. ___ on ___, at which time he was sober and being
followed
by ___ (___) ___. He was
subsequently seen in the BID ED on ___ for recurrent UTI,
discharged with cipro (despite cultures showing resistance to
this). He appears to have most recently contacted his PCP ___
___ with recurrent UTI Sx, was prescribed 9d of fosfomycin.
Of note, discharged ___ on 6 wks of fosfomycin for E. coli
prostatitis with resistance to ampicillin/Augmentin,
ciprofloxacin, TMP-SMX, but susceptible to cephalosporins, had
single follow-up visit with ID in early ___. His most recent
positive urine culture was from ___, once again showed E.
coli, with similar resistance pattern and additional resistance
to gentamicin.
In terms of his opioid use disorder, patient reports he has been
to multiple detox facilities as well has had outpatient
services.
He was previously on suboxone, last 2 months ago at which time
he
relapsed. He has intermittently relapsed and has been discharged
from multiple facilities due to inability to keep appointments.
He feels depressed with ___ when he relapses, which is what
prompted him to come to the ED during this time. He is motivated
to stay sober this time around.
In the ED, initial VS were: 6 98.4 111 147/90 18 98% RA
Exam notable for: paraplegia, abdomen soft, stage 1 sacral
ulcers, bilateral
EKG: Not visible on Dash
Labs showed:
CBC 8.0 > 13.7 / 40.9 < 296, MCV: 89, N:60.2%
BMP: K+ 4.2, BUN/Cr ___, Gluc 153
UA: ___, SG 1.030, Leuk Lg, Prot 30, Glu 150, Ket Tr, WBC >
182, Bact Few, Epi 2
Tox
Serum Negative - ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc
Urine Positive - Cocaine
Urine Negative - Benzos, Barbs, Opiates, Amphet, Mthdne,
Oxycodone
Imaging showed:
CXR ___
FINDINGS:
The lungs are hyperexpanded expanded but clear. There is no
pleural abnormality the heart size is within normal limits. The
mediastinal and hilar contours unremarkable. Calcific density
projecting over the lower thoracic vertebra are unchanged in
configuration.
Consults:
Psychiatry: "No s12, will contact BEST to look for EATS
(dual-diagnosis unlocked unit), if patient attempting to leave
prior to placement, please call psych for re-eval.
For opioid withdrawal, would recommend:
- Clonidine 0.1mg BID (hold for SBP <100, HR <55, or orthostatic
changes)
- Robaxin 750mg Q6H PRN muscle pain/cramps
- Bentyl 20mg PO Q4H PRN GI cramps
- Vistaril 50mg IM/PO Q4H PRN anxiety
- Kaopectate 30 mL PO PRN after each loose stool
- Acetaminophen 650mg Q6H PRN pain
Page ___ with questions."
Patient received:
- Ceftriaxone 1gm IV x2
- NS 1L x1
Transfer VS were: 98.4 77 138/78 18 100% RA
On arrival to the floor, patient reports feeling well. Endorses
story above. He reports he was supposed to have an appointment
with his PCP today but went to the ED due to symptoms of dysuria
and urinary frequency for the past 2 days despite taking
fosfomycin as well as wanting to be placed in a facility to
detox. He was also concerned that he possibly may have
pyelonephritis as he has had this previously and persistent pain
in his L buttock where he has a pressure ulcer.
Past Medical History:
1. Paraplegia after gun shout wound from T10 level downward ___
2. Chronic back pain
3. Partial right lung resection for GSW
4. Recurrent MRSA skin abcesses in neck, back, perianal
(recently
admitted in ___
5. Recurrent sacral decubitus ulcers status post debridement in
the OR on ___ and ___ & ___ (growing MRSA)
6. Pseudomonal prostatic abscess in ___ Prostatis in ___
7. Recurrent UTI: Past cultures have grown enterococcus,
morganella, pseudomonas
8. Cocaine use with history of perforated nasal septum
9. Urinary incontinence: chronically self-catheterizes
10. Grade 1 internal hemorrhoids seen on sigmoidoscopy ___
11. Chronic Constipation
12. Depression
13. ADHD
14. G6PD mutation
-Diagnoses: Depression, add, no hx.o psychosis prior to what is
described in HPI
-Prior Hospitalizations: 1x this month as per HPI.
-History of assaultive behaviors: Denies
-History of suicide attempts or self-injurious behavior: Denies
-Prior med trials: Report being on wellbutrin/concerta
longstanding. Has tried ritalin
Social History:
Born in ___ raised, in ___, completed high school in ___
and some
post grad ___ training. Has one son, now ___ yo, who he
still sees.
Currently living in assisted living facility.
***Recently fired his PCA on ___ who was taking care of
assistance with his ADLs, food and meds. Now in the process of
hiring his son as his new PCA.
SUBSTANCE ABUSE HISTORY:
-ETOH: Denies
-Tobacco: denies
-MJ/LSD/Ecstasy/Mushrooms: report last MJ use ___ ___.
-Cocaine/Crack/Amphetamines: Has significant history of cocaine
dependence, now in remission, c/b perforated septum, reports
last
use ___ ___ but was found with cocaine in his urine on this
admission in ___.
-Opiates: Denies IVDU, on opioids for pain, question of misuse
of
prescriptions.
-Benzos: Denies
Family History:
Notable for BPAD and schizophrenia - sister, cousin, maternal GM
Physical Exam:
ADMISSION PHYSICAL EXAM:
ADMISSION PHYSICAL EXAM:
VS: 98.3 PO 132 / 82 R Sitting 70 20 94 RA
GENERAL: NAD
HEENT: EOMI, PERRL, anicteric sclera, MMM, poor dentition
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB
ABDOMEN: NT, mildly firm, +BS, no hepatosplenomegaly
EXTREMITIES: ___ muscle wasting
NEURO: A&Ox3, ___ strength in UE bilaterally, intact rectal tone
GU: No prostate tenderness on DRE
SKIN: warm and well perfused, stage 1 pressure ulcer on the L
buttock
DISCHARGE PHYSICAL EXAM:
VS: ___ 0710 Temp: 98.5 PO BP: 119/52 L HR: 90 RR: 18 O2
sat: 98% O2 delivery: Ra
GENERAL: NAD
HEENT: EOMI, PERRL, anicteric sclera, MMM, poor dentition
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB
ABDOMEN: NT, mildly firm, +BS, no hepatosplenomegaly
EXTREMITIES: ___ muscle wasting
NEURO: A&Ox3, ___ strength in UE bilaterally, intact rectal tone
SKIN: warm and well perfused
Pertinent Results:
ADMISSION LABS
___ 01:59AM WBC-8.0 RBC-4.59* HGB-13.7 HCT-40.9 MCV-89
MCH-29.8 MCHC-33.5 RDW-11.8 RDWSD-38.1
___ 01:59AM NEUTS-60.2 ___ MONOS-12.3 EOS-2.0
BASOS-0.5 IM ___ AbsNeut-4.79 AbsLymp-1.97 AbsMono-0.98*
AbsEos-0.16 AbsBaso-0.04
___ 01:59AM PLT COUNT-296
___ 01:35AM URINE HOURS-RANDOM
___ 01:35AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS* amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 01:35AM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 01:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-150* KETONE-TR* BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-LG*
___ 01:35AM URINE RBC-0 WBC->182* BACTERIA-FEW* YEAST-NONE
EPI-2
___ 01:35AM URINE MUCOUS-FEW*
___ 12:40AM GLUCOSE-153* UREA N-14 CREAT-1.0 SODIUM-140
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-30 ANION GAP-12
___ 12:40AM estGFR-Using this
___ 12:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
IMAGING:
CXR ___
IMPRESSION:
No focal consolidation. No evidence of pneumonia.
CT A/P ___
IMPRESSION:
1. 2.2 x 1 cm oval-shaped hypodensity in the right
posterolateral prostatic
apex is similar in appearance to prior MRI from ___ and may
represent a
chronic abscess or phlegmon. Consider pelvic MRI for further
evaluation.
2. No CT evidence of pyelonephritis or renal abscess.
3. Diffuse fecal loading throughout the large bowel.
MRI ___
IMPRESSION:
1. No prostatic abscess or phlegmon. Specifically, abnormality
noted on CT
from ___ within right peripheral zone corresponds to
normal
prostatic parenchyma.
2. Evidence of prior prostatitis within left peripheral zone.
3. Chronic bilateral sacral decubitus ulcers. Of note, study
is not
dedicated for evaluation of osteomyelitis and the findings are
markedly
improved compared to prior MR.
___:
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROBACTER CLOACAE COMPLEX. >100,000 CFU/mL.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
STAPHYLOCOCCUS SAPROPHYTICUS, PRESUMPTIVE IDENTIFICATION.
10,000-100,000 CFU/mL.
Routine susceptibility testing of urine isolates of S.
saprophyticus is not advised because infections respond
to
concentrations achieved in urine of antimicrobial
agents commonly
used to treat acute uncomplicated urinary infections
(e.g.,
nitrofurantoin, trimethoprim, trimethoprim
sulfamethoxazole or a
fluoroquinolone)..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
DISCHARGE LABS:
___ 06:20AM BLOOD WBC-8.3 RBC-4.01* Hgb-12.0* Hct-38.0*
MCV-95 MCH-29.9 MCHC-31.6* RDW-12.6 RDWSD-43.5 Plt ___
___ 06:20AM BLOOD Glucose-91 UreaN-16 Creat-0.7 Na-143
K-4.5 Cl-102 HCO3-27 AnGap-14
___ 06:20AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ year old man with paraplegia as a result of
a GSW, neurogenic bladder with chronic intermittent straight
caths, with recurrent UTIs with various organisms, now on
chronic
suppressive methenamine presenting with urinary tract infection,
passive ___, and opioid withdrawal symptoms.
ACUTE ISSUES:
=============
# Opioid withdrawal, detox
# History of polysubstance abuse
# Passive ___
Serum and urine tox screens on admission only positive for
cocaine. As per prior records, enrolled in multiple detox
programs previously but discharged due to inconsistent
medication use and lost to follow-up. Evaluated by psych given
passive ___ on presentation but not sectionable on their
evaluation. Recommended BEST screening for placement vs. CCS,
dual diagnosis unit. Unable to successfully place this patient
in above during the hospitalization. HIV/HCV checked for risk
stratification and returned negative. Initiated on suboxone
while inpatient as patient was having mild withdrawal symptoms
not controlled with other medications with improvement. Plan to
follow-up with Dr. ___ from psychiatry for suboxone.
# UTI w/ history of drug-resistant E. Coli
# History of prostatitis
Symtpoms and UA consistent with UTI, started on IV ceftriaxone.
On prophylactic methenamine hippurate on admission though from
prior ID notes likely not providing much benefit as urine pH on
testing has been too high to activate the drug. Urine culture
growing cephalosporin/fluoroquinoline sensitive enterobacter. CT
A/P obtained to r/o chronic abscess vs. phlegmon, though no
signs of this on pelvic MRI. Transitioned from IV ceftriaxone to
PO ciprofloxacin on discharge. Plan for 2 week course for early
seeding of the prostate (end date ___. On discharge, for UTI
ppx, ID recommended 3g fosfomycin PO q10 days rather than
methanamine.
CHRONIC ISSUES:
===============
# Neurogenic bladder: Continued xxybutynin 10 mg PO BID (takes
ER 20 mg daily at home), Tamsulosin 0.4 mg PO QHS with
intermittent straight caths.
# Chronic constipation: Continue bowel regimen PRN
# history of ?bipolar vs schizophrenia - not currently taking
any
medications.
# chronic low back pain: Continued Gabapentin 800 mg PO TID,
Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
TRANSTIONAL ISSUES
===================
- Last date of ciprofloxacin ___.
- Start fosfomycin 3g PO q10 days on ___
- ID, PCP, and psychiatry for suboxone follow-up as above.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Gabapentin 800 mg PO TID
2. Tamsulosin 0.4 mg PO QHS
3. Ascorbic Acid ___ mg PO BID
4. methenamine hippurate 1 gram oral BID
5. oxybutynin chloride 20 mg oral DAILY
Discharge Medications:
1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*20 Tablet Refills:*0
3. Docusate Sodium 200 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 2 tablet(s) by mouth BID:PRN Disp
#*60 Tablet Refills:*0
4. Fosfomycin Tromethamine 3 g PO Q10DAYS UTI prophylaxis
Dissolve in ___ oz (90-120 mL) water and take immediately
RX *fosfomycin tromethamine [Monurol] 3 gram 1 packet(s) by
mouth Q10days Disp #*3 Packet Refills:*0
5. Polyethylene Glycol 17 g PO TID:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth TID:PRN Disp #*24 Packet Refills:*0
6. Senna 17.2 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 2 tablets by mouth BID:PRN Disp
#*60 Tablet Refills:*0
7. Gabapentin 800 mg PO TID
RX *gabapentin 800 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
8. oxybutynin chloride 20 mg oral DAILY
RX *oxybutynin chloride 10 mg 2 tablet(s) by mouth daily Disp
#*60 Tablet Refills:*0
9. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Complicated urinary tract infection
Opioid dependence with withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for a urinary tract infection. We
started you on intravenous antibiotics. We did imaging to make
sure that you did not have an abscess of your prostate. We
transitioned you to an oral antibiotic that you will take until
___. You also started experiencing withdrawal symptoms while
here. We started you on suboxone and arranged for you to follow
up with Dr. ___ for this. It was a pleasure caring for
you.
Wishing you the best,
Your ___ Team
Followup Instructions:
___
|
10038332-DS-23 | 10,038,332 | 27,818,008 | DS | 23 | 2173-08-11 00:00:00 | 2173-08-11 15:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
Pyelonephritis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with PMH of history of unspecified
psychotic disorder (bipolar vs schizophrenia) and significant
cocaine and opioid use disorders (sober >9 mo), prostatic
abscess, and T10 paraplegia ___ GSW in ___ with neurogenic
bladder resulting in recurrent UTIs who presents today with
flank
pain and foul smelling urine. The symptoms started a week ago
but
have worsened over the past 2 days, prompting him to present to
the ED.
Over the past week the patient noticed a foul odor in his urine
with purulent discharge and bilateral flank pain. These symptoms
felt similar to his prior kidney infections. He describes
subjective fevers and chills, neck pain, and joint pains in the
small joints of his hands. He has had chronic mild abdominal
tenderness that initially improved after having a bowel movement
yesterday but worsened somewhat today. He is taking all his
medications as prescribed but forgot to take fosfomycin over the
past 2 weeks and feels this may have triggered a UTI.
Of note, pt was seen in ___ clinic in ___. He had been
performing straight catheterization every few hours and has
noted
improvement over the past several months with weekly fosfomycin
therapy as the frequencies of infections has decreased.
However,
earlier that month he had sign/symptoms of a UTI for which he
was
prescribed ciprofloxacin and treated with 7 days.
ROS: He denies any URI symptoms, n/v, dysuria, chest pain,
dyspnea, palpitations, headache, or paresthesias. He states that
he feels like is developing an ulcer in his left buttock area as
well. Has had bilateral blurry vision since starting Zoloft 2
weeks ago, which prompted him to discontinue the medication.
ED COURSE:
Exam: NAD b/l flank pain, normal mentation, wheelchair bound
Labs notable for WBC 8, UA pos for nitrites and leuks with >182
WBC and bacteria.
Pt received iL NS and 1g CTX at 10:45 pm.
Past Medical History:
1. Paraplegia after gun shout wound from T10 level downward ___
2. Chronic back pain
3. Partial right lung resection for GSW
4. Recurrent MRSA skin abcesses in neck, back, perianal
(recently
admitted in ___
5. Recurrent sacral decubitus ulcers status post debridement in
the OR on ___ and ___ & ___ (growing MRSA)
6. Pseudomonal prostatic abscess in ___ Prostatis in ___
7. Recurrent UTI: Past cultures have grown enterococcus,
morganella, pseudomonas
8. Cocaine use with history of perforated nasal septum
9. Urinary incontinence: chronically self-catheterizes
10. Grade 1 internal hemorrhoids seen on sigmoidoscopy ___
11. Chronic Constipation
12. Depression
13. ADHD
14. G6PD mutation
-Diagnoses: Depression, add, no hx.o psychosis prior to what is
described in HPI
-Prior Hospitalizations: 1x this month as per HPI.
-History of assaultive behaviors: Denies
-History of suicide attempts or self-injurious behavior: Denies
-Prior med trials: Report being on wellbutrin/concerta
longstanding. Has tried ritalin
Social History:
Born in ___ raised, in ___, completed high school in ___
and some
post grad ___ training. Has one son, now ___ yo, who he
still sees.
Currently living in assisted living facility.
***Recently fired his PCA on ___ who was taking care of
assistance with his ADLs, food and meds. Now in the process of
hiring his son as his new PCA.
SUBSTANCE ABUSE HISTORY:
-ETOH: Denies
-Tobacco: denies
-MJ/LSD/Ecstasy/Mushrooms: report last MJ use ___ ___.
-Cocaine/Crack/Amphetamines: Has significant history of cocaine
dependence, now in remission, c/b perforated septum, reports
last
use ___ ___ but was found with cocaine in his urine on this
admission in ___.
-Opiates: Denies IVDU, on opioids for pain, question of misuse
of
prescriptions.
-Benzos: Denies
Family History:
Notable for BPAD and schizophrenia - sister, cousin, maternal GM
Physical Exam:
GENERAL: Pleasant gentleman 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. Normal S1 S2, no S3, no S4. No
murmur. No JVD.
PULM: Breathing comfortably on room air. A few bibasilar
crackles
on chest exam. Good air movement bilaterally.
GI: Bowel sounds present. Abdomen non-distended, soft,
non-tender to palpation. No HSM appreciated.
GU: No flank tenderness to palpation. No suprapubic fullness or
tenderness to palpation.
EXT: No lower extremity edema, distal extremity pulses palpable
throughout.
SKIN: Bilateral well healing ulcers over ischial spines, intact
skin and covered.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, bilateral lower extremities without movement
(baseline) and 50% sensation.
PSYCH: Pleasant, appropriate affect.
Pertinent Results:
RECENT LABS, MICRO, STUDIES:
___ 06:42AM BLOOD WBC-6.2 RBC-4.15* Hgb-12.0* Hct-38.4*
MCV-93 MCH-28.9 MCHC-31.3* RDW-12.4 RDWSD-41.9 Plt ___
___ 06:42AM BLOOD Glucose-94 UreaN-12 Creat-0.7 Na-142
K-4.8 Cl-100 HCO3-29 AnGap-13
___ 06:42AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.0
___ UA: hazy, +nit, 30 prot, LG leuk, 4 RBC, >182 WBC, many
bacteria, 2 epithelial cells
___ 6:15 pm URINE CULTURE
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Ertapenem AND Fosfomycin Susceptibility testing requested per ___
___ (___) ___.
Ertapenem = SENSITIVE.
Fosfomycin = SENSITIVE.
______________________________
ESCHERICHIA COLI
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
Mr. ___ is a ___ employee of ___ with T10
paraplegia s/p gunshot wound, neurogenic bladder (chronic
self-caths) living in a sober house who is admitted for
pyelonephritis.
His urine culture growing multidrug-resistant E.coli. Most
likely got pyelonephritis in setting of non-adherence with home
suppressive fosfomycin. Final sensitivities showed sensitivity
to pipercillin/tazobactam, meropenem, gentamycin, ertapenem,
fosfomycin. His sober house can't manage IV antibiotics so had
to be discharged to a facility to complete his antibiotics
course. After initially started on ceftriaxone, when
sensitivities he was switched to pip/tazo ___, per ID's
suggestion; on discharge he was switched to ertapenem to
complete a 7-day course (last day: ___. He was instructed to
restart his home fosfomycin when he completes his IV
antibiotics.
While in the hospital his discomfort was treated with
phenazopyridine (for dysuria), and his Suboxone was increased
from daily to BID; he was discharged back on his home daily
dosing. He was continued on his home dose of gabapentin for
neuropathic pain. During the hospitalization his non-formulary
Vyvanse for ADHD was held, and restarted at discharge. His home
venlafaxine was continued.
___ PMP was checked and was appropriate.
He had constipation while in the hospital, treated with miralax,
senna, docusate, and prn lactulose. He was continued on his home
oxybutynin and tamsulosin for neurogenic bladder and continued
his normal routine of serial self-catheterization.
He had constipation while in the hospital, treated with miralax,
senna, docusate, and prn lactulose. He was continued on his home
oxybutynin and tamsulosin for neurogenic bladder and continued
his normal routine of serial self-catheterization.
He also complained of neck pain and hand tingling and weakness,
so MR of the c/s was done and showed djd at mult levels with
cord contact and remodeling of cord without cord signal
abnormality; neurosurgery was consulted and recommended that he
follow up as an outpatient, no need for surgery or intervention
at this time
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 800 mg PO TID
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL DAILY
4. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
5. Oxybutynin XL (*NF*) 20 mg Other DAILY
6. Tamsulosin 0.4 mg PO BID:PRN urinary retention
7. alprostadil 20 mcg injection DAILY:PRN
8. Multivitamins 1 TAB PO DAILY
9. Vyvanse (lisdexamfetamine) 50 mg oral DAILY
10. Naloxone Nasal Spray 4 mg IH ASDIR
11. Venlafaxine XR 75 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
give on ___ and ___, last day ___. Fosfomycin Tromethamine 3 g PO 3 G EVERY 7 DAYS
Dissolve in ___ oz (90-120 mL) water and take immediately
3. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
4. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
6. alprostadil 20 mcg injection DAILY:PRN
7. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL DAILY
8. Gabapentin 800 mg PO TID
9. Multivitamins 1 TAB PO DAILY
10. Naloxone Nasal Spray 4 mg IH ASDIR
11. Oxybutynin XL (*NF*) 20 mg Other DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Tamsulosin 0.4 mg PO BID:PRN urinary retention
14. Venlafaxine XR 75 mg PO DAILY
15. Vyvanse (lisdexamfetamine) 50 mg oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pyelonephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Wheelchair/Bedbound (patient is paraplegic).
Discharge Instructions:
You were admitted for a kidney infection (pyelonephritis),
probably related to not taking your fosfomycin. We treated you
with fluids and antibiotics. Your infection is resistant to many
antibiotics, requiring treatment with IV antibiotics instead of
oral ones. You are being discharged to complete your IV
antibiotics at a facility. Afterward, please restart your
fosfomycin to help prevent future infections like this.
Followup Instructions:
___
|
10038999-DS-10 | 10,038,999 | 29,026,789 | DS | 10 | 2132-05-23 00:00:00 | 2132-05-23 12:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Valium
Attending: ___.
Chief Complaint:
right ankle pain
Major Surgical or Invasive Procedure:
right tibial intramedullary nail
History of Present Illness:
___ hx of developmental mental delay, seizure disorder, and
blindness resides at a group home and while at day care had a
witnessed fall. No head strike per staff. Refused to bear weight
to right lower extremity. Significant swelling and tenderness to
right lower extremity, outside hospital images showed right
ankle fracture, transferred to ___ for higher level care.
Past Medical History:
Blindness
Mental delay
Seizure disorder
Social History:
___
Family History:
Unknown
Physical Exam:
Exam on discharge:
VS: Consistently tachycardic, oAVSS
General: Unlabored breathing on RA
RLE:
-Leg in aircast boot, wrapped in ACE bandage -> dressing changed
today, incisions clean/dry/intact, staples in place
-Exam limited by patient cooperation: wiggles toes, attempts to
dorsi/plantarflex ankle, sensation intact over dorsum and
plantar aspects of forefoot as testable,
-Foot warm and well perfused
No acute distress
Unlabored breathing
Abdomen soft, non-tender, non-distended
Incision clean/dry/intact with no erythema or discharge, minimal
ecchymosis
Splint in place, clean, dry, and intact
Aircast boot in place
Right lower extremity - leg in aircast boot, ACE dressing
clean/dry/intact, intact toe flexion/extension, no pain with toe
range of motion, sensation intact over dorsum and plantar
aspects of forefoot as testable, foot warm and well perfused
Pertinent Results:
___ 01:00PM BLOOD WBC-7.7 RBC-4.59* Hgb-11.4* Hct-36.7*
MCV-80* MCH-24.8* MCHC-31.1* RDW-15.0 RDWSD-43.6 Plt ___
___ 11:50PM BLOOD Glucose-108* UreaN-20 Creat-0.7 Na-141
K-4.2 Cl-101 ___ AnGap-17*
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right tibial and right fibular fractures and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for a right tibial
intramedullary nail, 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 his rehab 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
partial weight-bearing in an aircast boot in the right lower
extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient and his
caretakers 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 and his
caretakers were also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient and his caretakers expressed readiness for
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 30 mg PO QHS
2. QUEtiapine Fumarate 150 mg PO QAM
3. QUEtiapine Fumarate 300 mg PO QHS
4. TraZODone 100 mg PO QHS
5. TraZODone 50 mg PO QAM
6. Divalproex (DELayed Release) 500 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO DAILY
3. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*28
Syringe Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain
Do not drive while taking narcotics.
Hold RR<12.
RX *oxycodone 5 mg 1 tablet by mouth every six (6) hours Disp
#*15 Tablet Refills:*0
5. Citalopram 30 mg PO QHS
6. Divalproex (DELayed Release) 500 mg PO BID
7. QUEtiapine Fumarate 150 mg PO QAM
8. QUEtiapine Fumarate 300 mg PO QHS
9. TraZODone 50 mg PO QAM
10. TraZODone 100 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right tibia fracture and right fibula fracture
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
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:
- partial weight-bearing right lower extremity in aircast boot
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 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.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Aircast boot must be left on until follow up appointment
unless otherwise instructed
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
FOLLOW UP:
Please follow up with Dr. ___ in the ___ Trauma
Clinic ___ days post-operation for evaluation. Please call
___ to schedule appointment.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
partial weight-bearing right lower extremity in aircast boot
Treatments Frequency:
-dressing change as needed
-staples remain until follow up visit
Followup Instructions:
___
|
10038999-DS-9 | 10,038,999 | 27,189,241 | DS | 9 | 2131-06-04 00:00:00 | 2131-06-04 20:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
abdominal pain, found to have pericardial effusion
Major Surgical or Invasive Procedure:
pericardiocentesis
intubation
bronchoscopy
History of Present Illness:
This is a ___ yoM with a PMH significant for developmental mental
delay, seizure disorder, and blindness who is being admitted to
the CCU following pericardial drainage for a moderate to large
pericardial effusion.
He lives ___ a group home and he has been complaining of
abdominal pain for about a week. He went to his PCP ___ ___, who
was unable to examine him due to agitation. He then went to
___ ED on ___ with the same complaints and his vitals at
the time were Afebrile, HR 110s-120s, SBP 130s, 91% RA. He was
acutely agitated and required Haldol 5 mg IM, Haldol 5 mg IV,
Ativan 2 mg IM, and dilaudid 0.5 mg IV. He then got a CT abdomen
to evaluate his abdominal pain and it showed a moderate to large
pericardial effusion, small bilateral pleural effusions, and no
significant intra-abdominal process. He then received a bedside
echocardiogram that showed RV collapse, he was given 2 L NS, and
he was transferred to BID ED. ___ the ED here, his BP was
143/104, HR 128, RR 24, and 93% room air. Labs significant for
wbc 10.8 (72% poly, 14% lymph), hgb 9.2, INR 1.3, K 5.7, Cr 0.8.
An echocardiogram ___ the ED showed the IVC was non-collapsible,
but the RA was not invaginating with diastole. EKG showed NSR,
tachycardia, with PR depression ___ I/II, elevation ___ AVR,
decreased voltages, no electrical alternans. He was acutely
agitated and required intubation (fentanyl, versed). He was then
taken to the cath lab to have a pericardial drain placed, but
prior to the procedure his pulse was nonpalpable with a dropping
BP, and he required 20 seconds of chest compressions with ROSC.
He then received a pericardial drain without complications and
~400 mL of bloody fluid was drained. He only received about 300
mL of IVF ___ the cath lab.
On arrival to the CCU: T 98.8, BP 98/64, HR 103, on
volume-controlled CMV with FiO2 50%, PEEP 5, set RR 20, set Vt
400 mL, 93% saturation. He is on fentanyl and versed gtt.
Past Medical History:
Blindness
Mental delay
Seizure disorder
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION:
==========
Vitals: T 98.8, BP 98/64, HR 103, on volume-controlled CMV with
FiO2 50%, PEEP 5, set RR 20, set Vt 400 mL, 93% saturation. He
is on fentanyl and versed gtt.
GENERAL: Intubated and sedated, ET tube ___ place
HEENT: Normocephalic atraumatic.
NECK: Supple. No appreciable JVP, but difficult to tell.
CARDIAC: Tachycardia, normal S1, S2, no m,r,g
LUNGS: Mechanical breath sounds bilaterally, no appreciable
rales
ABDOMEN: Distended, but soft without masses
EXTREMITIES: Cool arms, non-pitting edema ___ bilateral lower
extremities up to mid tibia.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
ACCESS: Left AC 18 and right AC 20.
DISCHARGE:
==========
Pertinent physical:
GENERAL: NAD, awake
HEENT: Normocephalic atraumatic.
NECK: Supple. No appreciable JVP, but difficult to tell.
CARDIAC: Tachycardia, normal S1, S2, no m,r,g
LUNGS: Slight rales bilateral bases, poor effort
ABDOMEN: Distended, but soft without masses, NTTP
EXTREMITIES: No pedal edema
SKIN: Rashes from EKG leads on chest.
PULSES: Distal pulses palpable and symmetric.
ACCESS: None
Pertinent Results:
ADMISSION LABS:
===============
___ 09:00PM BLOOD WBC-10.8* RBC-3.66* Hgb-9.2* Hct-30.0*
MCV-82 MCH-25.1* MCHC-30.7* RDW-15.2 RDWSD-45.4 Plt ___
___ 09:00PM BLOOD Neuts-72.4* Lymphs-14.9* Monos-11.5
Eos-0.3* Baso-0.3 Im ___ AbsNeut-7.84* AbsLymp-1.61
AbsMono-1.25* AbsEos-0.03* AbsBaso-0.03
___ 09:00PM BLOOD Plt ___
___ 09:00PM BLOOD ___ PTT-27.7 ___
___ 09:00PM BLOOD Glucose-123* UreaN-17 Creat-0.8 Na-136
K-5.7* Cl-102 HCO3-22 AnGap-18
___ 10:45PM BLOOD CK(CPK)-258
___ 04:54AM BLOOD ALT-54* AST-27 AlkPhos-95 TotBili-0.5
___ 09:00PM BLOOD cTropnT-<0.01
___ 10:45PM BLOOD Calcium-7.8* Phos-4.3 Mg-2.2
___ 10:45PM BLOOD TSH-7.4*
___ 09:11PM BLOOD ___ pO2-47* pCO2-47* pH-7.32*
calTCO2-25 Base XS--2 Intubat-INTUBATED Comment-PERIPHERAL
___ 09:11PM BLOOD Lactate-2.1*
___ 09:11PM BLOOD O2 Sat-77
___ 11:55PM BLOOD freeCa-1.02*
___ 09:59PM BLOOD SED RATE-Test
___
CYTOLOGY REPORT - Final
SPECIMEN(S) SUBMITTED: PERICARDIAL FLUID
DIAGNOSIS:
PERICARDIAL FLUID:
NEGATIVE FOR MALIGNANT CELLS.
OTHER PERTINENT LABS:
=====================
___ 06:29PM BLOOD WBC-11.5* RBC-3.92* Hgb-9.8* Hct-31.1*
MCV-79* MCH-25.0* MCHC-31.5* RDW-15.1 RDWSD-43.6 Plt ___
___ 05:08AM BLOOD WBC-9.3 RBC-3.47* Hgb-8.6* Hct-27.9*
MCV-80* MCH-24.8* MCHC-30.8* RDW-14.9 RDWSD-43.6 Plt ___
___ 04:54AM BLOOD Glucose-64* UreaN-15 Creat-0.8 Na-139
K-4.3 Cl-99 HCO3-26 AnGap-18
___ 06:29PM BLOOD calTIBC-264 VitB12-683 Folate-18.9
Hapto-474* Ferritn-457* TRF-203
___ 04:44PM BLOOD calTIBC-234* VitB12-1087* Folate->20
Ferritn-529* TRF-180*
___ 06:29PM BLOOD T4-4.5* T3-67*
___ 06:38AM BLOOD Free T4-1.1
___ 04:44PM BLOOD Free T4-0.9*
___ 09:28AM BLOOD ANCA-NEGATIVE B
___ 06:29PM BLOOD RheuFac-15* CRP->300.0*
___ 09:59PM BLOOD ___
___ 06:38AM BLOOD CRP-327.1*
___ 09:28AM BLOOD IgG-1087
___ 02:56AM BLOOD C3-180 C4-27
___ 09:28AM BLOOD HIV Ab-Negative
___ 05:21AM BLOOD Type-ART pO2-98 pCO2-51* pH-7.41
calTCO2-33* Base XS-5 Intubat-INTUBATED
___ 02:30PM BLOOD Type-ART FiO2-40 pO2-93 pCO2-57* pH-7.41
calTCO2-37* Base XS-8
___ 12:20PM BLOOD Lactate-1.5
___
Page 1 of 2
CYTOLOGY REPORT - Final
SPECIMEN(S) SUBMITTED: PERICARDIAL FLUID, Collected @ 16:45
DIAGNOSIS:
PERICARDIAL FLUID:
NEGATIVE FOR MALIGNANT CELLS.
Blood only.
___
CYTOLOGY REPORT - Final
SPECIMEN(S) SUBMITTED: BRONCHIAL LAVAGE
DIAGNOSIS:
BRONCHIAL LAVAGE:
NEGATIVE FOR MALIGNANT CELLS.
Bronchial epithelial cells and pulmonary macrophages ___ a
background of numerous inflammatory
cells including neutrophils, histiocytes and lymphocytes.
MICROBIOLOGY:
=============
___ 10:06 pm FLUID,OTHER
r/o coxsackievirus (types A and B) .
Enterovirus Culture (Final ___: No Enterovirus
isolated.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
___:
Negative for Cytomegalovirus early antigen by
immunofluorescence.
Refer to culture results for further information.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED
___ 6:25 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
GEMELLA SPECIES. PRESUMPTIVE IDENTIFICATION.
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
___.
GRAM POSITIVE COCCI ___ CLUSTERS.
___ 9:46 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 9:46 pm URINE Source: Catheter.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, ___
infected patients the excretion of antigen ___ urine may
vary.
___ 9:46 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
RESPIRATORY CULTURE (Final ___:
HEAVY GROWTH Commensal Respiratory Flora.
___ 8:42 am BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ 8:42 am BRONCHIAL WASHINGS BRONCHIAL WASH.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ 8:42 am Rapid Respiratory Viral Screen & Culture
BRONCHIAL WASH .
**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 ___:
Less than 60 columnar epithelial cells;.
Inadequate specimen for DFA detection of respiratory
viruses..
Interpret all negative DFA and/or culture results from
this specimen
with caution..
Negative results should not be used to discontinue
precautions..
Recommend new sample be submitted for confirmation..
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
Reported to and read back by ___ ___ ___ AT
14:44.
___ 2:30 pm Immunology (CMV) Source: Line-a.
**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 ___ the ___ patient
population.
___ 8:38 am PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
Blood Cultures (___): No growth
final
Urine Cultures (___): No growth final
IMAGING:
========
TTE ___:
The left atrium is normal ___ size. There is mild symmetric
left ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). The right ventricular cavity is
unusually small. with normal free wall contractility. There is a
large pericardial effusion. The effusion appears
circumferential. Stranding is visualized within the pericardial
space c/w organization. The pericardium appears thickened. There
are no echocardiographic signs of tamponade. No right atrial or
right ventricular diastolic collapse is seen.
IMPRESSION: Large circumferential pericardial effusion.
Thickened parietal pericardium. No echocardiographic evidence of
tamponade. Normal LV function. Small RV cavity size with normal
function.
CXR (AP Portable) ___:
IMPRESSION:
Evidence for bilateral pleural effusions and consolidation or
atelectasis ___ the left lower lobe. Prominent cardiac
silhouette.
TTE ___:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
systolic function is significantly depressed. The apical The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. There is a
small-moderate sized pericardial effusion ___ the apical views
the fluid is all echodense and there does appear to be tagging
of the RV wall to the pericardium raising question of
constriction. ___ those views the effusion is small, all < 1.0cm,
and the fluid is echodense. The subcostal windows are quite
limited, but the posterolateral pocket may be a little bigger
there measuring up to 1.3cm. It is hard to make out whether any
of that fluid is simple, but I suspect it is also echodense like
the rest of the pericardial fluid. There are no
echocardiographic signs of tamponade.
IMPRESSION: Small to moderate sized echodense circumferential
pericardial effusion. Pleural effusion. No 2D echo evidence of
tamponade. Depressed global right ventricular systolic function.
The images and the report from ___ are not available for
review
CTA Chest ___:
IMPRESSION:
1. No evidence of pulmonary embolism within limitations of the
study limited by patient motion.
2. There is a large nonhemorrhagic pericardial effusion with
pericardial
drain ___ place. There is associated leftward interventricular
septal bowing and contrast reflux into the hepatic veins
suggestive of right ventricular strain.
3. Bilateral nonhemorrhagic pleural effusions are larger
compared to ___.
4. Bilateral compressive atelectasis with collapse of the left
lower lobe and posterior basal segment of the right lower lobe.
There is also linear atelectasis ___ the left upper lobe.
CXR (AP Portable) ___:
IMPRESSION:
1. Central pulmonary vascular congestion with new mild edema
since the ___ examination.
2. The lung volumes remain low. Unchanged pleural effusions and
bibasilar
atelectasis.
CT Chest w/ Contrast ___:
IMPRESSION:
Decrease ___ size of pericardial effusion.
Extensive mediastinal lymphadenopathy is unchanged, the lymph
nodes are borderline, likely reactive.
Large bilateral layering pleural effusions associated with
adjacent atelectasis are stable.
No definitive new lung abnormalities are detected.
TTE ___:
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Left ventricular systolic
function is hyperdynamic (EF = 75%). Right ventricular chamber
size and free wall motion are normal. There is a moderate sized
pericardial effusion. The effusion appears circumferential. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There are no echocardiographic signs of
tamponade. However, ___ the presence of a non-free-flowing
pericardial effusion, these signs may be absent despite
impairment of right ventricular filling.
Compared with the prior study (images reviewed) of ___
the pericardial effusion is larger.
TTE ___:
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). There is a small to
moderate sized pericardial effusion. The effusion appears
circumferential. The effusion is echo dense, consistent with
blood, inflammation or other cellular elements. There are no
echocardiographic signs of tamponade. However, there is
significant, accentuated respiratory variation ___
mitral/tricuspid valve inflows, consistent with impaired
ventricular filling.
Compared with the prior study (images reviewed) of ___
the effusion appears smaller.
CXR ___:
IMPRESSION:
Compared to chest radiographs ___ through ___.
Previous pulmonary vascular congestion has resolved, but
moderate enlargement of the cardiac silhouette remains,
exaggerated by very low lung volumes.
There is no mediastinal venous engorgement to suggest elevated
central venous pressure. Pleural effusions are likely, but not
large. No pneumothorax.
DISCHARGE LABS (most recent since discharge):
==============================================
___ 11:10AM BLOOD WBC-7.0 RBC-4.24* Hgb-10.1* Hct-33.6*
MCV-79* MCH-23.8* MCHC-30.1* RDW-15.3 RDWSD-43.6 Plt ___
___ 11:10AM BLOOD ___ PTT-31.8 ___
___ 11:10AM BLOOD Glucose-92 UreaN-20 Creat-0.7 Na-138
K-4.4 Cl-101 HCO3-21* AnGap-20
___ 11:10AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ y/o man with history of developmental delay who
presented to an OSH with abdominal pain was found to have a
large pericardial effusion on CT Abd/Pelvis, transferred to
___ for further management.
#Pericardial effusion/Pericarditis: Patient initially presented
with abdominal pain with finding of pericardial effusion as
incidental finding. Unclear if symptoms are related to effusion,
however, as patient with limited ability to express himself
clearly due to developmental delay. He underwent
pericardiocentesis with findings consistent with
inflammatory/bloody output. Serial TTE post-procedure showed
persistent, but much improved and stable pericardial fluid as
well as possible constrictive physiology. He also had positive
inflammatory markers (CRP/ESR). Extensive work-up did not reveal
clear etiology with work-up negative for TB, thyroid
dysfunction, malignancy, and infection intrinsic to pericardial
fluid. Most likely explanation would be that patient had
pneumonia (as below), triggering para-pneumonic pericarditis and
effusion with subsequent heart failure as a result of effusion
and possible constriction. He was diuresed intermittently with
Lasix while ___ the CCU and started on colchicine therapy for
planned 90 days. He was evaluated by c-surg and after discussion
with patient's guardian (mother) and essential return to
baseline functional status, it was decided not to pursue any
invasive procedures such as pericardial stripping vs. window.
After evaluation and treatment with physical therapy, he was
discharged back to his home facility.
#Hypervolemia: Patient had low albumin, constrictive physiology
and lower extremity edema, bilateral pleural effusions, and
elevated CVP on admission. This was felt to be due to acute
inflammation (leading to low albumin) and effusive/constrictive
physiology, treated with Lasix while ___ the ICU. He was
euvolemic at discharge off any maintenance diuretics.
#Pleural effusions: Given extensive work-up (detailed above),
patient was noticed to have large pleural effusions likely due
to para-pneumonic inflammation and volume overload. He underwent
U/S guided drainage of his left-sided effusion (exudative)
without clear signs of infection with ___ during this admission
and improvement noted on subsequent imaging.
#HCAP: Patient was admitted with fever and pulmonary
infiltrates, and overall picture that was felt to be consistent
with pneumonia. He was treated with course of
vancomycin/cefepime/azithro as such. Unfortunately, only
positive growth from BAL and cultures from multiple sources was
Gamella from blood (per ID felt to be likely contaminant). His
respiratory status improved to baseline at time of discharge.
#Rash: During this admission, patient noted to have rash on back
from b/l shoulders to top of iliac crests, diffuse erythematous
plaques and papules with poorly demarcated borders covering most
of back; no sloughing, vesicles or purpura, blanchable ___
nature. This was felt to be possible heat rash or possible drug
effect. However, no concerning findings c/w SJS/TEN or
significant eosinophilia on lab work. This self resolved with
mobilization from the bed, prior to discharge.
#Hypoxic respiratory failure: The patient was initially
intubated and sedated prior to admission due to report of
hypoxia and agitation, which would have potentially complicated
pericardial drainage. He was found as above to have pneumonia,
pleural effusions, pericardial effusion, and
atelectasis/incomplete collapse of bilateral lower lobes. CTA
chest also showed no signs of PE. He was extubated with
treatment of his multiple conditions as above on ___ and
quickly was weaned to room air prior to discharge.
#Bradycardia: While intubated, patient had multiple episodes of
bradycardia with possible junctional rhythm, never lasting more
than seconds to a minute. These were all felt to be vagal ___
nature as they occurred ___ the setting of bladder scan, trach
adjustment, and ventilation changes. He was monitor closely on
tele without further episodes post-discharge.
#Anemia: Baseline H/H 13.2-___-40. Iron studies c/w slight
anemia of chronic disease. Has been low likely because of
hemodilution ___ the setting of IVF. His H&H improved with
supportive care.
#Malnutrition: He had low albumin possibly due to acute
inflammation/illness and prolonged intubation. He did receive
tube feeds while intubated and was quickly restarted on regular
diet prior to discharge.
#Coagulopathy: INR 1.2 on admission, today 1.7. Unknown
etiology. ___ malnutrition, liver dysfunction, medication
induced. This was most likely due to malnutrition and vitamin K
dysfunction as INR improved quickly after initiation of
nutrition.
#Seizures (chronic): Continued on home Depakote 500 mg BID
#Developmental delay/behavioral issues (chronic): Continued
during hospitalization on home Seroquel, trazodone, and celexa.
TRANSITIONAL ISSUES:
- Colchicine for 3 month course for possible pericarditis (Day 1
- ___
- Outpatient cards f/u ___ ___ weeks
- Repeat TTE ___ ___ weeks before cardiology appointment to
assess for pericardial fluid reaccumulation
- Decision made not to pursue pericardial stripping vs.
pericardial window placement given ability to return to baseline
functional status. Can consider ___ the future if recurrent
pericardial effusion
-During work-up for cause of pericardial effusion, patient had
negative Quantiferon Gold assay for TB
CODE STATUS: FULL CODE
CONTACT: ___ (mother) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. QUEtiapine Fumarate 300 mg PO QHS
2. Divalproex (DELayed Release) 500 mg PO BID
3. Citalopram 40 mg PO DAILY
4. QUEtiapine Fumarate 150 mg PO QAM
5. TraZODone 100 mg PO QHS
6. TraZODone 50 mg PO QAM
7. Vitamin D ___ UNIT PO DAILY
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Oyster Shell Calcium 500 (calcium carbonate) 500 mg calcium
(1,250 mg) oral DAILY
10. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP BID
Discharge Medications:
1. Colchicine 0.6 mg PO BID Duration: 90 Days
Please continue for 90 days. Day 1 = ___.
RX *colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp
#*180 Tablet Refills:*0
2. Citalopram 40 mg PO DAILY
3. Divalproex (DELayed Release) 500 mg PO BID
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Oyster Shell Calcium 500 (calcium carbonate) 500 mg calcium
(1,250 mg) oral DAILY
6. QUEtiapine Fumarate 150 mg PO QAM
7. QUEtiapine Fumarate 300 mg PO QHS
8. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP BID
9. TraZODone 100 mg PO QHS
10. TraZODone 50 mg PO QAM
11. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Pericarditis
Pericardial Effusion
Health Care Associated Pneumonia
Pleural Effusion
Hyperkalemia
Hypoxic Respiratory Failure
SECONDARY DIAGNOSES:
Developmental Delay
Seizure disorder
Discharge Condition:
Mental Status: Confused - sometimes. At baseline the patient is
AOx1 and he has returned to baseline on discharge.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. Patient is legally
blind so requires assistance at baseline.
Discharge Instructions:
Dear Mr. ___,
You came to ___ because you
were having stomach pain and it was discovered that you had
fluid around your heart.
What was found ___ the hospital?
- Your had fluid around your heart, called a pericardial
effusion.
- Your had fluid ___ your lungs, called a pleural effusion.
- You had an infection ___ your lungs, called pneumonia.
- You had high levels of potassium ___ your blood, called
hyperkalemia.
- You had difficulty breathing and were on a mechanical
ventilator for 1 week.
What was done for you ___ the hospital?
- The fluid around your heart was causing problems with pumping.
You went to the catheterization lab. A drain was placed to
remove fluid. After two days, most of the fluid was gone and the
drain was pulled out. The fluid was sent for laboratory studies
to look for a cause like infection or disease, but no cause was
found. We continued to monitor your heart with pictures
(transthoracic echocardiograms and chest xrays). You were given
oral medications to keep the combat the inflammation around your
heart. The fluid did not reaccumulate and you are safe to go
home with follow-up with your doctor.
- Samples of the fluid ___ your lungs were taken by two methods.
The first was a bronchoscopy, where a tube with a video camera
was placed down your throat to look inside your lungs. The
second method was a pleurocentesis, where a needle was put ___
your side and the fluid was pulled off. These samples were sent
to the laboratory for studies to look for a cause. We found
indicators of infection, but no specific bacterium that was
likely to cause it. You had chest x-rays to watch for
reaccumulation, and that did not happen.
- For your infection, you were see by specialists from the
infectious diseases and pulmonary divisions. You most likely had
a pneumonia. You received antibiotics for several days. You had
a fever with this infection. You received acetaminophen. You had
your intake and output monitored to make sure you did not become
dehydrated. Your symptoms improved and you are safe to go home.
- Initial laboratory studies showed that you had high levels of
potassium ___ your blood. You received fluids and diuresis at
different points during your hospitalization. You had frequent
electrocardiograms and laboratory studies to monitor for effects
of high potassium. Your potassium level returned to normal.
- You came to ___ on a mechanical ventilator to help your
breathing while you were sick. You were on the ventilator for
several days. You showed us you could breathe on your own, so we
stopped the ventilator and you were able to breathe on your own.
You did not require re-intubation.
What should you do when you go home?
- For the fluid around the heart, you should take a new
medicine, called colchicine, described below.
- Follow-up with your primary care doctor.
- Ask your primary care doctor to schedule follow-up appointment
and transthoracic echocardiogram with a cardiologist.
NEW MEDICATIONS
- Colchicine 0.6 mg by mouth ___ the morning and at night, every
day. This medication is for your pericarditis. You should take
it for 3 months, last dose ___.
Otherwise, you can continue taking the medications you had taken
at home before coming to the hospital.
Followup Instructions:
___
|
10039110-DS-14 | 10,039,110 | 25,345,103 | DS | 14 | 2165-12-14 00:00:00 | 2165-12-14 21:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Diflucan
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
HISTORY OF PRESENT ILLNESS: Ms. ___ is a ___ year old woman
with
history of dysfunctional uterine bleeding, iron deficiency
anemia, and polysubstance abuse including crack cocaine
presenting with chest pain.
Notably, she was seen the ED on ___ for chest and abdominal
pain
worsened with inspiration. She underwent CT abd/pelvis and was
diagnosed with a right lower lobe pneumonia based on that CT,
and
was discharged on azithromycin.
She initially felt better, but then the day prior to this
admission developed left-sided chest pressure, constant, worse
with deep breathing. She also reported dyspnea on exertion. She
denied any nausea, vomiting, diaphoresis, or exertional
component
to the pain.
She denied any unilateral leg pain, history of blood clots, or
recent surgeries. She did report a flight to ___ 2 weeks
prior
(12 hours). She is a daily smoker. Not on OCPs.
In the ED:
Initial vital signs were notable for: 99.0 92 155/70 16 99%
RA
Labs were notable for:
- D-Dimer ___
- Trop < 0.01
- BNP 113
- Lactate 0.7
- Hb 6.8 (has been ___ since ___
Studies performed include:
___ CTA CHEST
1. Segmental and subsegmental pulmonary emboli in the lingula,
right middle lobe and bilateral lower lobes. Upper lobes are not
particularly well assessed due to motion. No evidence of right
heart strain.
2. Findings compatible with a pulmonary infarct in the lingula.
Areas of atelectasis at the lung bases with suspected right
basilar infarct as well.
3. Small right and trace left pleural effusions.
4. The rounded 1.5 cm lesion in the upper and slightly outer
right breast which likely correlates with lesion worked up by
prior ultrasound in ___.
Patient was given:
___ 09:06 PO Acetaminophen 1000 mg
___ 12:14 PO Ibuprofen 600 mg
___ 13:42 IVF NS 1000 mL
___ 14:11 IV Heparin 6900 UNIT
___ 14:11 IV Heparin Started 1550 units/hr
___ 16:15 PO Ibuprofen 600 mg
Upon arrival to the floor, patient reports story as above. She
reports continued left chest pain with inspiration and dyspnea
with activity, but this has improved since initiation of the
heparin gtt.
She notes dysfunctional uterine bleeding and a history of
anemia.
We discussed blood transfusion given Hb < 7, although I relayed
that this is chronic and she does not need urgent transfusion at
this time. She preferred to think about it overnight.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
PMH
1. hypertension
2. genital herpes
3. fatty liver by ultrasound study
PSH
1. S/P C-section x ___ and ___
2. S/P multiple myomectomy for fibroids in ___
Social History:
___
Family History:
Her family history is noted for hyperlipidemia and
father living age ___ and diabetes in her mother living age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 98.2PO 152/77 86 18 98Ra
GENERAL: Alert and interactive.
HEENT: NCAT.
CARDIAC: Regular rhythm, normal rate.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Normal bowels sounds, non distended, non-tender.
EXTREMITIES: No clubbing, cyanosis, or edema. No palpable cords.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. AOx3.
=============================
DISCHARGE PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 946)
Temp: pt refused v/s (Tm 98.2), BP: 136/82 (136-152/77-82),
HR: 78 (78-86), RR: 18, O2 sat: 98%, O2 delivery: Ra, Wt: 190.7
lb/86.5 kg
GENERAL: Alert and interactive.
HEENT: NCAT.
CARDIAC: Regular rhythm, normal rate.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Normal bowels sounds, non distended, non-tender.
EXTREMITIES: No clubbing, cyanosis, or edema. No palpable cords.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. AOx3.
Pertinent Results:
ADMISSION LABS:
___ 09:08AM BLOOD WBC-10.4* RBC-4.36 Hgb-6.8* Hct-25.2*
MCV-58* MCH-15.6* MCHC-27.0* RDW-22.3* RDWSD-42.5 Plt ___
___ 09:08AM BLOOD Glucose-86 UreaN-10 Creat-1.0 Na-142
K-4.2 Cl-104 HCO3-23 AnGap-15
___ 09:08AM BLOOD ___ 09:08AM BLOOD cTropnT-<0.01
___ 09:08AM BLOOD proBNP-113
___ 09:08AM BLOOD Iron-15*
___ 09:08AM BLOOD calTIBC-529* Ferritn-29 TRF-407*
___ 09:12AM BLOOD Lactate-0.7
DISCHARGE LABS:
___ 06:35AM BLOOD WBC-10.3* RBC-4.00 Hgb-6.3* Hct-23.3*
MCV-58* MCH-15.8* MCHC-27.0* RDW-22.3* RDWSD-42.8 Plt ___
___ 06:35AM BLOOD Glucose-92 UreaN-9 Creat-0.8 Na-140 K-4.2
Cl-104 HCO3-23 ___ CXR:
IMPRESSION:
Perhaps minimal residual opacity at the right costophrenic angle
as seen on prior CT. No new consolidation.
___ CHEST CTA: IMPRESSION:
1. Segmental and subsegmental pulmonary emboli in the lingula,
right middle lobe and bilateral lower lobes. Upper lobes are
not particularly well assessed due to motion. No evidence of
right heart strain.
2. Findings compatible with a pulmonary infarct in the lingula.
Areas of
atelectasis at the lung bases with suspected right basilar
infarct as well.
3. Small right and trace left pleural effusions.
4. The rounded 1.5 cm lesion in the upper and slightly outer
right breast
which likely correlates with lesion worked up by prior
ultrasound in ___.
___ TTE: IMPRESSION: LVEF 69%. Mild symmetric left ventricular
hypertrophy with normal cavity size and regional/
global biventricular systolic function. Mild mitral
regurgitation. Mild pulmonary hypertension.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with history of dysfunctional
uterine bleeding, iron deficiency anemia, and polysubstance
abuse including crack cocaine presenting with chest pain, found
to have a pulmonary embolism.
# Non-submassive PE:
Pt presented with a week of worsening dyspnea and left sided
chest pain. ___ chest CTA notable for segmental PE in lingual,
RML, b/l lower lobes with pulmonary infarct in lingual and
suspected R. basilar infarct. She was hemodynamically stable.
___ TTE was obtained: LVEF 69%, there was no e/o R heart
strain, but TTE notable for mild symmetric LVH with regional
biventricular function, mild mitral regurg and mild pulm HTN.
Risk factors include smoking (7 cig/day), recent ~12 hr flight
from ___. She was started on a hep gtt and transitioned to PO
Eliquis 10mg bid x7 days followed by 5mg bid. For her pain, she
was given standing Tylenol ___ q8h + PRN ibuprofen.
# Dysfunctional uterine bleeding
# Iron deficiency anemia:
Reports Hgb ___ since ___ im the setting of fibroids and
dysfunctional uterine bleeding. She has undergone intermittent
iron infusions. This admission Hb 6.8 (baseline), with most
recent ferritin 6.8 in ___. Her Hgb was 6.3 on ___, but she
was asymptomatic. Previously, she repeatedly refused blood
transfusions, but was amenable to receiving 1U pRBC prior to
being discharged. She was adamant about being discharged on
___, as she had to go home to take care of her two younger
boys. She indicated she would present to the ED if she noticed
any active bleeding or become symptomatic. She has an outpatient
OBGYN appointment on ___ and said she would contact her PCP
for an appointment.
# Polysubstance use:
Pt with active EtOH use ___ drinker daily) and daily crack
cocaine inhalation. She was seen by addiction psychiatry in
___, started on acamprosate, and referred to social work. She
stopped taking this medication and missed her most recent social
work appointment. SW was initially consulted; however, pt did
not seem amenable to meeting with them. She denied any illicit
drug use after admission. Will suggest she f/u with outpatient
PCP ___ Psychiatry regarding substance use.
====================
MEDICATION CHANGES
====================
[]Started Eliquis 10mg bid x7 days (last day ___ followed by
5mg bid.
====================
TRANSITIONAL ISSUES
====================
[] Re-check H/H at next clinic visit, within 1 week of
discharge. Continue to monitor for active bleeding.
[] She has a f/u scheduled with OBGYN on ___. Please assess
for vaginal bleeding at that time, as she was recently started
on Eliquis for PE.
[] She denied a history of polysubstance abuse during this
admission. Please re-address possible illicit drug use either
with PCP or ___.
[]Consider EGD to evaluate for anastamosis, colonoscopy for
Fe-deficiency anemia.
[]s/p Roux-en-Y bypass. Consider multivitamin, Fe supplements,
B12, vitamin D and calcium supplementation.
# CONTACT: Husband, ___, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg two tablet(s) by mouth every 8 hours as
needed for pain Disp #*30 Tablet Refills:*0
2. Apixaban 5 mg PO BID
Take 10mg twice daily for a total of 7 days (until ___, then
5mg twice daily thereafter.
RX *apixaban [Eliquis] 5 mg one tablet(s) by mouth twice daily
Disp #*30 Tablet Refills:*2
3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
RX *ibuprofen 400 mg one tablet(s) by mouth every 8 hours as
needed for pain Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary embolism
Iron-deficiency Anemia
Polysubstance use
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 for a blood clot in your lungs.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received blood for your anemia.
- We gave you an IV blood thinner for your lung clot (called
heparin). We switched this to oral tablets called Eliquis
(apixaban).
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- You are now on a blood thinner that increases your risk of
bleeding. Please go to your nearest Emergency Department if you
experience any of the following: vaginal bleeding or bleeding
elsewhere, chest pain, palpitations (rapid heart beats),
shortness of breath, lightheadedness.
- Please follow up with your primary care doctor within 5 days
of being discharged. You will need to continue taking the
Eliquis (apixaban) for your lung clot.
- Take your Eliquis (apixaban) as directed:
___: Take 10mg in the morning + 10mg in the evening
for a total of 7 days.
___: Take 5mg in the morning + 5mg in the evening.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10039708-DS-13 | 10,039,708 | 20,572,787 | DS | 13 | 2138-11-06 00:00:00 | 2138-11-13 21:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Ataxia/Altered Mental Status
Major Surgical or Invasive Procedure:
No major surgical or invasive procedures.
History of Present Illness:
___ y/o F with HTN, hypothyroidism and alcoholism who presents
with of ~1 week dizziness. Patient states has had unstable gait
for several days causing her to fall on ___ in her bathroom
She denies any head injury or LOC but does report that she
bruised her right wrist. Dizziness is non-positional, does not
feel like room is spinning and is not exacerbated with head
movement. Denies changes in vision, headache, CP, SOB, n/v/d.
Endorses smoking 5x cigarettes/day and drinking half a pint of
EtOH daily. Denies drinking EtOH today, last drink was the day
prior to admission. Per family, patient is significantly altered
from her baseline over past week. Has also had some recent fecal
incontinence. Unclear if related to dizziness hindering
toileting or patient is unaware of incontinence.
In the ED initial vitals were: 98.0, 71, 105/76, 16, 100%
- Labs were significant for Mg 1.4, Cr 1.2 (baseline ). Serum
tox screen was negative (including EtOH).
- Patient was given thiamine 100mg x2, MVI, folate, magnesium
oxide 400mg x1.
Vitals prior to transfer were: 97.7, 65, 100/52, 18, 100% RA
On the floor, patient reports that she feels well and has no
complaints. History inconsistent, patient reports that her
dizziness is positional and only associated with standing. She
does not recall any episodes of fecal incontinence. Tried to
contact both patient's mother and son by phone but no answer.
Has trouble understanding some commands on examination.
Past Medical History:
ASTHMA
TOBACCO DEPENDENCE
ALCOHOL DEPENDENCE
HYPOTHYROIDISM
HYPERTENSION
S/P BARIATRIC SURGERY
H/O ALCOHOLIC HEPATITIS
GOUT
Social History:
___
Family History:
Family history significant for T2DM, HTN, hypothyroidism and
asthma.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals - 98.2, 90/56, 68, 16, 100% RA
GENERAL: NAD, lying in bed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, poor dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, normal S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Soft, nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, moving all 4 extremities with purpose.
Strength ___ for upper extremities, ___ for lower extremities.
Patient seems to have some difficulty understanding
instructions. Poor attention. Flat affect.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=======================
Vitals - Temperature 98.0-98.3 84-97/48-58, 63-80, 18, 98-100%
on RA
GENERAL: Patient is laying in bed comfortably watching
television. She appears more awake and oriented than yesterday.
She is A+Ox3. CARDIAC: Regular rate and rhythm, normal S1 and
S2, no m/r/g.
LUNG: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi. ABDOMEN: soft, non-tender, non-distended no rebound or
guarding, no organomegaly.
EXTREMITIES: Right ankle remains warm and tender to touch. Also
swelling noted surrounding the right ankle. The swelling is
decreased compared to yesterday. Dorsiflexion and plantarflexion
is ___ strength of right. Inversion and eversion of the right
foot is ___ although pain is noted on the lateral aspect of the
right foot. No swelling or warmth of the left ankle noted.
PULSES: 2+ DP pulses bilaterally.
COGNITIVE: Alert and oriented x 3.
Pertinent Results:
ADMISSION LABS
==============
___ 06:39PM BLOOD WBC-7.6 RBC-3.15* Hgb-11.9* Hct-37.5
MCV-119* MCH-37.8* MCHC-31.7 RDW-17.5* Plt ___
___ 06:39PM BLOOD Neuts-59.5 ___ Monos-5.5 Eos-2.0
Baso-0.3
___ 06:39PM BLOOD Plt ___
___ 06:39PM BLOOD Glucose-141* UreaN-16 Creat-1.2* Na-141
K-4.1 Cl-101 HCO3-26 AnGap-18
___ 06:39PM BLOOD Albumin-3.9 Calcium-9.2 Phos-4.2 Mg-1.4*
___ 09:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MICROBIOLOGY
============
Blood Culture, Routine (Final ___: NO GROWTH.
RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE.
Reference Range: Non-Reactive.
IMAGING
=======
___ CHEST (PA & LAT)
FINDINGS: PA and lateral views of the chest provided. There is
no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous
structures are intact. No free air below the right hemidiaphragm
is seen.
IMPRESSION: No acute intrathoracic process.
___ CT HEAD W/O CONTRAST
FINDINGS: There is no intra-axial or extra-axial hemorrhage,
edema, shift of normally midline structures, or evidence of
acute major vascular territorial infarction. Sulcal prominence
especially within the cerebellum is age hands consistent with
atrophy. The ventricles are normal in overall size and
configuration. The basilar cisterns are widely patent. The
imaged paranasal sinuses are clear. Mastoid air cells and middle
ear cavities are well aerated. The bony calvarium is intact.
IMPRESSION: No acute intracranial process. Age advanced atrophy.
___ LIVER OR GALLBLADDER US (SINGLE ORGAN) PRELIMINARY
REPORT
IMPRESSION: IMPRESSION: Normal exam. In particular, liver
appears normal.
OTHER NOTABLE LABS
==================
___ 06:39PM BLOOD ALT-18 AST-34 AlkPhos-102 TotBili-0.8
___ 09:25PM BLOOD VitB12-216*
___ 09:25PM BLOOD TSH-1.3
___ 05:40AM BLOOD Ret Aut-2.7
___ 05:40AM BLOOD calTIBC-221* Ferritn-90 TRF-170*
___ 05:35AM BLOOD Folate-8.5
___ 05:35AM BLOOD Cortsol-11.0
DISCHARGE LABS
==============
___ 05:50AM BLOOD WBC-4.9 RBC-2.39* Hgb-8.8* Hct-29.0*
MCV-121* MCH-36.8* MCHC-30.3* RDW-17.3* Plt ___
___ 05:50AM BLOOD Plt ___
___ 05:50AM BLOOD Glucose-81 UreaN-13 Creat-0.9 Na-141
K-4.6 Cl-109* HCO3-24 AnGap-13
___ 05:50AM BLOOD Calcium-8.9 Phos-5.8* Mg-1.9
Brief Hospital Course:
Ms. ___ is a ___ with PMH significant for HTN, hypothyroidism
and alcoholism who presents with one-two weeks of ataxia and
altered mental status per family.
#___'S ENCEPHALOPATHY: Ms. ___ came in with change in
mental status over the past two weeks. According to family, she
was slow to respond to questions and had forgotten to do some of
her daily activities. She has a history significant for chronic
alcohol use. In addition to change in mental status, she also
had ataxia with unbalance on feet. She did not have
opthalmoplegia. Given the altered mental status and ataxia, she
was treated for Wernicke's Encephalopathy. She was given
thiamine 500 mg IV TID for 3 days, followed by thiamine 500 mg
IV daily until she left against medical advice on ___. Prior to
discharge recommendation was to take thiamine 100 mg PO daily. A
CT of the head did show cerebellar atrophy which also likely
played a role in her change in mental status. Vitamin B12 was
found to be low at 216, therefore she was given B12 IM 1000 mcg
daily was from ___. Recommendation for was vitamin B12 IM
1000 mcg daily for 10 days and then vitamin B12 IM 1000 mcg
weekly for ___ weeks, then vitamin B12 IM 1000 mcg monthly.
Since the patient left AMA, she was given cyanocbolamin 1000 mcg
PO daily. Neurology was consulted. They believed the source of
the altered mental status likely was multifactorial including
vitamin deficiencies of thiamine, B12, as well as chronic
sequelae of alcohol use, recommended neurology f/u. With
supplementation with thiamine, vitamin B12, multivitamin and a
balanced diet, her altered mental status improved and she was
near baseline, however we advised that she stay in house for
further rehabilitation given that she didn't pass ___ due to
instability and did not qualify for rehab. She was advised of
the risks of discharge including further instability leading to
falls and at the extreme, death, however she elected to leave
regardles.
#GOUT: Ms. ___ has a history of gout. During hospitalization
she developed swelling, erythema, and warmth of the right ankle.
This was initially treated with naproxen 750 mg PO, followed by
250 mg PO Q8H with meals for five days (day 1: ___. The
gout responded well to the naproxen. As she left AMA, we
recommended she continue the naproxen for 2 additional days
after the symptoms resolve. We also advised her to contact her
PCP if the symptoms last more than one week.
#HYPOTENSION: During hospitalization, Ms. ___ had systolic
blood pressures ranging from the upper ___ to low 100s. She
remained asymptomatic when her blood pressures were low. She did
not feel chest pressure, tightness, shortness of breath, or
lightheadedness/dizziness when standing. Initial thought was
that it was due to poor nutrition/low volume satus. Fluid
repletion and improved diet did improve blood pressure into the
high ___. Even after IVFs and improved nutrition blood pressure
still remained low. An AM cortisol was obtained to assess
adrenal function and was normal at 11. She had no evidence of
infection and remained asymptomatic.
#ANEMIA: Patient presented with a macrocytic anemia. This was
likely in the setting of chronic alcohol use as well as her
previous bariatic surgery. B12 was low as noted above. To
replete B12, we gave Vitamin B12 IM 1000 mcg daily. We also
provided folic acid even though folate was within normal limits
at 8. H/H remained relatively stable during hospitalization and
was 8.8/29.2 at the time of discharge. She remained asymptomatic
with no lightheadedness, dizziness, sob, or chest pain. She
required no transfusions during hospitalization.
#ALCOHOL DEPENDENCE: Ms. ___ has a significant history of
alcohol consumption. She remained on CIWA protocol and did not
score. She received multivitamin, folate, thimaine and B12 as
noted above. Social work was consulted. Based on report from
social work, she was willing to attend ___
Substance Abuse Program. Social work also provided a list of
local AA meetings. Ms. ___ noted motivation in trying to
become sober. Her main motivation is improving herself for her
son.
#HYPOTHYROIDISM: TSH was obtained during hospitalization was
1.3. Hypothyroidism stable. She was continued on her home dose
of levothyroxine.
#ASTHMA: Well controlled and without wheezing or dyspnea on exam
during hospitalization. We continued home Advair and albuterol
rescue inhaler prn.
TRANSITIONAL ISSUES
====================
#ALTERED MENTAL STATUS/ATAXIA: Please follow-up in Neurology
clinic for further management of the altered mental
status/ataxia.
#OCCUPATIONAL THERAPY: Will followup recommendations from
occupational therapy: recommend intermittent supervision and
assist with IADLs from family given cognitive decline.
#HYPOTENSION: Blood pressures were low during hospitalization
(SBP between high ___ and low 100s). Remained asymptomatic. ___
be due to autonomic dysfunction given chronic alcohol use.
Consider tilt-table test and/or use of fludricortisone.
#ALCOHOL USE: Please follow-up with goal towards sobriety.
Patient willing to attend ___ Evening Substance
Abuse Program. SW provided list of local AA meetings.
#VITAMIN B12 REGIMEN for Vitamin B12 Deficiency: She was
prescribed cyanocobolamin 1000 mcg PO daily.
#GOUT: please follow-up with examination of the right ankle, as
this is the site the gout developed. If not improving, consider
use of colchicine.
#CODE STATUS: FULL CODE
#CONTACT: ___ (son); ___. ___
(mother); ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 2.5 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
6. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB, wheezing
7. Ascorbic Acid ___ mg PO DAILY
8. Calcium Carbonate 600 mg PO BID
9. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB, wheezing
2. Ascorbic Acid ___ mg PO DAILY
3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
4. FoLIC Acid 1 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN pain
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Naproxen 250 mg PO Q8H
RX *naproxen [Naprosyn] 250 mg 1 tablet(s) by mouth q8 hrs Disp
#*21 Tablet Refills:*0
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO BID constipation
12. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
13. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: ___'s Encephalopathy
SECONDARY: Alcohol use, anemia, vitamin B12 deficiency, gout,
hypotension, hypothyroidism.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent but difficulty with
stairs
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___
with ataxia (difficulty with your balance) as well as slowing of
your thinking. You were initially evaluated with imaging of your
head (head CT) which showed atrophy (weakening) of the
cerebellum (part of the brain). This was likely due to chronic
alcohol use in the past. The ataxia and slowing of your thinking
was also likely due to the chronic alcohol use in the past. In
order to help improve your thinking, we gave you a vitamin
called thiamine which helped improve your thinking as well as
your balance. We also continued you with other vitamins and
minerals including Vitamin B12, folic acid, a multivitamin. We
also had the neurologists (brain doctors) come and see you to
evaluate your unsteadiness on your feet and slowed thinking.
They also recommended continuing with the vitamins that we had
been giving you. The neurologists would also like to have you
seen as an outpatient with a neurologist within the At___
network. We also had social work come see you to discuss options
regarding resources to help quit alcohol consumption. We
recommended that you stay in the hospital given your ongoing
difficulty with standing and climbing stairs, and need for
physical therapy as well as ongoing IV thiamine. You elected to
leave against medical advice. You were advised of the risks of
leaving against medical advice, including falling with
possibility of serious injury including death, worsening
confusion, poor pain control and worsening of gout. You
understood and accepted these risks and elected to leave against
medical advice regardless.
While in the hospital, you were also treated for a gout flare.
You should continue to take naproxen for 2 days after your
symptoms resolve and you should contact your PCP if your
symptoms last for more than a week.
We encourage you to continue taking these vitamins as they are
helping improve your symptoms.
It was a pleasure taking care of you in the hospital!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10039708-DS-14 | 10,039,708 | 28,258,130 | DS | 14 | 2140-02-26 00:00:00 | 2140-02-27 19:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chief Complaint: Hypotension
Reason for MICU transfer: Refractory hypotension, severe anemia
Major Surgical or Invasive Procedure:
Intubation: ___
Sigmoidoscopy ___
EGD ___
Tunneled hemodialysis line placement ___
Colonoscopy ___
History of Present Illness:
___ with a PMH of EtOH abuse, liver disease, hypothyroidism, and
hypertension who presents with hypotension and severe anemia.
The patient was seen at her PCPs office today for a a few days
of fatigue and weakness. There she was found to be hypotensive
to the 64/34, pulse 93. She was sent to ___ by ambulance. She
has also been having diarrhea for the past few days with normal
stool color. She denies CP, SOB, Abd pain, N/V, dysuria. No hx
of GIB. No previous EGDs or colonoscopies.
Of note, the patient had a recent admission to ___ ___
for dizziness and hypotension that responded to IVF. At that
time her H/H was 9.9/29, cr 1.3.
In the ED, initial vitals: 97.8 90 70/42 18 100% RA.
She was hypothermic in the ED to 34 degrees C after getting 3L
IVF; was given a bear hugger.
Labs were notable for: H/H 4.3/14.4 with MCV 107, PTT 140 with
INR 1.1, transaminitis with AST 168 and ALT 89, Tbili 0.7, alb
2.3, creatinine 2.9->2.5 (baseline 0.9), bicarb 8->11, VBG
7.25/33/40/15, lactate 2.1-> 1.5, neg UA.
Exam was significant for normal mentation and brown, guaiac
negative stool.
CXR was without acute findings, and CTA abd/pelvis was without
source of bleed, but showed hepatic steatosis, colitis versus
portal colopathy, and heterogenous kidneys.
A cordis was placed in the R femoral vein for resuscitation.
The patient was given:
___ 13:12 IVF 1000 mL NS 1000 mL
___ 13:53 IVF 1000 mL NS 1000 mL
___ 15:23 IVF 1000 mL NS 1000 mL
___ 15:34 IV Piperacillin-Tazobactam 4.5 g
___ 15:34 PO Acetaminophen 1000 mg
___ 15:34 IV BOLUS Pantoprazole 80 mg
___ 16:16 IVF 1000 mL NS 1000 mL
___ 16:16 IV Vancomycin 1000 mg
___ 16:30 IV DRIP Pantoprazole Started 8 mg/hr
4 units pRBCs.
On arrival to the MICU, the patient's vitals were 97.8 77 81/43
18 99% on RA. She was persistently hypotensive to ___. She
was mentating well. She was given a total of 4L IVF and started
on levophed without blood pressure response. A-line was placed.
Past Medical History:
___'S ENCEPHELOPATHY
ASTHMA
TOBACCO DEPENDENCE
ALCOHOL DEPENDENCE
HYPOTHYROIDISM
HYPERTENSION
S/P BARIATRIC SURGERY
H/O ALCOHOLIC HEPATITIS
GOUT
Social History:
___
Family History:
Family history significant for T2DM, HTN, hypothyroidism and
asthma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 97.8 90 70/42 18 100% RA.
GENERAL: Alert, oriented, no acute distress.
HEENT: PERRL, MMM
NECK: supple, JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, mildly distended, no tenderness to palpation.
EXT: Warm, no edema
LINES: right femoral CVL, right PIV, foley in place
DISCHARGE PHYSICAL EXAM:
========================
VS 98.3 124/84 66 18 100%RA FSBG 67 (getting juice)
GENERAL: NAD, ill appearing, awake and interactive
HEENT: AT/NC, MMM, NGT in place
Chest: R anterior chest wall improved tenderness at tunneled HD
site. without erythema or fluctance.
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTA in anterior and axillary fields
ABDOMEN: scaphoid. +BS, minimal tenderness diffusely
EXTREMITIES: RLE edema present 1+ to around mid thigh
asymmetrically w/ LLE with no edema.
SKIN: warm, DP 2+ b/l
Pertinent Results:
ADMISSION LABS
==============
___ 01:40PM BLOOD WBC-7.5# RBC-1.35*# Hgb-4.3*# Hct-14.4*#
MCV-107*# MCH-31.9# MCHC-29.9* RDW-19.8* RDWSD-74.3* Plt ___
___ 01:40PM BLOOD Neuts-60.3 ___ Monos-11.2
Eos-0.8* Baso-0.0 Im ___ AbsNeut-4.54 AbsLymp-1.99
AbsMono-0.84* AbsEos-0.06 AbsBaso-0.00*
___ 01:40PM BLOOD ___ PTT-140.0* ___
___ 02:39PM BLOOD ___ 01:40PM BLOOD Glucose-123* UreaN-62* Creat-2.9*# Na-140
K-5.4* Cl-123* HCO3-8* AnGap-14
___ 01:40PM BLOOD ALT-89* AST-168* AlkPhos-259* TotBili-0.7
___ 07:30PM BLOOD CK-MB-1 cTropnT-<0.01
___ 02:39PM BLOOD Albumin-2.1*
___ 07:14PM BLOOD Calcium-6.4* Phos-3.7# Mg-1.2*
___ 11:51PM BLOOD calTIBC-90* VitB12-GREATER TH
Folate-GREATER TH ___ Ferritn-1085* TRF-69*
___ 07:30PM BLOOD Cortsol-7.4
___ 07:30PM BLOOD ASA-NEG Acetmnp-9* Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 01:43PM BLOOD ___ pO2-40* pCO2-33* pH-7.25*
calTCO2-15* Base XS--11
___ 01:43PM BLOOD Lactate-2.1*
PERTINENT LABS:
===============
Lactate trend:
___ 02:44PM BLOOD Lactate-1.5
___ 07:48PM BLOOD Lactate-3.4*
___ 12:10AM BLOOD Lactate-3.9*
___ 12:49AM BLOOD Lactate-3.6*
___ 12:15PM BLOOD Lactate-6.7*
___ 05:30PM BLOOD Lactate-7.2*
___ 09:55PM BLOOD Glucose-187* Lactate-5.8* Na-133 K-3.3
Cl-112*
___ 01:49AM BLOOD Lactate-4.9*
___ 11:35AM BLOOD Lactate-3.4*
___ 03:54AM BLOOD Lactate-2.5*
___ 06:27PM BLOOD Lactate-1.7
Troponin trend:
___ 07:30PM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:51AM BLOOD CK-MB-1 cTropnT-<0.01
___ 08:45AM BLOOD CK-MB-1 cTropnT-0.04*
___ 06:41PM BLOOD CK-MB-2 cTropnT-0.07*
___ 12:04AM BLOOD CK-MB-2 cTropnT-0.09*
___ 03:38AM BLOOD cTropnT-0.05*
___ 01:36AM BLOOD cTropnT-0.03*
___ 07:19AM BLOOD CK-MB-3 cTropnT-0.02*
BNP:
___ 12:04AM BLOOD ___
___ 05:32AM BLOOD Ret Aut-6.0* Abs Ret-0.16*
___ 04:15AM BLOOD ALT-19 AST-32 LD(LDH)-201 AlkPhos-217*
TotBili-1.0
___ 04:15AM BLOOD calTIBC-104* VitB12-GREATER TH Hapto-8*
TRF-80*
___ 03:06AM BLOOD Ferritn-2632*
___ 11:10AM BLOOD %HbA1c-5.6 eAG-114
___ 02:30PM BLOOD Triglyc-59
___ 05:08PM BLOOD Osmolal-308
___ 07:30PM BLOOD TSH-0.82
___ 05:25AM BLOOD Cortsol-13.8
___ 05:44AM BLOOD HAV Ab-POSITIVE IgM HAV-NEGATIVE
___ 03:29PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 02:39PM BLOOD ANCA-NEGATIVE B
___ 05:41AM BLOOD AMA-NEGATIVE
___ 05:41AM BLOOD ___
___ 05:45AM BLOOD C3-88* C4-27
___ 07:30PM BLOOD HIV Ab-Negative
___ 05:27PM BLOOD ANTI-PLATELET ANTIBODY-Test
Test Flag Result Unit
Reference Value
---- ---- ------ ----
---------------
Platelet Ab, S Positive
Not Applicable
Comment
Antibody reacts with glycoprotein to HLA Class I, probable
alloimmunization due to pregnancy/transplant/transfusion.
___ 12:00AM BLOOD COPPER (SERUM)-Test
Test Result Reference
Range/Units
COPPER 91 70-175 mcg/dL
___ 12:00AM BLOOD ZINC-Test
Test Result Reference
Range/Units
ZINC 48 L 60-130 mcg/dL
___ 11:55PM BLOOD VITAMIN B1-WHOLE BLOOD-Test
Test Result Reference
Range/Units
VITAMIN B1 (THIAMINE), 1118 H 78-185 nmol/L
BLOOD, LC/MS/MS
___ 11:55PM BLOOD VITAMIN C-Test
Test Result Reference
Range/Units
VITAMIN C, LC/MS/MS 0.2 0.2-1.5 mg/dL
___ 09:10PM BLOOD SELENIUM-Test
Test Result Reference
Range/Units
SELENIUM 29 L 63-160 mcg/L
___ 09:10PM BLOOD COPPER (SERUM)-Test
Test Result Reference
Range/Units
COPPER 34 L 70-175 mcg/dL
___ 09:10PM BLOOD ZINC-Test
Test Result Reference
Range/Units
ZINC 32 L 60-130 mcg/dL
ZINC
Test Result Reference
Range/Units
ZINC (repeat on ___ 27 L 60-130 mcg/dL
___ 09:10PM BLOOD VITAMIN C-Test
Test Result Reference
Range/Units
VITAMIN C, LC/MS/MS 0.2 0.2-1.5 mg/dL
___ 09:10PM BLOOD CERULOPLASMIN-Test
Test Result Reference
Range/Units
CERULOPLASMIN 14 L ___ mg/dL
___ 06:35PM BLOOD VITAMIN B1-WHOLE BLOOD-Test
Test Result Reference
Range/Units
VITAMIN B1 (THIAMINE), >1200 H 78-185 nmol/L
BLOOD, LC/MS/MS
___ 01:17PM BLOOD HEPARIN DEPENDENT ANTIBODIES-TEST
TEST RESULTS REFERENCE RANGE
UNITS
____________________ _______ _______________
_____
PF4 Heparin Antibody .10 0.00 - 0.39
___ 01:17PM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-Test
Test Result Reference
Range/Units
SOURCE Whole Blood
EBV DNA, QN PCR <200 <200 copies/mL
___ 10:28AM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG &
IGM)-Test
Test Result Reference
Range/Units
PARVOVIRUS B19 ANTIBODY 8.48 H
(IGG)
Reference Range
<0.9 Negative
0.9-1.1 Equivocal
>1.1 Positive
IgG persists for years and provides life-long immunity.
To diagnose current infection, consider Parvovirus
B19 DNA, PCR.
Test Result Reference
Range/Units
PARVOVIRUS B19 ANTIBODY <0.9
(IGM)
Reference Range
<0.9 Negative
0.9-1.1 Equivocal
>1.1 Positive
Results from any one IgM assay should not be used as a
sole determinant of a current or recent infection.
Because IgM tests can yield false positive results and
low levels of IgM antibody may persist for months post
infection, reliance on a single test result could be
misleading. If an acute infection is suspected, consider
obtaining a new specimen and submit for both IgG and IgM
testing in two or more weeks. To diagnose current
infection, consider parvovirus B19 DNA,PCR.
___ 11:56AM BLOOD T4, FREE, DIRECT DIALYSIS-Test
Test Result Reference
Range/Units
T4, FREE, DIRECT DIALYSIS 3.3 H 0.8-2.7 ng/dL
Urine studies:
___ 09:33AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 09:33AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 10:39PM URINE RBC-151* WBC->182* Bacteri-FEW Yeast-NONE
Epi-2 TransE-1
___ 01:20PM URINE AmorphX-FEW
___ 09:33AM URINE Hours-RANDOM UreaN-332 Creat-101 Na-41
K-43 Cl-12 TotProt-171 Prot/Cr-1.7* Albumin-36.1 Alb/Cre-357.4*
DISCHARGE LABS:
===============
___ 04:57AM BLOOD WBC-9.6 RBC-2.84* Hgb-9.0* Hct-27.5*
MCV-97 MCH-31.7 MCHC-32.7 RDW-19.0* RDWSD-67.4* Plt ___
___ 12:30PM BLOOD ___ PTT-56.4* ___
___ 04:57AM BLOOD Glucose-61* UreaN-33* Creat-2.9*# Na-137
K-4.6 Cl-100 HCO3-24 AnGap-18
___ 05:45AM BLOOD Glucose-75 UreaN-59* Creat-4.1* Na-138
K-5.4* Cl-106 HCO3-20* AnGap-17
___ 04:15AM BLOOD ALT-19 AST-32 LD(LDH)-201 AlkPhos-217*
TotBili-1.0
___ 04:57AM BLOOD Calcium-8.7 Phos-5.8*# Mg-2.1
___ 04:15AM BLOOD calTIBC-104* VitB12-GREATER TH Hapto-8*
TRF-80*
___ 03:06AM BLOOD Ferritn-2632*
___ 02:30PM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND
___ 05:44AM BLOOD HAV Ab-POSITIVE IgM HAV-NEGATIVE
___ 03:29PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 07:30PM BLOOD HIV Ab-Negative
___ 02:30PM BLOOD HCV Ab-PND
___ 03:29PM BLOOD HCV Ab-NEGATIVE
___ 06:27AM BLOOD freeCa-1.17
MICROBIOLOGY:
=============
__________________________________________________________
___ 11:53 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).
__________________________________________________________
___ 1:29 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 9:07 am BLOOD CULTURE Source: Line-hd line.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:07 am BLOOD CULTURE Source: Line-aline 1 OF 2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 3:39 pm Mini-BAL
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
YEAST. ~3000/ML.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Preliminary):
YEAST.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
__________________________________________________________
___ 1:39 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. ~3000/ML.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
Negative results:
___ URINE URINE CULTURE-FINAL INPATIENT
___ Immunology (CMV) CMV Viral Load-FINAL
INPATIENT
___ SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL INPATIENT
___ SWAB Chlamydia trachomatis, Nucleic Acid
Probe, with Amplification-FINAL; NEISSERIA GONORRHOEAE (GC),
NUCLEIC ACID PROBE, WITH AMPLIFICATION-FINAL INPATIENT
___ URINE Chlamydia trachomatis, Nucleic Acid
Probe, with Amplification-FINAL; NEISSERIA GONORRHOEAE (GC),
NUCLEIC ACID PROBE, WITH AMPLIFICATION-FINAL INPATIENT
___ STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; FECAL CULTURE - R/O VIBRIO-FINAL; FECAL CULTURE -
R/O YERSINIA-FINAL; FECAL CULTURE - R/O E.COLI 0157:H7-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ STOOL C. difficile DNA amplification
assay-FINAL INPATIENT
___ MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___- urine cultures x2
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 ORGANISMS/ML..
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION
___ - blood cultures x2 - no growth
PERTINENT STUDIES:
==================
___ CXR:
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are
normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural
effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
Chain sutures are noted in the left upper quadrant of the
abdomen.
IMPRESSION:
No acute cardiopulmonary abnormality
___ CT abd/pelvis:
IMPRESSION:
1. No active extravasation of contrast to suggest active GI
bleeding at this time.
2. Profound hepatic steatosis. Enlarged periportal lymph nodes
with hazy
mesentery and retroperitoneum likely reflect underlying liver
disease.
3. Colonic and rectal wall thickening which may reflect colitis
versus portal colopathy.
4. Heterogeneous appearance of the kidneys with possible
striated nephrograms. Correlate with urinalysis to exclude
pyelonephritis.
___ TTE:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF = 65%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are mildly thickened.
The mitral valve leaflets are mildly myxomatous. Frank mitral
valve prolapse is not seen but cannot be excluded with
certainty. An eccentric, posteriorly directed jet of moderate
(2+) mitral regurgitation is seen. Due to the eccentric nature
of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
___ ___
IMPRESSION:
1. Occlusive thrombus of all right lower extremity deep veins
from the common femoral vein down to the calf veins.
2. Patent left lower extremity veins.
___ ECHO
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears depressed (LVEF = 40%)
secondary to hypokinesis of the basal two-thirds of the left
ventricle. The apical one-third of the left ventricle is
hyperdynamic. Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. The pulmonary artery is not well visualized.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
left ventricular systolic dysfunction is now present. Findings
suggestive of stress cardiomyopathy with inverse Takotsubo
pattern of left ventricular contractile dysfunction.
___ CTH:
IMPRESSION:
1. There is mild progression of global cerebral atrophy since
the prior
examination of ___, greater than would be expected
for the
patient's age.
2. No intracranial hemorrhage or territorial infarct.
___ LIVER US:
IMPRESSION:
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. Trace ascites and small right pleural effusion.
___ IVC filter placement:
FINDINGS:
1. Patent normal sized, non-duplicated IVC with no evidence of
a IVC
thrombus. A small circumaortic renal vein originating from the
IVC just above the bifurcation was noted however is very small
in caliber and likely of no clinical significance.
2. Successful deployment of an infra-renal retrievable IVC
filter.
IMPRESSION:
Successful deployment of an infra-renal removable IVC filter.
___ ECHO:
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and low normal global biventricular systolic function.
No valvular pathology or pathologic flow identified. Trivial
pericardial effusion.
___ Unilateral RLE veins
IMPRESSION:
Extensive deep venous thrombosis involving the wall of the right
lower
extremity veins, overall similar to ___, but now with
perhaps minimal flow in the distal right SFV.
___ Video oropharyngeal swallow study
Aspiration with thin liquid consistency.
___ Portable abdomen x-ray
Patient is post gastric bypass surgery. The Dobbhoff tube ends
in the
proximal jejunum.
___ Renal ultrasound
No evidence of hydronephrosis. Increased renal echogenicity
consistent with diffuse parenchymal renal disease.
Small bilateral effusions and small to moderate volume ascites.
___ - EGD
Duodenum was not examined. Small gastric pouch consistent with
Roux en y anatomy the blind limb and jejunal limb were both
visualized. No varices. Otherwise normal EGD to the jejunum.
Brief Hospital Course:
___ hx gastric bypass surgery, alcohol abuse complicated by
Wernicke's encephalopathy, concern for autonomic insufficiency,
presented originally with hypotension, anemia and academia. Her
course in the MICU was complicated by severe nutritional
deficiency, volume overload, renal failure, cardiomyopathy,
hypoxemia and hypoxemic respiratory failure, and deep vein
thrombosis.
# Hypotension:
# Cardiomyopathy:
# Presumed alcoholic liver disease:
Patient was given 4u PRBCs in the ED prior to FICU admission;
her Hgb was stable for days afterward, and there was low
suspicion for active GIB initially in her MICU course. She was
empirically antiobiosed for concern of sepsis, but no source was
found, and these antibiotics were held until a series of
presumed aspiration events that will be discussed below. Morning
cortisol was within normal limits twice; TSH was also within
normal limits. She underwent several echocardiograms to explain
her persistent hypotension with pressor requirement that showed
in sequence: mitral regurgitation with eccentric jet; inverse
Takutsubo's cardiomyopathy; and then resolution of these issues.
Of note, the resolution occurred after initiation of high-dose
thiamine repletion, which may suggest an element of wet
beriberbi from severe nutritional deficiency in the setting of
gastric bypass and alcoholism. There was also strong suspicion
of cirrhosis given her imaging and alcohol abuse history, for
which she was started on midodrine. With these measures, she was
successfully weaned from pressors. Unresolved at the time of her
MICU discharge was a question of autonomic insufficiency raised
in her last Discharge Summary of ___ where it was thought her
alcohol abuse could be contributing to baseline systolic
pressures in the ___. This in part resolved on the floor as the
patient was weaned off midodrine and maintained systolic blood
pressure in the 100s.
# Anemia:
-Unexplained, possible GI source with lack of erythropoietin in
the setting of subacute renal failure . Patient had decreasing
pRBC transfusion requirements over the course of her stay,
ultimately needing 1U pRBC every 4 days. She was evaluated by
Hem/Onc who felt there was no evidence of significant hemolysis
or malignancy and felt that there was an element of anemia of
chronic inflammation, as well as decreased erythropoietin in the
setting of subacute renal failure. She was evaluated by GI who
found no source of bleed on sigmoidoscopy early in her course
and no varices or bleeding on EGD. She had an episode of guaiac
positive stool but had no significant bleeding on colonoscopy.
Patient may benefit from outpatient capsule study if bleeding is
ongoing.
# Thrombocytopenia:
There was no evidence of active bleed on presentation (stool
normal color, not tachycardic, no clinical or radiographic
evidence of extravasation into a compartment). Surgery and GI
were consulted early in her MICU course for concern of ischemic
gut in the setting of rising lactate, but flexible sigmoidoscopy
was negative for this and lactate resolved with fluid
resuscitation. ___ Hematology consulted, and believe her
anemia and thrombocytopenia are likely a combination of
alcoholic bone marrow suppression, malnutrition and critical
illness. She may benefit from a bone marrow biopsy when more
stable; additionally, given her renal failure, she may have a
developing EPO deficiency. She was transfused by ED prior to
MICU admission and did not require further blood products until
___ (gradually dropping Hct attributed to anemia of chronic
illness/inflammation/underproduction; she held her Hct each time
after transfusion).
# Diarrhea:
Negative c. diff, improved over the course of the hospital stay.
Possibly related to tube feeding formulas as this improved with
changing to a higher fiber formula and with the addition of
banana flakes. Recommend continued loperamide as needed and
optimization of tube feeds in patient s/p gastric bypass.
# Renal Failure (Addressed Separately Below):
Presented with serum bicarbonate of 8 of unclear etiology. She
manifested diarrhea in the early part of her ICU stay (C diff
assay negative, thought related to either alcohol abuse or early
course of antibiotics administered empirically for presumed
sepsis, resolved); her renal function markers may also have been
under-estimates of her true GFR given her nutritionally
deficient state. Acidemia corrected with bicarbonate drip, but
recurrence remains in a concern in the setting of her renal
failure with poor UOP. CRRT was started in the setting of volume
overload in the ICU as described above, though she was noted to
have ATN by muddy brown casts in her urine as well as
persistently poor UOP. At time of FICU discharge she is being
trialed off CRRT, though with her poor UOP she may need to be
initiated on standing dialysis. Upon transfer to the floor, her
renal function did not improve and she remained oliguric. She
was evaluated by nephrology who felt that ATN without renal
recovery was the most likely diagnosis based on her urine
sediment and history. A renal biopsy was considered, but
nephrology felt that the risks of the biopsy on a patient
already requiring heparin for DVT would outweigh the benefits
with the suspicion of ATN being high already. Urine output
remained low prior to discharge, and tunneled HD line was placed
for longer-term access.
# Respiratory Failure:
Patient developed progressive hypoxemia from volume overload
eventually requiring CRRT with resolution of the same. However,
on ___ she had an unexplained hypoxemic respiratory episode
with persistent SpO2 measurements in the ___ despite NRB and NC;
she was intubated with ___ of continued O2 saturations in
the ___ before resolution not attributable to any particular
intervention (nebs, suction, etc). This first hypoxemic episode
was attributed to aspiration though subsequent CXR and
bronchoscopy were not impressive for evidence of the same. She
was extubated within 24hrs, but then reintubated in the setting
of a break in her CRRT line that caused acute hypotension from
blood loss (trapped in the CRRT circuit) and then hypoxemia.
After restoration of hemodynamic stability and passing her RSBI,
she was again extubated, but re-intubated for nearly the same
exact sequence of events that evening(break in the CRRT circuit
due to equipment failure; this has been reported and is being
investigated). She was finally extubated on ___ and remains
off supplemental O2 at time of MICU discharge. Antibiotics were
empirically started in the setting of possible aspiration with
leukocytosis (that could have been a stress reaction to
aspiration pneumonitis or intubations/exbuations); these will
finish on ___. She completed her course of antibiotics and
remained afebrile and without respiratory distress the rest of
her hospitalization.
# Alcohol Abuse:
Patient endorses heavy alcohol use. She was seen by social work
who gave resources, though patient is not interested in
counseling.
# Severe Nutritional Deficiency:
Nutritional deficiencies including zinc and selenium requiring
significant repletion. Repeat testing of zinc showed continued
need for repletion. Caloric needs and repletion addressed below.
# Severe malnutrition: likely contributor to pancytopenia
resulting from bone marrow suppression. Required tube feeding
tube feed which was continued at discharge in order to meet her
caloric needs. She was initially found to aspirate thin liquids
by a speech and swallow evaluation, however on reevaluation
after receiving tube feeds for some time, she was able to
tolerate a regular diet and thin liquids. Her caloric intake by
mouth was not sufficient to decrease tube feeds.
# Hx Wernicke's Encephalopathy:
Patient had waxing/waning mental status for much of her early
hospital course which was initially attributed to delirium;
however, for history of Wernicke's she was started on high-dose
thiamine that seemed to improve her mental status. Nutrition was
consulted, and nutrition labs were sent that were all markedly
low. She was supplemented through her TFs and will need to
remain on standing thiamine.
# Deep Vein Thrombosis:
Patient arrived to MICU with L femoral CVL; shortly thereafter,
asymmetric R > L lower extremity swelling was noticed for which
___ was obtained - this showed extensive venous clot burden in
the R lower extremity. IV heparin was started. Because of
persistent thrombocytopenia, an IVC filter was placed, though
because of her high clot risk IV heparin was continued. She
should have interval follow-up of her DVTs after discharge, as
well as scheduled follow-up with ___ for filter removal. She was
maintained on a heparin drip and should be bridged to Coumadin
to follow up with hematology/oncology as an outpatient.
# Concern for Gastrointestinal Bleed:
As described above, GI and Surgery were consulted early in her
MICU stay for rising lactate and concern of gut ischemia in the
setting of her hypotension; flexible sigmoidoscopy was
unimpressive and lactate improved with pressors and IVF. Near
the end of her FICU stay she had fresh blood coating a stool
which raised concern for GIB; however, her Hct was stable, she
was HD stable, and guaiacs of subsequent stools were negative
prior to MICU discharge. She underwent evaluation by Hepatology
and EGD which showed no varices, negative colonoscopy. Capsule
study failed, but patient's H/H stabilized and hepatology felt
the study could be done as an outpatient if necessary.
**Transitional:**
TRANSITIONAL ISSUES:
-Patient will need daily assessment for hemodialysis needs, EPO
with HD given renal failure
-Reassess nutritional status and continued need for tube
feeding, potential need for G-tube
-Daily electrolytes and every other day CBC to evaluate need for
blood transfusion
-Patient on heparin gtt for DVT. Recommend bridge to coumadin
-Needs appointment with OBGYN for Mirena IUD removal. Pt states
this was places at least ___ years ago.
-encourage smoking/alcohol cessation
-f/u for potential IVC filter removal in the future
-Outpatient hepatology f/u, consider outpatient capsule study
-Outpatient Hematology f/u with Dr. ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 2.5 mg PO DAILY
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
4. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. Cyanocobalamin 50 mcg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins W/minerals 1 TAB PO BID
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Heparin IV per Weight-Based Dosing Guidelines
Initial Bolus: 3900 units IVP
Initial Infusion Rate: 850 units/hr
Start: Today - ___, First Dose: 1600
Target PTT: 60 - 100 seconds
7. Nephrocaps 1 CAP PO DAILY
8. Warfarin 5 mg PO DAILY16
first dose ___
9. sevelamer CARBONATE 800 mg PO TID W/MEALS
10. LOPERamide 2 mg PO QID:PRN diarrhea
11. Sarna Lotion 1 Appl TP PRN itching
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY: acute oliguric renal failure, deep vein thrombosis,
anemia, thrombocytopenia, hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at the ___
___. You were hospitalized with low blood pressure
and low blood counts. You were treated with blood transfusions,
kidney replacement therapy, and antibiotics. You were found to
have a blood clot in your leg and are being treated with blood
thinning medications. Your platelets were low but these
recovered. Your kidney function has not recovered prior to
leaving the hospital and you will be discharged with a
hemodialysis line. You were evaluated for GI bleeds, and these
studies were reassuring. If you continue to bleed, you may
benefit from a capsule study as an outpatient.
Best wishes,
Your ___ Care Team
Followup Instructions:
___
|
10039708-DS-15 | 10,039,708 | 23,819,016 | DS | 15 | 2140-06-22 00:00:00 | 2140-06-24 20:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypotension, Abdominal Pain
Major Surgical or Invasive Procedure:
Right internal jugular line placement
History of Present Illness:
Ms. ___ is a ___ w/ PMH of EtOH abuse (currently still
drinking) c/b EtOH hepatitis, Wernicke's encephalopathy,
hypotension likely due to autonomic neuropathy; hypothyroidism,
hypertension, Hx of bariatric surgery, and other issues who was
sent to the ED with hypotension. She was at a ___
appointment at her oncologist's office today where her SBP was
noted to be in the ___. On review of systems, she endorsed
nausea, vomiting, and diffuse abdominal pain. She also endorsed
night sweats. She denied dysuria, cough, chest pain. Denied
diarrhea, BPR, or melena.
In the ED, initial vitals: 98.1 89 98/68 16 98% RA. Exam
notable for suprapubic, periumbilical, epigastric, and RUQ TTP.
Labs were notable for WBC 4.7 w/ 71% PMNs and 9% bands, Hgb
12.5, plts 232, BUN/Cr 94/3.3 (most recent Cr 2.9), HCO3 18,
anion gap 27, ALT/AST 247/286, alk phos 590, T bili 3.2, Lactate
4.4. UA unremarkable. serum bHCG was 7 (equivocal). Stool was
guiac negative. RUQ US notable for "Small amount of gallbladder
sludge, without gallbladder distention or pericholecystic
fluid., and Normal CBD caliber, without intrahepatic biliary
dilatation." CT abdomen/pelvis was ordered, and BCx were
collected. Patient received 2L NS, Zofran, and
piperacillin/tazobactam and was admitted. On transfer, vitals
were: 99.1 77 110/56 15 100% RA.
On arrival to the MICU, the patient reported ongoing diffuse
abdominal pain.
Past Medical History:
___'S ENCEPHELOPATHY
ASTHMA
TOBACCO DEPENDENCE
ALCOHOL DEPENDENCE
HYPOTHYROIDISM
HYPERTENSION
S/P BARIATRIC SURGERY
H/O ALCOHOLIC HEPATITIS
GOUT
Social History:
___
Family History:
Family history significant for T2DM, HTN, hypothyroidism and
asthma.
Physical Exam:
==================================
PHYSICAL EXAMINATION ON ADMISSION:
==================================
Vitals: 99.1 77 110/56 15 100% RA.
GENERAL: Alert, oriented, cachectic, ___ woman in mild
distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs
ABD: soft, diffuse TTP worse in the RUQ, bowel sounds present
EXT: Warm, well perfused, 2+ pulses, no edema
SKIN: Dressing covering surgical site on R thigh
NEURO: Moving all extremities
==================================
PHYSICAL EXAMINATION ON DISCHARGE:
==================================
Vitals: T 97.9 BP ___ HR ___ 96 RA
GENERAL: Alert, oriented, cachectic, ___ woman in no
acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: clean dressing over site of previous R IJ CVL
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs
ABD: soft, mild diffuse TTP, no rebound, slight guarding
EXT: Warm, well perfused. trace RLE edema
SKIN: no rashes, lesions appreciated
NEURO: Moving all extremities
Pertinent Results:
======================
LABS ON ADMISSION
======================
___ 10:03PM BLOOD ___
___ Plt ___
___ 10:03PM BLOOD ___
___
___
___ 10:03PM BLOOD ___
___ Tear
___
___ 10:03PM BLOOD ___ ___
___ 10:03PM BLOOD Plt ___
___ 10:03PM BLOOD ___
___
___ 10:03PM BLOOD ___
___
___ 10:03PM BLOOD ___
___ 10:03PM BLOOD ___
___ 10:03PM BLOOD ___
___ 10:08PM BLOOD ___
___ 02:33AM BLOOD ___
___ Base XS--1 ___ TOP
___ 12:19AM URINE ___ Sp ___
___ 12:19AM URINE ___
___
___ 12:19AM URINE ___
Epi-<1
___ 10:27AM URINE ___
======================
PERTINENT INTERVAL LABS
======================
LFT TREND:
___ 10:03PM BLOOD ___
___
___ 02:17AM BLOOD ___ LD(LDH)-189
___
___ 09:35AM BLOOD ___ LD(LDH)-139
___
___ 12:06PM BLOOD ___ LD(LDH)-140
___
___ 05:37AM BLOOD ___
___
___ 09:53AM BLOOD ___
Lipase:
___ 10:03PM BLOOD ___
___ 02:17AM BLOOD ___
Lactate:
___ 10:08PM BLOOD ___
___ 02:33AM BLOOD ___
___ 06:11AM BLOOD Ret ___ Abs ___
======================
MICROBIOLGY
======================
___ 9:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ ___ 11:10
___.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ 11:10 ___.
GRAM NEGATIVE ROD(S).
___ 10:18 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
KLEBSIELLA PNEUMONIAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
___ 4:55 am URINE Site: CATHETER Source: Catheter.
**FINAL REPORT ___
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final
___:
Negative for Chlamydia trachomatis 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.
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.
___ - Blood Culture x 2 - Pending
___ - Blood Culture x 2 - Pending
___ - Blood Culture x 2 - Pending
======================
LABS ON DISCHARGE
======================
___ 09:53AM BLOOD ___
___ Plt ___
___ 09:53AM BLOOD ___
___
___ 09:53AM BLOOD ___
___ 09:53AM BLOOD ___
======================
IMAGING/STUDIES
======================
Cardiovascular Report ECG Study Date of ___ 6:08:45 ___
Sinus rhythm. Compared to the previous tracing of ___
voltage has
normalized.
Cardiovascular Report ECG Study Date of ___ 9:26:38 ___
Baseline artifact. Probable sinus rhythm.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
1. Small amount of gallbladder sludge, without gallbladder
distention or
pericholecystic fluid.
2. Normal CBD caliber, without intrahepatic biliary dilatation.
PELVIS LIMITED Study Date of ___ 5:51 ___
The uterus and ovaries are not visualized. The patient declined
the
transvaginal portion of the exam for further although evaluation
CT ABD & PELVIS W/O CONTRAST Study Date of ___ 2:09 ___
1. No etiology for the patient's pain identified. No evidence
for infection in the abdomen and pelvis. No ovarian masses.
2. 0.9 cm opacity in the right lower lobe is new from ___ and may represent an infectious focus. Further evaluation
with full chest CT is recommended
3. Significant improvement in hepatic steatosis.
CT CHEST W/O CONTRAST Study Date of ___
Normal Chest CT. No evidence of active intrathoracic infection
or malignancy. Right lower lobe opacity described on recent CT
has almost completely resolved consistent with resolving
atelectasis
Brief Hospital Course:
Ms. ___ is a ___ w/ PMH of EtOH abuse (currently still
drinking) c/b EtOH hepatitis, Wernicke's encephalopathy,
hypotension likely due to autonomic neuropathy; hypothyroidism,
hypertension, Hx of bariatric surgery, and other issues who was
sent to the ED with hypotension and bandemia concerning for
pancreatitis.
#Septic shock: Patient presented with abdominal pain and fever,
was found to have hypotension requiring IVF resuscitation and
levophed for which she had a R IJ CVL placed. She was
subsequently found to have GNR bacteremia which speciated to pan
sensitive klebsiella in ___ bottles. She was initialy treated
with broad spectrum antibiotics with IV Vancomycin/Zosyn which
was narrowed to PO Ciprolfoxacin on discharge. Her blood
pressure gradually increased and patient was off levophed with
overall improvement of her symptoms. The etiology of the
bacteremia as thought likely to be intrabdominal given pain and
further findings described below in # abdominal pain. The
differential also included pelvic process given adnexal
tenderness on physical exam. Urinary etiologies were on the
differential, though no urine culture prior to antibiosis
obtained. The patient had previous hematoma evacuation of right
thigh though wound appeared intact without evidence of
infection. Of note the patient had a history of high risk HPV
with ASCUS and there was concern that cervical etiologies could
be the source of infection, particularly concerning for
malignancy in the setting of her anemia and recent thrombosis as
well. The patient understood the need for outpatient follow up
with pap smear and IUD removal, and this was relayed to the
patient's PCP as well. There were no other appreciate sources of
infection on non contrast (in setting ___ on CKD) scans of
the chest, abdomen and pelvis. The patient remained afebrile and
hemodynamically stable after transfer to the medicine floor from
the MICU.
# Abdominal pain: Patient presented with abdominal pain and
fever, was found to have GNR bacteremia speciated to pan
sensitive klebsiella as above. In terms of source of infection,
RUQ ultrasound was without evidence of cholecystitis or CBD
dilatation and CT chest/abdomen was not notable for any
abnormalities that could explain the symptoms. Elevated lipase
with elevated LFTs was suggestive of pancreatitis; however, her
pain was not entirely typical (not prominent in epigastrium) and
CT abdomen did not show signs of pancrteatitis.
Choledocholithiasis with a passed stone was thought to be a
possibility as well given the downtrending LFTS. The
differential also included pelvic etiology, though patient
denied any urinary or vaginal symptoms. The patient's pain
improved thoughout the admission and the patient was tolerating
PO well on discharge.
# Pancreatitis: Patient with lipase >3X ULN and abdominal pain
(though somewhat atypical), however no evidence of pancreatitis
on CT (though non contrast given ___ on CKD). Differential
included EtOH given history of heavy drinking, biliary sources
given elevated LFTs on admission as well. However lipase may
also have been elevated for alternate etiologies in the setting
of possible GI infection and may not have been representative of
true pancreatitis. As above the patient's pain improved
throughout the admission and was tolerating PO well on
discharge.
# Transaminitis: The differential included biliary infection,
however RUQ US without cholecystitis or biliary dilatation, vs.
choledochlithiasis with passed stone. Could consider
contribution from heavy EtOH as well, though ration of ALT/AST
less suggestive of this etiology. The patient's LFTs improved
throughout the hospital course, and T bili normalized.
# ___: Patient was recently discontinued from
hemodialysis in the past month, as her renal function has
recovered from a prior ATN. Cr was elevated on admission to 3.3.
She received fluid and her creatinine gradually decreased.
Creatinine on discharge was 1.8.
# Anemia: Patient with chronic anemia extensively worked up in
the past. No evidence of current hemolysis given normalized T
bili. Likely component of hemoconcentration on admission in the
setting of septic shock. Differential included infection and
medication (Zosyn) causing bone marrow suppression, as well as
heavy EtOh use. The patient did not require any blood
transfusions during the admission.
# EtOH abuse: Patient reported drinking ___ to 1 pint of hard
liquor per day, with her last drink being the day before
admission. She was placed on CIWA scale, and treated with
multivitamins and thiamine. The patient attempted to leave AMA
the day prior to discharge and was evaluated by psychiatry
overnight who were concerned that the patient lacked capacity to
at that time. The patient as re evaluated in the morning by
psychiatry and after further discussion was deemed to have
capacity regarding her plan of care. The patient was instructed
regarding risks of alcohol withdrawal and referred to substance
abuse treatment by psychiatry which she declined.
# ___ metabolic acidosis: Resolved. Most likely due to
lactic acidosis on presentation
# Equivocal Serum HCG: Patient denied possibility of pregnancy.
Urine hCG was negative. Patient with IUD in place with plans for
outpatient removal.
====================
CHRONIC ISSUES
====================
# Hypothyroidism: Patient continued Levothyroxine Sodium 62.5
mcg PO DAILY.
# Hx of wet beri beri: Furosemide was held in the setting of
septic shock and held on discharge given no evidence of volume
overload and soft pressures.
# HTN: Home Hydrochlorothiazide held as well given infection and
soft pressures as well.
# Gout: Patient restarted on home allopurinol.
====================
TRANSITIONAL ISSUES
====================
- Please continue PO Ciprofloxacin through ___ (___)
- Patient will need pap smear as outpatient for further
evaluation of high risk HPV in setting of bacteremia, anemia,
and thrombosis
- Please discuss with PCP the need for restarting furosemide as
an outpatient.
- Patient will need removal of IUD
- Patient will need removal of IVC filter in future - please
discuss with PCP
- ___ obtain CBC and Chem 10 at next PCP appointment for
evaluation of anemia and Creatinine given ___ on CKD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 50 mcg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins W/minerals 1 TAB PO BID
4. Levothyroxine Sodium 62.5 mcg PO DAILY
5. Furosemide 40 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Allopurinol ___ mg PO DAILY
8. Thiamine 100 mg PO DAILY
9. Ascorbic Acid ___ mg PO BID
10. Ferrous Sulfate 325 mg PO DAILY
11. Fluticasone Propionate NASAL 1 SPRY NU BID
12. Acetaminophen 650 mg PO Q8H:PRN pain
13. Vitamin E 400 UNIT PO QD
14. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. FoLIC Acid 1 mg PO DAILY
5. Levothyroxine Sodium 62.5 mcg PO DAILY
6. Multivitamins W/minerals 1 TAB PO BID
7. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth daily Disp #*9
Tablet Refills:*0
8. Ascorbic Acid ___ mg PO BID
9. Cyanocobalamin 50 mcg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Thiamine 100 mg PO DAILY
12. Vitamin D unknown PO DAILY
13. Vitamin E 400 UNIT PO QD
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
===================
Sepsis
Klebsiella pneumoniae bacteremia
Pancreatitis
Transaminitis
Abdominal Pain
Acute on chronic kidney disease
Anemia
Anion gap metabolic acidosis
Secondary Diagnoses
===================
Hypothyroidism
Alcohol use disorder
Tobacco use disorder
History of wet beri beri
History of Wernicke's encephalopathy
Gout
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 caring for you during your stay at ___. You
were admitted to the hospital with low blood pressure. You were
treated with fluids and medications to increase your blood
pressure. You were also found to have an infection in your blood
stream. You will need to continue to take antibiotics for this
infection for a total of 2 weeks.
It is very important that you follow up with your primary care
doctor. You will need to have a pap smear as an outpatient. You
will also need to have your IUD removed. You should also discuss
the optimal timing with your primary care doctor of removal of
the IVC filter that was placed in your leg because of blood
clots.
Please take ciprofloxacin daily THROUGH ___
It was a pleasure to be a part of your care,
Your ___ treatment team
Followup Instructions:
___
|
10039708-DS-17 | 10,039,708 | 25,864,431 | DS | 17 | 2142-04-11 00:00:00 | 2142-04-12 02:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
EGD (___)
Paracentesis x3 (___)
HD line placement (___)
History of Present Illness:
___ with history of active alcohol abuse with cirrhosis,
Wernicke encephalopathy, gastric bypass, severe anemia, stage IV
CKD w/ history of temporary HD (last ___, HTN, DVT, p/w 2
weeks of abdominal distension and 2 days of abdominal pain.
She reports worsening abdominal pain over the past 2 weeks,
described as a constant dull pain diffusely through her abdomen.
She has not been taking anything for pain, no Tylenol or NSAID
use. She did try pepto-bismal, gas x without improvement She
reports pain unchanged with position, hasn't been able to
tolerating PO intake. She has noticed worsening abdominal
distension. She reports nausea, dry heaves over the past few
days and today had an episode of non-bloody emesis of clear
fluid. She has been passing gas, denies diarrhea but has been
having small non-bloody BMs. She has felt constipation and
trialed Colace without improvement.
She reports subjective fevers and chills over the past week, new
palpitations over the past month, dyspnea with exertion and
sometimes at rest. She reports chronic seasonal allergies with
congestion and rhinorrhea. She reports chronic poor UOP, mild
dysuria when starting stream. She denies any chest
pain/pressure, confusion.
She reports that she was seen at ___ about 2 weeks ago and
treated with amoxicillin for a sinus infection. She had a blood
transfusion a week ago. She is on pro-crit, increased to weekly
recently.
She reports that on day of presentation that she drank half a
pint, usually drinks 1 pint daily but had been drinking less due
to abdominal pain. At ___ had ethanol of 138, had diagnostic
para done with 60 cc's removed results are pending, given IV CTX
and IV thiamine.
Past Medical History:
EtOH Cirrhosis
Stage IV CKD
Wernicke's Encephalopathy
Anemia
Asthma
Tobacco Use
HTN
Hypothyroidism
CIN II (cervical intraepithelial neoplasia II)
RLE DVT ___ s/p IVC filter (removed ___, with catheter
directed thrombolysis c/b ?extravasation into right thigh. DVT
in setting of immobility from left patella fracture.
S/P BARIATRIC SURGERY ___ - ___ w/ Dr. ___
___ History:
___
Family History:
- T2DM
- HTN
- hypothyroidism
- asthma
- lung cancer (uncle)
- ovarian cancer in ___ (MGM)
Physical Exam:
ADMISSION EXAM
VS:98.7 PO 149 / 91 96 18 94 RA
GENERAL: AOx3, mild distress
HEENT: AT/NC, EOMI, PERRL, MM dry, icteric sclera
HEART: RRR, S1/S2, ___ holosystolic murmur
LUNGS: CTAB except crackles in bases (R>L), no wheezes, rhonchi,
breathing comfortably without use of accessory muscles
ABDOMEN: distended, diffusely tender in all quadrants (L>R), no
rebound/guarding, hepatomegaly
EXTREMITIES: bilateral edema, R>L, 1+ non-pitting
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose. Able to
recount medical history and medications without difficulty. +
asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM
VS: 98.2 PO___
GENERAL: Cheerful, alert.
HEENT: MMM.
CV: RRR.
RESP: CTAB without increased WOB
ABDOMEN: Distended, soft, non-tender.
EXTREMITIES: WWP. Bilateral ___ edema.
NEURO: Alert, oriented, attentive. No asterixis.
Pertinent Results:
ADMISSION LABS
=====================
___ 12:30AM BLOOD WBC-10.4* RBC-2.47* Hgb-8.4* Hct-25.7*
MCV-104* MCH-34.0* MCHC-32.7 RDW-21.2* RDWSD-79.6* Plt ___
___ 12:30AM BLOOD Neuts-72.3* Lymphs-15.4* Monos-10.0
Eos-0.6* Baso-0.4 Im ___ AbsNeut-7.50* AbsLymp-1.60
AbsMono-1.04* AbsEos-0.06 AbsBaso-0.04
___ 12:30AM BLOOD ___ PTT-29.9 ___
___ 12:30AM BLOOD Glucose-67* UreaN-45* Creat-4.7* Na-140
K-3.5 Cl-100 HCO3-14* AnGap-26*
___ 12:30AM BLOOD ALT-32 AST-120* AlkPhos-239* TotBili-3.1*
___ 10:55AM BLOOD Calcium-8.3* Phos-4.8* Mg-1.5*
___ 12:30AM BLOOD calTIBC-146* VitB12-868 Ferritn-560*
TRF-112*
___ 11:46AM BLOOD ___ pO2-166* pCO2-35 pH-7.28*
calTCO2-17* Base XS--9 Comment-GREEN TOP
___ 12:53AM BLOOD Lactate-3.7*
MICRO
========================
__________________________________________________________
___ 12:14 pm BLOOD CULTURE Source: Line-dialysis.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:53 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 3:47 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 9:55 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FUID.
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___: NO GROWTH.
__________________________________________________________
___ FLUID
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___. difficile DNA amplification assay- negartiv
___ CULTURE GRAM NEGATIVE ROD(S). ~1000 CFU/mL.
___ CULTUREnegative
___ CULTUREnegative
IMAGING & STUDIES
======================
___ CT Abdomen and Pelvis:
Fatty liver with large volume ascites. No splenomegaly. Patient
is status post gastric bypass with the excluded stomach appears
severely edematous with thickened walls. Diffuse anasarca.
___ RUQ US:
1. Patent portal vasculature. Patent right and middle hepatic
veins as well as the main hepatic artery. The left hepatic vein
was not visualized.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study.
3. Large volume ascites.
___ CXR
Bilateral low lung volumes with moderate bibasilar atelectasis.
No evidence of intraperitoneal free air.
___ TTE
IMPRESSION: A left pleural effusion is present. Late bubbles
seen in the left heart suggesting intrapulmonary shunting
(bubbles appear at 8 beats). Normal biventricular size and
systolic function. No pathologic valvular flow.
Compared with the prior study (images reviewed) of ___
global biventricular systolic function is more vigorous.
___ EGD
Findings:
Esophagus:
Protruding Lesions1-2 small varices were seen in the lower
esophagus with no stigmata of bleeding.
Stomach:
Lumen:Evidence of a previous RNYGB was seen with a
gastrojejunostomy.
Duodenum:
Flat LesionsA single small angioectasia was seen in the jejunal
efferent limb. There was no evidence of bleeding.
Otherduodenum not seen due to post surgical anatomy.
Other findings:A jejunal feeding tube was placed into the small
intestine endoscopically, however during oro-nasal conversion
was noted to have become dislodged and was no longer as deep at
the nares as when endoscopically placed. It was then advanced
and bridled at 70 cm, however due to the fact it moved after
endoscopic visualization it will require CXR prior to use.
___ CXR
Increased opacities at the right lung base may reflect a
combination of
atelectasis and pneumonia.
___ Duplex Abdominal U/S
1. No evidence of portal vein thrombosis. Intermittent reversal
flow within the left portal vein. Slow flow within the main
portal, splenic, and superior mesenteric veins.
2. Cirrhotic liver without focal liver lesions.
3. Circumferential gallbladder wall edema, likely due to third
spacing/underlying liver disease.
4. Small volume ascites.
DISCHARGE LABS
======================
___ 07:55AM BLOOD WBC-14.2* RBC-2.12* Hgb-7.1* Hct-21.1*
MCV-100* MCH-33.5* MCHC-33.6 RDW-20.7* RDWSD-68.7* Plt ___
___ 07:55AM BLOOD ___ PTT-35.3 ___
___ 07:55AM BLOOD Glucose-121* UreaN-28* Creat-3.7* Na-136
K-4.3 Cl-95* HCO3-27 AnGap-14
___ 07:55AM BLOOD ALT-20 AST-66* AlkPhos-219* TotBili-1.7*
___ 07:55AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.5
Brief Hospital Course:
==================
BRIEF SUMMARY
==================
___ with active alcohol use, alcoholic cirrhosis, Stage IV CKD,
admitted for alcoholic hepatitis, decompensated cirrhosis, and
anuric ___ requiring initiation of HD. Patient was alert,
oriented, and feeling well at discharge. Outpatient HD and
Hepatology follow-up were arranged.
==================
ACUTE ISSUES
==================
# Decompensated alcoholic cirrhosis with ascites
# Alcoholic hepatitis
# Hepatic encephalopathy
MELD Na 26 and Child C on presentation. LFTs and symptoms
consistent with alcoholic hepatitis on cirrhosis; DF not high
enough to warrant steroids. Had confusion and asterixis on
admission consistent with HE. Had goals of care discussion with
patient and family on ___ and confirmed she wants to pursue
aggressive therapy, including EGD and HD; DNR/DNI in the event
of arrest. She wants to be abstinent and eventually be placed on
the transplant list. EGD showed ___ small varices with no
stigmata of bleeding. She started lactulose and rifaximin for
HE. Serial diagnostic paracentesis were negative for SBP. She
had large-volume paracentesis on ___ for relief of tense
ascites. ___ need outpatient LVP depending on whether she
continues to be able to remove fluid via UF. She was maintained
on high protein, ___ gm sodium diet and tube feeds. She will
follow up with hepatology as an outpatient.
# Anuric ___ on CKD Stage IV
# ?Hepatorenal syndrome
She did not respond to albumin challenge, nor to
octreotide/midodrine for possible HRS. Octreotide was stopped
but she was maintained on midodrine for soft BPs. Outpatient HD
___ arranged. PPD negative.
# Abdominal pain
Multifactorial - alcoholic hepatitis, tense ascites, and
possible acute on chronic pancreatitis (lipase 190). Was
initially treated empirically for possible SBP but cell counts
were not consistent; prophylaxis not indicated per Hepatology.
Pain much improved after LVP ___. Repeat diagnostic para ___
remained negative.
# Severe protein calorie malnutrition
Nutrition was consulted. Dobhoff was placed for ongoing tube
feeds, and high-protein diet and supplements were prescribed.
# Hypoxemia
# Hepatic hydrothorax
# ?Hepatopulmonary syndrome
Patient had new 2L O2 requirement in setting of large R pleural
effusion/hepatic hydrothorax, resolved after LVP. TTE did show
evidence of pulmonary shunting which could represent HPS.
# Leukocytosis
Patient developed a new leukocytosis several days prior to
discharge. Also had slight rise in bili and alk phos around this
time. No fevers or localizing symptoms. Repeat infectious workup
was unrevealing, including repeat diagnostic paracentesis,
except for CXR equivocal for pneumonia. She was started on
empiric oral levofloxacin for possible pneumonia, and
leukocytosis stabilized for several days and LFTs improved
somewhat prior to discharge.
# Chronic macrocytic anemia
Retics inappropriately low, consistent with marrow suppression.
Likely multifactorial - EtOH, cirrhosis, splenomegaly,
malnutrition, renal failure. No evidence of acute bleeding and
not iron deficient on labs. B12 wnl. Hemolysis labs negative.
EGD results as above. Will need continued attention as
outpatient.
# Chronic thrombocytopenia
Likely multifactorial - EtOH, cirrhosis, splenomegaly,
malnutrition. No evidence for DIC or other consumptive process.
# Coagulopathy
PTT was elevated due to SC heparin, normalized after this was
held and dose decreased to 2500 units BID. ___ were elevated
due to cirrhosis. No evidence of bleeding, DIC, or other acute
pathology.
# Alcohol use disorder
Reports daily drinking prior to admission, about ___ pint qod to
1 pint/day. Last drink ___. Denies h/o withdrawal. She
received IV thiamine x 3 days and maintained on oral thiamine,
folate and MVI. We discussed the importance of abstinence and SW
helped arrange outpatient supports. We also discussed
pharmacological assistance to treat alcohol use disorder and
depression, however patient deferred at this time.
# Chronic RLE edema
# History of RLE provoked DVT
DVT occurred after left knee fracture. IVC filter was placed in
___. Course complicated by need for catheter lysis and
extravasation into right thigh per patient. No longer on
anticoagulation. Repeat Doppler this admission negative for
persistent DVT. She continued on half-dose heparin SC.
=====================
CHRONIC ISSUES
=====================
# Hypothyroidism
TSH 2.1 this admission. Continued home levothyroxine.
# Gout
Reduced home allopurinol from 100 mg daily to every other day
due to renal failure.
==================
TRANSITIONAL ISSUES
===================
- WBC elevated to 14.0 on discharge. Please recheck at HD on
___ and evaluate for signs of infection. Discharged on empiric
levofloxacin for possible pneumonia (500mg q48h, last day ___.
- Other medications started: midodrine 20mg TID, lactulose
titrated to ___ BM/day, rifaximin 550mg BID.
- HD arranged ___
- ___ follow-up arranged
- Discharged with tube feeds
- ___ need intermittent LVP depending on whether she tolerates
UF
- Did not start beta blocker for varices b/c HR ___
- Patient should have CBC and MELD labs checked checked within 1
week of discharge. Script provided.
# CODE: DNR/DNI
# CONTACT: ___ (son, HCP) ___
> 30 minutes in patient care and coordination of discharge on
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Levothyroxine Sodium 62.5 mcg PO DAILY
3. Multivitamins W/minerals 1 TAB PO BID
4. Thiamine 100 mg PO DAILY
5. Allopurinol ___ mg PO DAILY
6. Ascorbic Acid ___ mg PO BID
7. Cyanocobalamin 50 mcg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. Pyridoxine 100 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Vitamin E 400 UNIT PO QD
12. Epoetin ___ ___ units SC EVERY 2 WEEKS (MO)
Discharge Medications:
1. Lactulose 30 mL PO TID
RX *lactulose 10 gram/15 mL (15 mL) 30 mL by mouth ___ times per
day Disp #*50 Package Refills:*0
2. Levofloxacin 500 mg PO Q48H Duration: 5 Days
RX *levofloxacin 500 mg 1 tablet(s) by mouth every other day
Disp #*3 Tablet Refills:*0
3. Midodrine 20 mg PO TID
RX *midodrine 10 mg 2 tablet(s) by mouth three times a day Disp
#*180 Tablet Refills:*3
4. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*5
5. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08
gram-1.8 kcal/mL oral TID
RX *nut.tx.imp.renal fxn,lac-reduc [Nepro Carb Steady] 0.08
gram-1.8 kcal/mL 237 mL by mouth three times a day Refills:*0
6. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*5
7. Allopurinol ___ mg PO EVERY OTHER DAY
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. Levothyroxine Sodium 62.5 mcg PO DAILY
10.Outpatient Lab Work
ICD-10 Code: ___
Please obtain by ___ and fax to: Dr. ___ ___
CBC; Chem-10 (Na, K, Bicarb, Cl, BUN, Cr, Ca, Mg, Phos); Hepatic
Panel (AST, ALT, Alk Phos, Tbili, Albumin, INR)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
Alcoholic hepatitis
Decompensated alcoholic cirrhosis with ascites
Acute on chronic renal failure
Hepatic encephalopathy
Severe protein calorie malnutrition
Alcohol use disorder
Thrombocytopenia
Coagulopathy
Anemia
Community-acquired pneumonia
Secondary Diagnoses
====================
Hypothyroidism
Gout
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.
WHY WAS I ADMITTED?
You were admitted because alcohol damaged your liver and your
kidneys.
WHAT HAPPENED TO ME WHILE I WAS IN THE HOSPITAL?
-You were followed closely by our liver and kidney experts.
-You were started on dialysis for your kidneys. This helps
remove fluid from your body since you are unable to urinate.
-You had an endoscopy test which showed some dilated veins in
your esophagus.
-You had a tube placed from your nose into your intestine to
give you more nutrition to help you recover.
WHAT SHOULD I DO WHEN I GET HOME?
-Follow up with your liver doctors, kidney doctors ___ see
them at dialysis), and your primary care doctor.
-___ will need to go to dialysis three times a week ___,
___.
-You may need to have fluid drained from your abdomen from time
to time. This can be arranged through your liver doctor.
-___ all your medicines and continue your tube feeds.
-Do not drink any alcohol. We strongly recommend you sign up for
a program such as Alcoholic Anonymous to help you stay sober.
We wish you all the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10039708-DS-20 | 10,039,708 | 29,488,258 | DS | 20 | 2144-01-21 00:00:00 | 2144-01-23 14:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
cats, dogs, dust, pollen
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo F with hx of EtOH cirrhosis c/b esophageal
varices s/p recent banding (___), stomach ulcer, ESRD on HD,
HTN, asthma who presents with altered mental status from
dialysis.
She had a recent admission (___) with a similar
presentation, and was treated for hepatic encephalopathy with
lactulose, alcoholic hallucinosis with lorazepam, and uremic
encephalopathy with resumption HD.
In the ED initial vitals:
96.6, 55, 159/80, 16, 99% RA
- Exam notable for:
Lethargic but arousable, Ox2-3, +asterixis
- Labs notable for:
CBC: ___
Chem7: lytes OK
LFTs: AST/ALT: 73/33, ALP 429, Tbili 1.8, lip 50
Coags: INR 1.1
EtOH level: negative
- Imaging notable for:
Clean CTH, non-con
RUQUS: 1. There is cholelithiasis without evidence of
cholecystitis.
2. Echogenic kidneys which can be seen with chronic medical
renal
disease.
- Patient was given:
Home meds
Ceftriaxone for SBP(?) iso HE
On arrival to the floor the patient states that her confusion is
starting to improve. Her son is at bedside and agrees. She
describes being at dialysis and feeling more confused along with
whole body cramping, with a single episode of non-bloody
non-bilious emesis. Of note, she denies abdominal pain despite
eliciting pain on exam. She stopped taking lactulose several
months ago due to the diarrhea. Last drink was yesterday and she
drinks around 5 shots of vodka/brandy a day.
Past Medical History:
EtOh Cirrhosis
Stage IV CKD
Anemia
Wernicke's Encephalopathy
Asthma
Tobacco Use
HTN
Hypothyroidism
CIN II (cervical intraepithelial neoplasia II)
RLE DVT ___ dt L patella fx s/p IVC filter (removed), w/
catheter
directed thrombolysis c/b ?extravasation into right thigh. DVT
in
setting of immobility from left patella fracture
S/P BARIATRIC SURGERY ___ - ___ w/ Dr. ___
___
Seasonal allergies
ascites
esophageal varices
malnutrition
HEMORRHOIDS
HEPATIC HYDROTHORAX
COLONIC ADENOMA
Social History:
___
Family History:
Mother ASTHMA
DIABETES ___
HYPERTENSION
THYROID DISORDER
OBESITY
Father SUBSTANCE ABUSE
CARDIAC
HYPERTENSION
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: ___ ___ Temp: 97.8 PO BP: 133/80 R Lying HR: 61 RR:
16
O2 sat: 99% O2 delivery: ra Dyspnea: 0 RASS: -1 Pain Score: ___
GENERAL: NAD, tired appearing
HEENT: Sclera icteric
CARDIAC: Regular rhythm, normal rate.
LUNGS: Bilateral crackles, No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, diffusely tender
to palpation in all quadrants, greatest in RUQ.
EXTREMITIES: mild non pitting edema to ankles
SKIN: Warm. Cap refill <2s. Multiple ecchymoses on bilateral
forearms, shoulder/flank. Large ecchymosis with mild erythema
with no fluctuance on right AC.
NEUROLOGIC: AOx3 to person place and time. asked to say days of
week backward and she answered days of week forward. asterixis
on
exam
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 812)
Temp: 98.5 (Tm 98.9), BP: 101/63 (94-121/52-75), HR: 80
(77-92), RR: 18 (___), O2 sat: 95% (94-100), O2 delivery: Ra,
Wt: 166.7 lb/75.62 kg (163.3-166.7)
GENERAL: NAD, tired appearing
HEENT: Sclera icteric
CARDIAC: Regular rhythm, normal rate.
LUNGS: Bilateral crackles, No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, diffusely tender
to palpation in all quadrants, greatest in RUQ.
EXTREMITIES: mild non pitting edema to ankles
SKIN: Warm. Cap refill <2s. Multiple ecchymoses on bilateral
forearms, shoulder/flank. Large ecchymosis with mild erythema
with no fluctuance on right AC.
NEUROLOGIC: AOx3 to person place and time. asterixis on exam.
Days of week backwards
Pertinent Results:
ADMSSION LABS:
=======================
___ 01:15PM BLOOD WBC-5.5 RBC-3.09* Hgb-10.4* Hct-32.9*
MCV-107* MCH-33.7* MCHC-31.6* RDW-17.9* RDWSD-68.9* Plt Ct-73*
___ 01:45PM BLOOD ___ PTT-32.1 ___
___ 01:15PM BLOOD Glucose-85 UreaN-35* Creat-7.9*# Na-136
K-4.2 Cl-98 HCO3-22 AnGap-16
___ 01:15PM BLOOD ALT-33 AST-73* AlkPhos-429* TotBili-1.8*
___ 01:15PM BLOOD Albumin-4.0 Calcium-9.2 Phos-4.4 Mg-2.3
___ 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS:
========================
___ 05:05AM BLOOD WBC-7.5 RBC-2.57* Hgb-8.5* Hct-28.0*
MCV-109* MCH-33.1* MCHC-30.4* RDW-17.8* RDWSD-70.4* Plt Ct-92*
___ 05:05AM BLOOD ___ PTT-31.0 ___
___ 05:05AM BLOOD Glucose-105* UreaN-18 Creat-5.3*# Na-138
K-3.6 Cl-98 HCO3-26 AnGap-14
___ 05:05AM BLOOD ALT-26 AST-66* AlkPhos-365* TotBili-1.0
___ 05:05AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.1
PERTINENT IMAGING:
=======================
CT HEAD
IMPRESSION:
1. No acute intracranial findings.
LIVER OR GALLBLADDER US
IMPRESSION:
1. ThEre is cholelithiasis without evidence of cholecystitis.
2. Echogenic kidneys which can be seen with chronic medical
renal disease.
Brief Hospital Course:
PATIENT SUMMARY
===================
Ms. ___ is a ___ yo F with hx of EtOH cirrhosis complicated by
esophageal varices s/p recent banding (___), stomach ulcer,
ESRD on HD, HTN, asthma who presented with altered mental status
from dialysis. The AMS is likely multi-factorial including
lethargy from dialysis, recent excessive etoh intake, and
non-compliance with lactulose. Specifically, she reports not
taking lactulose for several months due to it causing diarrhea,
therefore, she may only need 1x dosing a day. Her mental status
completely improved the day after admission. The patient was
encouraged to stop drinking and educated on the importance of
taking lactulose and rifaximin. The patient is unaware of the
medications she is taking and would benefit from close follow
up. We discharged her with some medications to bedside. Please
see below for more information
TRANSITIONAL ISSUES:
====================
MED CHANGES
[] Gave the patient four tiny bottles of lactulose and
instructed her to use it if she or her son was concerned about
confusion. Also filled rifaximin
[] Filled Advair prescription for asthma. Unclear if she is
using inhaler and would likely benefit from getting a rescue
inhaler as well
[] Filled baclofen that she takes for back pain (tiny dose) but
this may be a deliriogenic that should be avoid in the future if
she has recurrent confusion
[] Gave the patient folic acid and thiamine given concern for
malnutrition and Wernickes during previous hospitalization
[] It was too soon to fill her levothyroxine. She states she has
it at home.
[] It was too soon to fill midodrine and dialysis vitamins
[] Continued Alcohol Cessation Counseling
[] Encourage cessation of tobacco
--Discharge Hgb 8.5
--Discharge weight 166 lbs
ACTIVE ISSUES
=============
# Encephalopathy
Multifactorial with most important factor likely hepatic
encephalopathy. Patient and son confirm that she has not taken
her lactulose for ~ 1 month, had drank a marked amount of
alcohol the night prior. Has hx of concern for wernicke's
encephalopathy and prior admissions for alcoholic hallucinosis
but no signs of withdrawal this admission. Treated predominantly
with lactulose with recovery of mental status and folate and
thiamine by mouth.
#Alcohol use disorder
Patient met with social work on last hospitalization but stated
she does not wish to stop drinking at this time. Was given
resources for relapse prevention. This admission she states
that she has a social worker already and not interested in
another consultation. Patient received thiamine, MV, and folate.
She was monitored for signs of withdrawal but did not require
treatment.
#Etoh Cirrhosis
History of etoh cirrhosis with continued etoh intake. MELD score
21 Childs Class 6 on admission. Not a transplant candidate given
continued etoh intake.
Volume: no ascites on RUQUS, not discharged on diuretics and
denies taking at home
Infection: see above
Bleed: Hgb 10.4 on admit and last was 7.3. history
of anemia requiring transfusions, last EGD in ___ s/p banding
of varices.
Encephalopathy: on home rifaximin, but was not taking lactulose,
discharged with lactulose PRN confusion
CHRONIC ISSUES:
======================
#ESRD on iHD (___)
Missed ___ dialysis as she was sent to ED. She received
dialysis while in patient
#asthma
patient is taking advair at home twice a day.
#hypothyroidism
continued home levothyroxine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. Baclofen 2.5 mg PO BID
3. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
4. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN wheezing
5. FoLIC Acid 1 mg PO DAILY
6. Ipratropium Bromide Neb 1 NEB IH BID:PRN wheezing
7. Levothyroxine Sodium 62.5 mcg PO DAILY
8. Lidocaine 0.5% 2 mL TT DAILY:PRN during dialysis
9. Midodrine 20 mg PO TID
10. Multivitamins 1 TAB PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. rifAXIMin 550 mg PO BID
13. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
Discharge Medications:
1. Lactulose 30 mL PO Q6H:PRN encephalopathy
RX *lactulose 20 gram/30 mL 30 ml by mouth every six (6) hours
Disp #*1 Bottle Refills:*1
2. Thiamine 100 mg PO DAILY Duration: 5 Days
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*1
3. Allopurinol ___ mg PO EVERY OTHER DAY
RX *allopurinol ___ mg 1 tablet(s) by mouth every other day Disp
#*30 Tablet Refills:*1
4. Baclofen 2.5 mg PO BID
RX *baclofen 5 mg 0.5 (One half) tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*1
5. Dialyvite (B complex ___
complex-vitamin C-folic acid) ___ mg-mg-mcg-mg oral
DAILY
RX *B complex ___ [Dialyvite] 1 mg-100 mg-300
mcg-50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet
Refills:*1
6. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN wheezing
RX *fluticasone propionate 50 mcg/actuation 1 spray intranasally
each nostril, once a day Disp #*1 Spray Refills:*0
7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
RX *fluticasone propion-salmeterol 100 mcg-50 mcg/dose 1 inhaled
twice a day Disp #*1 Disk Refills:*1
8. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet by mouth once a day Disp #*30
Tablet Refills:*1
9. Ipratropium Bromide Neb 1 NEB IH BID:PRN wheezing
10. Levothyroxine Sodium 62.5 mcg PO DAILY
RX *levothyroxine 125 mcg 0.5 (One half) tablet(s) by mouth once
a day Disp #*30 Tablet Refills:*1
11. Lidocaine 0.5% 2 mL TT DAILY:PRN during dialysis
12. Midodrine 20 mg PO TID
RX *midodrine 10 mg 2 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*1
13. Multivitamins 1 TAB PO DAILY
14. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
15. rifAXIMin 550 mg PO BID
RX *rifaximin [___] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hepatic Encephalopathy
Secondary:
Alcohol Intoxication
ESRD on Dialysis
Cirrhosis
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 to the hospital because you were confused and sleepy at
dialysis.
You were given lactulose to help with your confusion. This
medicine works by helping you stool frequently. Please remember
that if you do not take lactulose the confusion will return. We
also encourage you to stop drinking alcohol. Your liver disease
is worsening and you may die if you do not stop drinking. We
wish you all the best, and once again it was a pleasure caring
for you.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10039709-DS-7 | 10,039,709 | 22,530,397 | DS | 7 | 2136-05-14 00:00:00 | 2136-05-14 17:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Pneumococcal Vaccine / nuts / treenuts
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with H/O pulmonary embolus, hypertension, and asthma
presents with 2 days of right lower chest pain. The patient was
on a boat 14 miles off shore on ___ when he felt nauseated,
then developed right-sided lower chest discomfort, ___ in
severity, with occasional spikes of sharp ___ pain that
radiated to the back and shoulder. He presented initially to
___ where EKG showed "possible age
indeterminate inferior MI", however the actual tracing was not
available for review. Troponins negative, D-dimer normal, CXR
normal. He was started on a heparin gtt and was loaded with
clopidogrel. He was also given nitropaste and morphine with some
improvement of his symptoms. He was then transferred to ___.
At the ___ ED, initial vitals were T 97.4 HR 88 BP 158/87 RR
18 SaO2 96% on RA. Labs significant for normal troponins x2,
bicarb 20, LDH 345. He was given heparin gtt, SL NTG, metoprolol
25 mg, ipratropium nebs, IV morphine x3, and ondasentron. He was
also given his home medications: valsartan 160 mg, ranitidine
150 mgx2, atenolol 50 mg, Advair, tiotropium, aspirin 81 mg.
Cardiology saw the patient and recommended stopping the heparin
gtt, controlling chest pain with NTG, and trending cardiac
biomarkers.
On arrival to the cardiology floor, the patient reported
persistent ___ right sided chest pain, unchanged from previous.
The pain had been waxing and waning but mostly constant with
bursts of sharp pain. It was non-pleuritic, non-exertional. No
pain with palpation. Sharp pain radiated to his back with
persistent associated nausea. He stated that morphine and NTG
did not help much to relieve pain. He stated the discomfort felt
different than at the time of his prior PE. He denied recent
travel, however drives a lot for work. No recent surgeries, no
H/O cancer.
Past Medical History:
- Asthma
- Seasonal allergies
- History of pulmonar embolus (thought to be provoked by flight
from ___ ___, now s/p 6 months of warfarin
- Hypertension
- Previous knee surgery
- Negative stress test several years ago
Social History:
___
Family History:
Father had CABG at age ___. No other family history of heart
disease.
Physical Exam:
On Admission
General: ___ middle aged Caucasian man in NAD, comfortable,
pleasant
VS: T 98.2 BP 150/93 HR 72 RR 24 SaO2 96% on RA
HEENT: NCAT, PERRL, injected sclera bilaterally, mucous
membranes moist
Neck: supple, no JVD
CV: regular rhythm; no murmurs, rubs or gallops; no pain with
palpation of right lower chest
Lungs: CTAB--no wheezing, rales or rhonchi
Abdomen: soft, non-tender, not distended, BS+
Ext: no edema, no erythema, no pain with palpation of calves
bilaterally
Neuro: moving all extremities grossly, grossly intact
At discharge
General: NAD
Neck: supple, no JVD
CV: regular rhythm; no murmurs, rubs or gallops; no pain with
palpation of right lower chest
Lungs: CTAB--no wheezing, rales or rhonchi
Abdomen: soft, non-tender, not distended, BS+
Ext: no edema
Neuro: grossly intact
Pertinent Results:
___ 02:30PM BLOOD WBC-8.3 RBC-4.44* Hgb-13.5* Hct-40.9
MCV-92 MCH-30.5 MCHC-33.1 RDW-13.2 Plt ___
___ 02:30PM BLOOD ___ PTT-79.3* ___
___ 02:30PM BLOOD Glucose-91 UreaN-11 Creat-0.9 Na-138
K-4.6 Cl-106 HCO3-20* AnGap-17
___ 02:30PM BLOOD ALT-29 AST-32 LD(LDH)-345* AlkPhos-34*
TotBili-0.6
___ 02:30PM BLOOD Lipase-32
___ 02:30PM BLOOD cTropnT-<0.01
___ 08:24AM BLOOD cTropnT-<0.01
___ 01:06PM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:12AM BLOOD CK-MB-1 cTropnT-<0.01
___ 08:12AM BLOOD WBC-7.0 RBC-4.76 Hgb-14.7 Hct-44.9 MCV-94
MCH-30.9 MCHC-32.8 RDW-13.6 Plt ___
___ 08:12AM BLOOD Glucose-106* UreaN-12 Creat-1.0 Na-141
K-4.4 Cl-106 HCO3-30 AnGap-9
___ 08:12AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.5
EKG ___: NSR, HR 68, normal axis, normal intervals, q wave in
lead III, T wave invesion in lead III, no ST segment changes
CTA chest ___
Adequate opacification of the pulmonary arterial tree was
noted. No filling defects are identified in the pulmonary
arterial tree to the subsegmental level. No evidence of
pulmonary embolus. The main pulmonary artery is normal in
caliber. Respiratory motion artifact limits assessment of the
ascending aorta, however no aneurysmal dilation of the thoracic
aorta is identified.
No intrathoracic or extrathoracic lymphadenopathy. Cardiac
size is within normal limits. No pericardial or pleural
effusions are identified. Minor bibasilar atelectasis is noted.
No evidence of consolidation. No suspicious nodules are
identified. Limited assessment of the subdiaphragmatic
structures is unremarkable.
OSSEOUS STRUCTURES:
No suspicious focal osteolytic or osteoblastic lesions are
identified. Mild multilevel degenerate changes of the thoracic
spine are evident.
IMPRESSION:
No evidence of acute pulmonary embolus. No abnormality
identified to explain patient's chest pain.
Brief Hospital Course:
___ M with H/O pulmonary embolus in ___, hypertension, asthma
presented with 2 days of right lower chest pain.
ACUTE ISSUES:
# Chest pain: Etiology unclear. The patient's cardiac biomarkers
were negative x4, and there were no worrisome EKG changes
despite prolonged pain. CXR and CTA chest were negative for
pneumonia, pulmonary embolus or aortic dissection. LFTs and
lipase were within normal limits. His pain was treated
symptomatically with pain medications, and by discharge his pain
had improved. He should follow up with his PCP for further
management and evaluation.
CHRONIC ISSUES:
# Asthma: Continued home Advair, tiotropium. Gave prn nebs,
cough medications.
# GERD: Continued ranitidine
# Hypertension: Continued home valsartan, atenolol
TRANSITIONAL ISSUES:
- PCP follow up for ongoing management
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 160 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Ranitidine 150 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Ranitidine 150 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
7. Valsartan 160 mg PO DAILY
8. Ibuprofen 600 mg PO Q8H pain
Take this medication with food.
RX *ibuprofen 200 mg ___ tablet(s) by mouth q8h prn Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
-Chest pain, etiology uncertain, but without objective evidence
of ischemia or myocardial infarction, pulmonary embolus, aortic
pathology, or intrathoracic process
-Asthma
-Gastroesophageal reflux disease
-Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay.
You were admitted for chest pain. Your EKG and lab tests were
reassuring that you did not have a heart attack. Imaging of your
lungs did not reveal a pulmonary embolism or other concerning
findings. Your pain was treated with pain medications and
improved. Please follow up with your PCP for further
management.
If you symptoms worsen, please ___ medical attention.
Best,
Your ___ care team
Followup Instructions:
___
|
10040025-DS-22 | 10,040,025 | 27,553,957 | DS | 22 | 2145-07-31 00:00:00 | 2145-08-01 14:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
allopurinol
Attending: ___.
Chief Complaint:
"I had A-fib"
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient is a ___ year old female with a PMHx of paroxysmol afib
on coumadin, CAD w/ MI ___ s/p PCI, CHF, IDDM2 who is presenting
with palpitations and ___ edema.
Patient started to have symptoms 5 days ago with worsening ankle
swelling despite medication compliance. This morning she felt
her heart pounding and palpitations similar to an episode ___
months ago when she was diagnosed with AFib, however it was
worse then. She denies DOE, orthopnea, PND. Denies fevers,
chills, chest pain, nausea, vomiting or diarrhea. Due to
persistent symptoms this morning, patient presented to the ED
for evaluation.
Of note, patient was admitted at the end of ___ with
___ cellulitis, ___, HTN and hyperglycemia.
In the ED intial vitals were: 98.5, 122, 182/78, 18, 98% RA.
EKG showed afib with RVR to 124 without ischemic changes.
Labs were notable for WBC 9.6K, Hct 35.5, INR 2.0, BNP of 2393,
Cr 1.6 with K of 3.8.
CXR showed hyperinflation without cardiopulmonary process.
Patient was given: 40mg IV lasix, metoprolol 25mg PO followed by
metoprolol IV 5mg x2. HR improved to ___ with metoprolol.
Vitals on transfer: 97 158/88 16 99% RA.
On the floor she is having mild chest discomfort but it is
improved. She is very upset that she was not given insulin with
dinner.
ROS: Per HPI. Denies stroke/TIA/DVT/PE.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia +
Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: Reportedly in ___.
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- HTN, labile
- HLD
- HYPOTHYROIDISM
- RETINAL ARTERY OCCLUSION - BRANCH
- MIGRAINE EQUIVALENT
- CAD/MI (MIs in ___ and ___: This demonstrated a mid
RCA lesion which was stented with a drug-eluting stent. LAD had
a proximal 30% stenosis, left circumflex had a ostial 50%
stenosis. The distal RCA also had a 50% stenosis)
- CHF (EF 60-65% in ___
- OBESITY,
- insulin-dependent DMII
- Gout
- Renal artery stenosis
- CKDIII
- Anemia
- a-fib on anticoagulation
- Depression
Social History:
___
Family History:
"Everybody's dead. I don't remember."
Physical Exam:
ADMISSION PHYSICAL:
=============================
VS: 98.1, 168/110, 122, 20, 99/RA
GENERAL: obese, well appearing female in NAD
HEENT: Anicteric sclera, PERRL, MMM
NECK: Mild JVD
CARDIAC: Tachycardic, irregular, normal S1/S2, no m/r/g
LUNGS: CTA b/l, non-labored
ABDOMEN: Obese, +BS, soft, NT/ND
EXTREMITIES: 1+ edema of the ankles. WWP. 2+ DP pulses
bilaterally.
DISCHARGE PHYSICAL:
==============================
Vitals: 97.5, 141/71 (115-155 SBP), 40s-90s in AF, 18, 98 on RA
Last 24 hours I/O: 1420/1400
Last 8 hours I/O: 60/500
Weight on admission: 103.8 kg
DISCHARGE WEIGHT: 103 kg
GENERAL: obese, well appearing female in NAD
NECK: No appreciable JVD
CARDIAC: irregular, normal S1/S2, no m/r/g
LUNGS: very mild crackles at bases, non-labored
ABDOMEN: Obese, +BS, soft, NT/ND
EXTREMITIES: trace to 1+ edema of the ankles. WWP.
Pertinent Results:
ADMISSION LABS:
======================
___ 11:45AM BLOOD WBC-9.6 RBC-3.69* Hgb-11.8* Hct-35.5*
MCV-96 MCH-31.9 MCHC-33.1 RDW-13.9 Plt ___
___ 11:45AM BLOOD Neuts-72.6* ___ Monos-6.5 Eos-2.4
Baso-0.2
___ 11:45AM BLOOD ___ PTT-42.0* ___
___ 11:45AM BLOOD Glucose-187* UreaN-47* Creat-1.6* Na-136
K-7.2* Cl-98 HCO3-26 AnGap-19
___ 11:45AM BLOOD proBNP-2393*
___ 01:17PM BLOOD CK-MB-2 cTropnT-0.02*
___ 05:35AM BLOOD CK-MB-2 cTropnT-0.01
___ 05:35AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.0
DISCHARGE LABS:
======================
___ 05:55AM BLOOD WBC-5.7 RBC-3.20* Hgb-10.1* Hct-30.3*
MCV-95 MCH-31.7 MCHC-33.5 RDW-14.3 Plt ___
___ 05:55AM BLOOD ___
___ 05:55AM BLOOD Glucose-219* UreaN-86* Creat-2.7* Na-133
K-3.8 Cl-93* HCO3-26 AnGap-18
___ 05:55AM BLOOD Mg-2.3
STUDIES:
======================
CXR (___):
FINDINGS:
The lungs are hyperinflated but clear of focal consolidation,
effusion, or vascular congestion. Cardiomediastinal silhouette
is within normal limits. No acute osseous abnormalities
identified.
IMPRESSION:
Hyperinflation without acute cardiopulmonary process.
Brief Hospital Course:
Patient is a ___ with history of paroxysmal afib on coumadin,
CAD w/ MI x4 and stents, CHF, and IDDM2 presenting with
palpitations and ___ edema.
# Atrial fibrillation: Patient with afib with RVR in ED possibly
related to mild volume overload triggering worsening afib
-Discharged on warfarin 5 mg daily, with instructions to have
INR checked on ___
-Changed carvedilol to metoprolol succ 100 daily for rate
control
-Added diltiazem 30 mg Q6H, and transitioned to 180 ER daily on
discharge
# Hypertension: Hypertensive to 160s/100s on arrival to the
floor.
-Switched home carvedilol for metoprolol and diltiazem as above
-Initially increased irbesartan to 150mg BID but discharged on
150 mg once daily given ___
-Held spironolactone on discharge for ___
# Acute on chronic diastolic heart failure: Last EF 60-65% in
___. Unclear cause for CHF exacerbation, though patient was
recently on prednisone. Denies dietary or medication
indiscretions. No recent illnesses. Leg swelling started before
palpitations, so suspect CHF triggered AF with RVR and not the
other way around.
-Trops and CK-MB negative
-Diuresis with 2.5 of metolazone and 120 IV lasix
-Discharge with torsemide 40 mg daily for home diuretic, though
this may need to be uptitrated as tolerated based on renal
function
-DISCHARGE WEIGHT HERE: 103 kg
#Flu exposure from roommate
-Received oseltamivir x1 for prophylaxis then refused.
# CAD:
-Continued asa 81mg
-Metoprolol and irbesartan as above
-Consider statin as outpatient
# IDDM.
-Continued home lantus 20u QHS
-HISS with 10u with meals
# CKD III: Baseline cr 1.6, likely related to DM and HTN.
Increase in Cr to 2.7 in the setting of diuresis.
-Patient given Rx to have Chem7 checked on ___, which should
be followed up by PCP ___ ___
-Held home spironolactone, decreased home torsemide as above
Other home medications were continued without changes.
TRANSITIONAL ISSUES:
[ ] continue to titrate rate control medications,
antihypertensive, and diuretics per outpatient cardiology and
primary care
[ ] consider statin for history of CAD
[ ] f/u lytes and INR from ___ at PCP appointment on ___ to
ensure resolution/improvement ___ (secondary to diuresis) and
adjust warfarin dose PRN
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB or wheezing
2. Aspirin 81 mg PO DAILY
3. BuPROPion (Sustained Release) 150 mg PO QAM
4. Carvedilol 25 mg PO BID
5. Ezetimibe 10 mg PO DAILY
6. Ferrous Sulfate 325 mg PO BID
7. irbesartan 150 mg oral Daily
8. Levothyroxine Sodium 112 mcg PO DAILY
9. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
10. Spironolactone 25 mg PO DAILY
11. Torsemide 40 mg PO BID
12. Warfarin 2 mg PO 5X/WEEK (___)
13. Cyanocobalamin 1000 mcg IM/SC MONTHLY
14. Warfarin 2.5 mg PO 2X/WEEK (___)
15. Glargine 20 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB or wheezing
2. Aspirin 81 mg PO DAILY
3. BuPROPion (Sustained Release) 150 mg PO QAM
4. Ezetimibe 10 mg PO DAILY
5. Ferrous Sulfate 325 mg PO BID
6. Glargine 20 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
7. Levothyroxine Sodium 112 mcg PO DAILY
8. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
9. Cyanocobalamin 1000 mcg IM/SC MONTHLY
10. Outpatient Lab Work
INR (ICD9 427.31)
CHEM7 (ICD9 428.30)
Please send results to ___.
___
11. irbesartan 150 mg ORAL DAILY
12. Torsemide 40 mg PO DAILY
13. Diltiazem Extended-Release 180 mg PO DAILY
RX *diltiazem HCl 180 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
14. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
15. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
atrial fibrillation with rapid ventricular response
acute on chronic diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for palpitation and leg
swelling. We think that your legs were swollen because your
heart was not adequately circulating blood (heart failure). As a
result, your heart also became stressed and started beating too
fast (AFib with rapid ventricular response).
We changed one of the medicines that control your heart rate in
order to slow it down and added a new medicine to help control
your heart rate and blood pressure. We also gave you medicine to
remove fluid from your body (called a diuretic). Your heart rate
came under control and your leg swelling improved.
You also had an injury to your kidneys, likely from trying to
remove fluid with diuretics. You will have your kidney function
tests monitored closely after discharge and we have stopped or
decreased medications that may be harmful to your kidneys.
You should weigh yourself every day and call your PCP if your
weight goes up by more than 3 lbs, as this could indicate that
you are having more fluid build-up.
Unfortunately, during your stay you were exposed to someone with
the flu. We offered you medicine to prevent you from also
getting the flu and monitored you for signs of illness.
We have scheduled follow up appointments with cardiology and
your primary care provider (detailed below). You should review
your discharge medication list because it details the changes we
made to your home medications. We are giving you a prescription
to have your INR and electrolytes (including kidney function
tests) checked on ___.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10040025-DS-24 | 10,040,025 | 21,791,856 | DS | 24 | 2147-06-22 00:00:00 | 2147-06-23 15:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
allopurinol / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___
Chief Complaint:
Dyspnea and cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo with h/o CAD s/p DES, CKD, HFpEF (EF>60%) on torsemide,
AF on coumadin, presented to ED w/3 days of productive cough and
gradual onset dyspnea.
Patient reports she developed URI symptoms soon after
___, including nasal congestion and cough. Over the
past few days cough has worsened, productive of white/yellow
sputum. She has also noted some SOB when lying flat and
worsening dyspnea on exertion. She denies fevers, chest pain,
abdominal pain, nausea, vomiting, diarrhea or urinary symptoms.
She has been compliant with all of her medications, including
her diuretics and denies worsening leg swelling or PND. Weight
is down to 199lbs, from 210 in the past (intentional weight
loss). No increase in her weight since she has been feeling
unwell. Patient has been hospitalized in past w/HF exacerbation
and states that her symptoms are not similar to those episodes.
No history of asthma or COPD.
In the ED, initial vitals were: 98.1, 71, 168/80, 16, 93% NC
(improved to 95% on RA w/nebs). Exam notable for diffuse
wheezes, no crackles. Labs revealed WBC 8.7, Hb 10.4 (baseline),
BUN/CR 110/3.5 (unclear baseline-last measured ___ 93/2.41),
trop 0.03, BNP ___. EKG NSR rate 70, no ischemic changes. UA
negative, CXR showed "possible minimal pulmonary vascular
congestion, no focal consolidation". Patient given duonebs with
improvement in her respiratory status and transferred to
medicine for further management.
On the floor, patient complains of persistent productive cough.
She is also requesting oxygen to be worn while she sleeps, for
comfort (on no O2 at home). No additional acute complaints.
Review of systems:
(+) Per HPI
(-) Otherwise 10 point ROS negative.
Past Medical History:
- HTN, labile
- HLD
- HYPOTHYROIDISM
- RETINAL ARTERY OCCLUSION - BRANCH
- MIGRAINE EQUIVALENT
- CAD/MI (MIs in ___ and ___: This demonstrated a
mid
RCA lesion which was stented with a drug-eluting stent. LAD had
a proximal 30% stenosis, left circumflex had a ostial 50%
stenosis. The distal RCA also had a 50% stenosis)
- CHF (EF 60-65% in ___
- OBESITY,
- insulin-dependent DMII
- Gout
- Renal artery stenosis
- CKDIII
- Anemia
- a-fib on anticoagulation
- Depression
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION
==========
Vital Signs: 97.9 PO 152 / 72 L Sitting 63 20 90 RA
Weight: 90.58kg (199.7lbs)
General: sitting up in bed, appears comfortable, NAD
HEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple,
JVP difficult to appreciate, given obese neck, but does not
appear grossly elevated.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Poor air movement throught, diffuse expiratory wheezes.
No crackles.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
Ext: Warm, well perfused, trace edema midway up calves b/l
Neuro: no focal deficits
LABS: Reviewed, see below.
DISCHARGE
=========
Vitals: 98.4, HR 78, 93% RA, RR 20, BP ___
GENERAL: Alert, NAD, sitting up in bed
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: JVP difficult to appreciate due to habitus
RESP: Kyphotic chest. Poor air movement but no wheezing or
crackles
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
ABD: +BS, soft, obese, nontender, nondistended.
EXT: warm, well perfused. Trace edema bilaterally of medial
ankles.
NEURO: Grossly intact motor and sensory function.
Pertinent Results:
ADMISSION LABS
==============
___ 08:20PM BLOOD WBC-8.7 RBC-3.43* Hgb-10.4* Hct-33.6*
MCV-98 MCH-30.3 MCHC-31.0* RDW-13.6 RDWSD-48.1* Plt ___
___ 08:20PM BLOOD Neuts-72.5* Lymphs-18.4* Monos-6.7
Eos-1.2 Baso-0.2 Im ___ AbsNeut-6.27* AbsLymp-1.59
AbsMono-0.58 AbsEos-0.10 AbsBaso-0.02
___ 08:20PM BLOOD ___ PTT-52.3* ___
___ 08:20PM BLOOD Glucose-192* UreaN-110* Creat-3.5*#
Na-135 K-4.4 Cl-91* HCO3-29 AnGap-19
___ 08:20PM BLOOD ___ 08:20PM BLOOD cTropnT-0.03*
___ 08:20PM BLOOD Calcium-8.9 Phos-4.2 Mg-2.7*
___ 08:20PM BLOOD Digoxin-0.9
___ 08:20PM URINE Color-Straw Appear-Clear Sp ___
___ 08:20PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 08:20PM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-1
___ 10:11AM URINE Hours-RANDOM UreaN-359 Creat-36 Na-87
TotProt-81 Prot/Cr-2.3*
___ 10:11AM URINE Osmolal-339
DISCHARGE LABS
==============
___ 07:35AM BLOOD WBC-12.4* RBC-3.66* Hgb-11.4 Hct-36.3
MCV-99* MCH-31.1 MCHC-31.4* RDW-13.6 RDWSD-49.7* Plt ___
___ 07:35AM BLOOD ___
___ 07:35AM BLOOD Glucose-168* UreaN-112* Creat-2.3* Na-141
K-4.0 Cl-95* HCO3-29 AnGap-21*
___ 07:35AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.0
REPORTS
========
CT Chest ___. Bronchial wall thickening, endobronchial secretions, and
peribronchial ground-glass and nodular opacities in the middle
lobe and bilateral lower lobes, suspicious for aspiration
pneumonia.
2. At least one pulmonary nodule measuring 10 mm in the middle
lobe, possibly with a second 10 mm nodule in the right lower
lobe. Recommend follow-up chest CT in 6 weeks, after appropriate
treatment.
3. Probably reactive mediastinal and hilar lymphadenopathy.
4. Mild dilation of the ascending aorta, measuring 41 mm. Mild
aortic valve calcifications.
5. Coronary calcifications.
6. Indeterminate 12 x 12 mm left adrenal nodule. Recommend
further
characterization with adrenal protocol CT or MRI.
CXR PA-Lateral ___
COPD. Increasing left lower lobe opacities could be atelectasis
or pneumonia in the appropriate clinical setting
Renal US ___: Normal renal ultrasound.
CXR ___
Possible minimal pulmonary vascular congestion. No focal
consolidation.
MICROBIOLOGY
============
Blood cultures - negative
Urine culture - negative
Brief Hospital Course:
___ y/o F with a h/o CAD, diastolic CHF, AFib, DM, CKD 4, Gout,
who presented with hypoxic respiratory failure most consistent
with a COPD exacerbation, and ___ on CKD.
ACTIVE PROBLEMS
===============
# Hypoxic Respiratory Failure
# COPD Exacerbation
# Aspiration PNA
Her presenting symptoms included a preceding URI, which led to
wheezing, cough, and dyspnea, in a patient with longstanding
smoking history. She had a low peak flow. Thus, her diagnosis
was most consistent with a COPD exacerbation, although there was
no diagnosis of COPD prior to admission. She remained hypoxic
when ambulatory on room air throughout her admission despite
several days of high dose PO steroid (Methylpred 32mg daily -
this chosen as opposed to Prednisone for simplicity's sake as
she is chronically on low dose Methylpred), and scheduled/PRN
nebulizers. Thus, due to continued hypoxia, repeat CXR was done
on ___, which showed only radiographic evidence of COPD, as
well as atelectasis. She was thus given Incentive Spirometry
for atelectasis. As she remained hypoxic, CT chest was then
done ___, showing likely consolidation due to aspiration in
both lower lobes. She was thus started on Augmentin, and will
complete ___s outpatient. There was no evidence of
CHF exacerbation based on bedside eval or imaging. PE unlikely
given she is chronically on Warfarin. Home O2 was arranged, but
the patient declined this on day of discharge. Started inhaled
fluticasone BID given clinical certainty of COPD. Outpatient
PFT's recommended on discharge.
# ___ on Stage 4 CKD: Presented with Cr 3.5, but quickly
downtrended back to baseline mid-2's without any intervention.
She appeared euvolemic, although volume status is certainly
complex given CHF history. It is unclear what the acute insult
was to cause worsening Cr of admission. FE-Urea was 28%, which
is consistent with pre-renal azotemia, but not a fully reliable
test. Renal US was unremarkable. Her home Torsemide was
continued. Her home ___ (irbesartan) was replaced with Losartan
while in house, as irbesartan is not formulary.
CHRONIC PROBLEMS
================
# Chronic Diastolic CHF: No e/o exacerbation. She is below prior
dry weight and had minimal edema and no significant rales.
Continued home Torsemide, Carvedilol. Continued ___. Monitored
volume status. Low salt diet
# CAD: Stable.
- Continue home ASA 81mg, Ezetimibe, Carvedilol
- ___ as above
# A-Fib on Warfarin: INR was supratherapeutic on admission, held
Warfarin, and resumed once INR was therapeutic. There were no
further INR issues.
- Continued Warfarin
- Daily INR, should recheck as outpatient with ___ Anticoag
Team per their routine
- Continue home digoxin (level checked, was 0.9)
# Diabetes
- Continue home Glargine/Humalog regimen, along with sliding
scale
# Gout
- Continue home Febuxostat
- Continue home Methylprednisolone 4mg (initially was on higher
dose of 32mg daily to treat COPD exacerbation)
# Hypothyroidism
- Continue home Levothyroxine
# Anxiety
- Continue home Bupropion, Lorazepam
# Incidental findings
- Pulm nodules need f/u CT in 6 weeks
- Adrenal nodule needs f/u CT or MRI with adrenal protocol as
outpatient
TRANSITIONAL ISSUES
===================
- Augmentin 500mg BID x7 days for aspiration pneumonia, ___
- Started inhaled fluticasone BID given likely COPD
- Arranged for home O2 and offered to the patient, but she
declined it
- Outpatient PFT's recommended
- Needs f/u CT chest in 6 weeks to assess for resolution of x2
10mm pulmonary nodules seen on CT chest
- Adrenal nodule noted on CT chest. Needs outpatient adrenal
protocol CT or MRI for further characterization of left adrenal
nodule
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q8H:PRN nausea
2. Ezetimibe 10 mg PO DAILY
3. Methylprednisolone 4 mg PO DAILY
4. LORazepam 0.5 mg PO BID:PRN anxiety
5. Avapro (irbesartan) 150 mg oral DAILY
6. Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Vitamin D ___ UNIT PO DAILY
8. Warfarin 6.25 mg PO 3X/WEEK (___)
9. Metolazone 2.5 mg PO DAILY
10. Febuxostat 40 mg PO DAILY
11. Torsemide 60 mg PO BID
12. nystatin 100,000 unit/gram topical ___ daily
13. BuPROPion (Sustained Release) 150 mg PO QAM
14. Digoxin 0.125 mg PO 4X/WEEK (___)
15. Carvedilol 37.5 mg PO BID
16. Levothyroxine Sodium 112 mcg PO DAILY
17. Miconazole Powder 2% 1 Appl TP BID
18. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
19. Ferrous Sulfate 325 mg PO BID
20. Aspirin 81 mg PO DAILY
21. Warfarin 5 mg PO 4X/WEEK (___)
22. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN BREAKTHROUGH
PAIN
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate [Augmentin] 500 mg-125 mg 1
tablet(s) by mouth twice daily Disp #*14 Tablet Refills:*0
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
RX *fluticasone [Flovent HFA] 110 mcg/actuation 2 puffs inhaled
twice daily Disp #*1 Inhaler Refills:*2
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
4. Aspirin 81 mg PO DAILY
5. Avapro (irbesartan) 150 mg oral DAILY
6. BuPROPion (Sustained Release) 150 mg PO QAM
7. Carvedilol 37.5 mg PO BID
8. Digoxin 0.125 mg PO 3X/WEEK (___)
9. Ezetimibe 10 mg PO DAILY
10. Febuxostat 40 mg PO DAILY
11. Ferrous Sulfate 325 mg PO BID
12. Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Levothyroxine Sodium 112 mcg PO DAILY
14. LORazepam 0.5 mg PO BID:PRN anxiety
15. Methylprednisolone 4 mg PO DAILY
16. Metolazone 2.5 mg PO DAILY
as directed
17. Miconazole Powder 2% 1 Appl TP BID
18. nystatin 100,000 unit/gram topical ___ daily
19. Ondansetron 4 mg PO Q8H:PRN nausea
20. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN BREAKTHROUGH
PAIN
21. Torsemide 60 mg PO BID
22. Vitamin D ___ UNIT PO DAILY
23. Warfarin 6.25 mg PO 3X/WEEK (___)
24. Warfarin 5 mg PO 4X/WEEK (___)
25.Home Oxygen
ICD-10: J44.9, COPD
2 liters/minute flow rate
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
COPD exacerbation
___ on CKD
Aspiration pneumonia
Secondary:
CAD, diastolic CHF, AFib, DM, Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure caring for you at ___. You were admitted to
our hospital because of trouble breathing. It was discovered
that the most likely cause of this was an exacerbation/crisis of
"COPD." You were treated with high dose steroids and
nebulizers.
The CT scan of your chest also showed evidence of a small
pneumonia. We will prescribe you an antibiotic for this, to take
twice per day for 1 week.
You were also found to have worsening of your kidney function on
arrival. However, this fortunately improved back to baseline
during your stay.
It was a pleasure caring for you, and we wish you the best.
Please contact your PCP to get ___ follow up appointment.
- ___ team
Followup Instructions:
___
|
10040025-DS-27 | 10,040,025 | 27,259,207 | DS | 27 | 2147-12-18 00:00:00 | 2147-12-18 17:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
allopurinol / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
left foot ulcer
Major Surgical or Invasive Procedure:
___: Excisional debridement down to tendon of left diabetic
foot ulcer
___: diagnostic angiogram, left lower extremity
History of Present Illness:
Ms. ___ presents for evaluation of an infected left foot
diabetic ulcer. She complains of severe pain and tenderness
over
the site. She tells me that approximately 7 weeks ago, she
dropped a pacemaker cell onto her left foot while in the
hospital. She developed a blister that broke down and became
infected. She has received topical wound care but no vascular
assessment as of yet.
Past Medical History:
HTN, labile
HLD
HYPOTHYROIDISM
RETINAL ARTERY OCCLUSION - BRANCH
MIGRAINE EQUIVALENT
CAD/MI (MIs in ___ and ___: This demonstrated a mid
RCA lesion which was stented with a drug-eluting stent. LAD had
a proximal 30% stenosis, left circumflex had a ostial 50%
stenosis. The distal RCA also had a 50% stenosis)
CHF (EF 60-65% in ___
OBESITY,
insulin-dependent DMII
Gout
Renal artery stenosis
CKDIII
Anemia
afib on anticoagulation
Depression
Social History:
___
Family History:
Father died of colon cancer in ___.
Physical Exam:
At admission:
VS: 96.6 78 126/87 16 98% RA
General: Alert, oriented, no acute distress
HEENT: Pale conjunctivae, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: CTAB anteriorly
CV: ___
Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
Ext: 2+ pitting edema ___ bilateral heel ulceration; dorsum of
left foot with purulent, foul smelling defect with eschar edges
and erythema extending from it. ulceration along posterior left
leg 2x2cm
Left: DP ___ none; Right: ___ doppler
Neuro: CN2-12 intact, no focal deficits
At discharge:
GEN: NAD, annoyed--speaking in short, sarcastic,
profranity-filled sentences
HEENT: EOMI, MMM
CV: RRR
PULM: non-labored breathing
ABD: soft, nontender, nondistended
EXT: 2+ edema bilaterally, approximately 2x2 cm ulcer over left
lateral dorsum of foot without foul odor or drainage, minimal
surrounding erythema, L shallow heel ulcer, shallow clean based
ulcer over posterior aspect left calf; right shallow clean based
heel ulcer dressed with adaptic, Kerlix and ACE
NEURO: A&Ox3
Pertinent Results:
ABI/PVR (___):
FINDINGS:
TBIs obtained bilaterally and measuring 0.28 in the right lower
extremity and 0.19 the left lower extremity.
Wound Culture (L foot) ___:
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
Brief Hospital Course:
Ms. ___ was admitted to ___ On ___ with a non-healing
left diabetic foot ulcer. She was started on IV antibiotics and
taken to the Operating Room on ___ for debridement and
application of VAC. For full details of the procedure, please
refer to the separately dictated Operative Report. She was
returned to the PACU in stable condition and after satisfactory
recovery from anesthesia, she was transferred to the floor for
further monitoring and wound care.
___ was consulted on ___ and recommended discharge to rehab.
On ___, patient demanded that wound VAC be removed and
refused replacement. Plastic surgery was consulted for wound
care and also recommended VAC therapy. Patient was counseled
that this was optimal medical care, yet she persisted in her
refusal. Daily wet-to-dry dressings were initiated. ABI/PVRs
were done on ___ and were consistent with severe peripheral
vascular disease. Both Vascular Surgery and Plastics were in
agreement that patient should have an angiogram. She was
consented for procedure and taken to the Endovascular Suite on
___. She was on the table and Foley had been placed when she
refused all procedures. She was returned to the floor where she
continued to refused recommended treatment.
She was transitioned to oral antibiotics on ___ when culture
data resulted.
She returned to the Operating Room on ___ for angiogram which
showed long segment occlusion of the left SFA. Vein mapping
studies were obtained for OR planning for a left femoral to
AK-popliteal artery bypass.
She was discharged to rehab on ___ with plan for antibiotics
to continue through ___. She will follow up in clinic with
Dr. ___ to discuss operative planning.
At the time of discharge, she was tolerating a regular diet,
ambulating independently to the rest room and with assistance in
the hallways, voiding spontaneously and pain was well
controlled.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Digoxin 0.125 mg PO 3X/WEEK (___)
4. Ezetimibe 10 mg PO DAILY
5. Febuxostat 40 mg PO DAILY
6. Ferrous Sulfate 325 mg PO BID
7. HydrALAZINE 20 mg PO Q8H
8. Isosorbide Dinitrate 20 mg PO TID
9. Levothyroxine Sodium 112 mcg PO DAILY
10. Methylprednisolone 4 mg PO DAILY
11. Metoprolol Succinate XL 200 mg PO DAILY
12. Miconazole Powder 2% 1 Appl TP BID
13. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe
14. Prasugrel 10 mg PO DAILY
15. Simethicone 40-80 mg PO QID:PRN bloating
16. Torsemide 60 mg PO BID
17. Vitamin D ___ UNIT PO DAILY
18. Acetaminophen 650 mg PO Q8H
19. Bisacodyl ___AILY:PRN constipation
20. Docusate Sodium 100 mg PO BID constipation
21. FoLIC Acid 1 mg PO DAILY
22. Omeprazole 20 mg PO DAILY
23. Polyethylene Glycol 17 g PO DAILY constipation
24. Senna 8.6 mg PO BID:PRN constipation
25. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
26. Fluticasone Propionate 110mcg 2 PUFF IH BID
27. Metolazone 2.5 mg PO PRN as directed by cardiologist
28. nystatin 100,000 unit/gram topical ___ daily
29. Spironolactone 12.5 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*12 Tablet Refills:*0
3. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
4. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*18 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
6. Acetaminophen 650 mg PO Q8H
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
8. Aspirin 81 mg PO DAILY
9. Bisacodyl ___AILY:PRN constipation
10. BuPROPion (Sustained Release) 150 mg PO QAM
11. Digoxin 0.125 mg PO 3X/WEEK (___)
12. Docusate Sodium 100 mg PO BID constipation
13. Ezetimibe 10 mg PO DAILY
14. Febuxostat 40 mg PO DAILY
15. Ferrous Sulfate 325 mg PO BID
16. Fluticasone Propionate 110mcg 2 PUFF IH BID
17. FoLIC Acid 1 mg PO DAILY
18. HydrALAZINE 20 mg PO Q8H
19. Isosorbide Dinitrate 20 mg PO TID
20. Levothyroxine Sodium 112 mcg PO DAILY
21. Methylprednisolone 4 mg PO DAILY
22. Metolazone 2.5 mg PO PRN as directed by cardiologist
23. Metoprolol Succinate XL 200 mg PO DAILY
24. Miconazole Powder 2% 1 Appl TP BID
25. nystatin 100,000 unit/gram topical ___ daily
26. Omeprazole 20 mg PO DAILY
27. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Severe
28. Polyethylene Glycol 17 g PO DAILY constipation
29. Prasugrel 10 mg PO DAILY
30. Senna 8.6 mg PO BID:PRN constipation
31. Simethicone 40-80 mg PO QID:PRN bloating
32. Spironolactone 12.5 mg PO DAILY
33. Torsemide 60 mg PO BID
34. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
non-healing left lateral diabetic foot ulcer
long segment left SFA occlusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with a non-healing left foot ulcer.
You were taken to the Operating Room for debridement and a VAC
was applied to the wound. You then refused replacement of the
VAC and were started on wet-to-dry dressing changes. You were
started on antibiotics (Augmentin) which you are being
discharged with. Plastic Surgery was consulted and also
recommended VAC treatment and angiogram. You were taken to the
Operating Room for angiogram which showed blockage of arteries
in your leg. You will need a bypass surgery at a later date. you
are being discharged to rehab with follow up in 2 weeks with Dr.
___ to discuss the results of your vein mapping studies and
to discuss the date of your operation.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Surgery Team
Followup Instructions:
___
|
10040025-DS-29 | 10,040,025 | 27,996,267 | DS | 29 | 2148-02-04 00:00:00 | 2148-02-04 19:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
allopurinol / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
Left lower extremity surgical site infection
Major Surgical or Invasive Procedure:
___ Left lower extremity incision and drainage,
debridement of left foot ulcer
___ Left lower extremity washout, wound vac placement
___ Left lower extremity wound vac change, debridement
left lower extremity ulcers
History of Present Illness:
Ms. ___ is a ___ year old female recently admitted for
management of a chronic, non-healing left foot ulcer who
underwent a left femoral to above knee popliteal bypass with
NRGSV and left foot ulcer debridement with wound vac
placement. She was seen in clinic 3 days ago with left leg
incision healing slowly and evidence of skin separation and
wound infection in the left thigh. There was weeping fluid but
not purulent and staples intact. There also was significant
surrounding erythema and so she was sent to rehab with augmentin
and was to follow-up in clinic in 2 weeks. She presents to the
ED today with worsening pain and L groin to medial though wound
dehiscence and purulent drainage. She is otherwise feeling well
without fevers or chills, nausea or vomiting. She was admitted
to the vascular surgery service for management of suspected left
lower extremity surgical site infection.
Past Medical History:
PMH:
-HTN, labile
-HLD
-HYPOTHYROIDISM
-RETINAL ARTERY OCCLUSION
-Migraine
-CAD/MI (MIs in ___ and ___: This demonstrated a mid
RCA lesion which was stented with a drug-eluting stent. LAD had
a proximal 30% stenosis, left circumflex had a ostial 50%
stenosis. The distal RCA also had a 50% stenosis)
-CHF (EF 60-65% in ___
-OBESITY
-insulin-dependent DMII
-Gout
-Renal artery stenosis
-CKDIII
-Anemia
-afib
-Depression
PSH:
-Debridement of L foot infected ulcer
-LLE diagnostic angiogram
-L fem-AK pop bypass
Social History:
___
Family History:
Father died of colon cancer in ___.
Physical Exam:
General: NAD
CV: RRR
Pulm: No respiratory distress
Extremities: left groin wound with dressings in place. Bilateral
chronic nonhealing ulcers of the lower extremities
Pertinent Results:
ADMISSION LABS:
___ 04:00PM BLOOD Neuts-86* Bands-1 Lymphs-3* Monos-9 Eos-1
Baso-0 ___ Myelos-0 AbsNeut-7.57* AbsLymp-0.26*
AbsMono-0.78 AbsEos-0.09 AbsBaso-0.00*
___ 04:00PM BLOOD ___ PTT-53.7* ___
___ 04:00PM BLOOD Glucose-118* UreaN-57* Creat-1.8* Na-139
K-4.8 Cl-97 HCO3-28 AnGap-14
DISCHARGE LABS:
___ 05:46AM BLOOD WBC-11.9* RBC-2.95* Hgb-8.7* Hct-27.5*
MCV-93 MCH-29.5 MCHC-31.6* RDW-18.4* RDWSD-59.9* Plt ___
___ 05:46AM BLOOD Plt ___
___ 05:46AM BLOOD ___ PTT-28.0 ___
___ 05:46AM BLOOD Glucose-79 UreaN-68* Creat-2.2* Na-136
K-3.7 Cl-96 HCO3-27 AnGap-13
___ 05:46AM BLOOD Calcium-7.6* Phos-5.3* Mg-2.1
Brief Hospital Course:
Ms. ___ presented on ___ to the emergency room with a
concern for a surgical site infection and was given
vanc/cipro/flagyl immediately. Her INR was also noted to be 5,
so she received 10 of vitamin K in the emergency room. Her
repeat INR was 2.3 preop. She was then taken to the operating
room in the morning of ___ for a debridement and washout of
the LLE. Please see OP note for more details regarding the
procedure. Postoperatively, the LLE continued to exsanguinate.
Cauterization and compression was done in the PACU and she was
transferred to the wards. On ___ evening, she was noted to
be hypotensive to SBP ___ and her Hct had drifted from 27 to 21.
She was transferred to the SICU for monitoring. She received 2
units of pRBC and 1 unit of FFP along with 10 of vitamin K. Her
INR was noted to be 1.7 with Hct stable at 28. Since her last
echo was only done in ___, a repeat echo was done that revealed
her EF to be 40%, and so she was carefully volume resuscitated
in preparation for another debridement, washout and vac
placement on ___. Please see op report for more details.
Following her ___ postop course, her summary will be written by
systems.
#NEURO: Patient was kept intubated and sedated to help
facilitate multiple evaluation of her wound, however she was
extubated on HD4 due to hypotension. Her pain was controlled
with oxycodone and dilaudid.
#CV: Patient was noted to become transiently hypotensive to SBP
___ while she was sedated and so required levo on HD4. Her
pressures improved once she was extubated. 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. She was
extubated on HD4 without issues.
#GI/GU/FEN: The patient had a foley placed intra-operatively for
volume monitoring as well as to keep her incision clean. She was
restarted on her home torsemide on ___. The patient was
given oral diet once extubated, which she tolerated well. She
was noted to have loose bowel movements and incontinent. Her
C.diff was negative and so was given a flexiseal on HD3 to keep
her wound clean.
#ID: The patient's fever curves were closely watched for signs
of infection. She was kept on vanc/cipro/flagyl as her initial
wound cultures from her initial washout was noted to be 4+GNR,
2+ GPC in pairs and chains and 1+ GPRs. On HD4, her cultures
showed enterococcus and acinetobacter that were resistant to
cipro and so was transitioned to ___ on HD4. ID was
consulted on HD5. Given that there were no cultures showing MRSA
and her vanc trough continued to be high, they recommended
holding off on vanc. Her VAC was changed q3d and on her second
VAC change, tissue swabs and cultures were sent that showed GPC
in chains and pairs and GNRs. Updated culture data suggested VRE
and daptomycin was started per ID recs. At the time of her
discharge, antibiotics were discontinued according to the
patient and her daughter's wishes (see below).
#HEME: Patient received several units of blood over her hospital
course for low hematocrits related to bleeding from her left
thigh wound. Her last transfusion was ___ and her hematocrits
were stable the following two days.
#WOUNDS: The patient's left thigh wound vac was changed every
___ days. She was also found to have bilateral lower extremity
pressure ulcers, more extensive on the left than the right leg.
The ulcers on the left leg were found to have purulent
discharge, so she was taken to the operating room again on HD9
(___) for debridement of her left lower extremity pressure
ulcers. Santyl was used on these ulcers for the first 3 days
post operatively. At the time of discharge to hospice, the wound
vac was removed and the thigh wound was redressed with wet to
dry gauze and overlying curlex.
On ___ a family meeting was held with the patient's daughter
and healthcare proxy with a discussion about the lack of
progression in her wounds. The following day a second meeting
was held with the patient's daughter as well as representatives
from palliative care, social work, case management, and vascular
surgery. At that time the patient and her daughter elected to
transfer the patient to a ___ facility and enact a DNR/DNI
order. At the time of her discharge, the patient's vitals were
stable.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
3. Aspirin 81 mg PO DAILY
4. Bisacodyl ___AILY:PRN constipation
5. BuPROPion (Sustained Release) 150 mg PO QAM
6. Digoxin 0.125 mg PO 3X/WEEK (___)
7. Docusate Sodium 100 mg PO BID constipation
8. Ezetimibe 10 mg PO DAILY
9. Febuxostat 40 mg PO DAILY
10. Ferrous Sulfate 325 mg PO BID
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. FoLIC Acid 1 mg PO DAILY
13. HydrALAZINE 20 mg PO Q8H
14. Isosorbide Dinitrate 20 mg PO TID
15. Levothyroxine Sodium 112 mcg PO DAILY
16. Methylprednisolone 4 mg PO DAILY
17. Metoprolol Succinate XL 200 mg PO DAILY
18. Miconazole Powder 2% 1 Appl TP BID
19. nystatin 100,000 unit/gram topical ___ daily
20. Omeprazole 20 mg PO DAILY
21. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe
22. Polyethylene Glycol 17 g PO DAILY constipation
23. Prasugrel 10 mg PO DAILY
24. Senna 8.6 mg PO BID:PRN constipation
25. Vitamin D ___ UNIT PO DAILY
26. Metolazone 2.5 mg PO PRN as directed by cardiologist
27. Simethicone 40-80 mg PO QID:PRN bloating
28. Spironolactone 12.5 mg PO DAILY
29. Torsemide 60 mg PO BID
30. Levofloxacin 500 mg PO Q48H foot infection
Discharge Medications:
1. Gabapentin 100 mg PO BID
2. Insulin SC
Sliding Scale
Fingerstick QACHS, HS
Insulin SC Sliding Scale using REG Insulin
3. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone 20 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*4 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q8H
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
6. Aspirin 81 mg PO DAILY
7. Bisacodyl ___AILY:PRN constipation
8. BuPROPion (Sustained Release) 150 mg PO QAM
9. Docusate Sodium 100 mg PO BID constipation
10. Ezetimibe 10 mg PO DAILY
11. Febuxostat 40 mg PO DAILY
12. Ferrous Sulfate 325 mg PO BID
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. FoLIC Acid 1 mg PO DAILY
15. HydrALAZINE 20 mg PO Q8H
16. Isosorbide Dinitrate 20 mg PO TID
17. Levofloxacin 500 mg PO Q48H foot infection
18. Levothyroxine Sodium 112 mcg PO DAILY
19. Methylprednisolone 4 mg PO DAILY
20. Metoprolol Succinate XL 200 mg PO DAILY
21. Miconazole Powder 2% 1 Appl TP BID
22. nystatin 100,000 unit/gram topical ___ daily
23. Omeprazole 20 mg PO DAILY
24. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
25. Polyethylene Glycol 17 g PO DAILY constipation
26. Prasugrel 10 mg PO DAILY
27. Senna 8.6 mg PO BID:PRN constipation
28. Simethicone 40-80 mg PO QID:PRN bloating
29. Spironolactone 12.5 mg PO DAILY
30. Torsemide 60 mg PO BID
31. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Surgical site infection of left thigh
Infection of left lower extremity pressure ulcers
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: somnolent but arousable.
Activity Status: Out of Bed with lift assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on
___ with a surgical site infection of your left thigh. You
were started on antibiotics and taken to the operating room for
left thigh debridement and subsequently for placement of a wound
vac. You were also found to have left lower extremity pressure
ulcers which appeared to be infected, so you were taken back to
the operating room for debridement to ensure removal of any dead
or infected tissue.
At this time, you have elected to be transferred to a hospice
facility. You ongoing care will be under the direction of the
hospice team.
Followup Instructions:
___
|
10040056-DS-13 | 10,040,056 | 27,850,323 | DS | 13 | 2145-07-24 00:00:00 | 2145-07-24 18:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with hx of htn, PE here with abd pain.
Pt reports that ___ days ago he began to have a burning in the
epigastric area. Over time, it increased to a "fire" with
radiation to the back. He has also been having nausea and
vomiting, has not been eating due to vomiting. He has had a few
cold sweats, but no known fevers. He does not think that
eating/drinking was making the pain worse. He denies diarrhea,
hx of gallstones. He states that he usually drinks a "few
gallons" of water a day because he likes to be always drinking
something. He reports taking "anticoagulant" for PE for 90 days.
He states that he hasn't taken his BP medications this week due
to feeling weak and the pain. He states that he is not
currently drinking alcohol, but sometimes does based on the
client he is working with. States that he used to drink much
more, but is not clear about how much.
10 systems reviewed and are otherwise negative.
Past Medical History:
longstanding HTN
--states that he has multiple medications for it, but cannot tel
me what they are, thinks that he goes to ___, but not sure
--in atrius records I do not see refill of norvasc, meto,
lisinpril recently
DVT/PE ___ thinks that it was from going back and forth from
___ and ___
depression/anxiety-states no longer on zoloft, not taking
gabapentin
Social History:
___
Family History:
sister with ___
htn in family
Physical Exam:
Admission physical exam:
Afeb, ___ 97%RA
Cons: NAD, lying in bed
Eyes: EOMI, no scleral icterus
ENT: MMM
Cardiovasc: rrr, no murmur, no edema
Resp: CTA B
GI: +bs,soft, nd, +epigastric and RUQ ttp
MSK: no significant kyphosis
Skin: no rashes
Neuro: no facial droop
Psych: blunted affect
Discharge physical exam
tmax 99.2 167/100 97 18 100%RA
Cons: NAD, lying in bed
Eyes: EOMI, no scleral icterus
ENT: MMM
Cardiovasc: rrr, no murmur, no edema
Resp: CTA B
GI: +bs,soft, nt, nd
MSK: no significant kyphosis
Skin: no rashes
Neuro: no facial droop
Psych: blunted affect
Pertinent Results:
___ 10:26PM LACTATE-2.5*
___ 10:20PM GLUCOSE-285* UREA N-10 CREAT-1.1 SODIUM-128*
POTASSIUM-3.4 CHLORIDE-83* TOTAL CO2-19* ANION GAP-29*
___ 10:20PM ALT(SGPT)-49* AST(SGOT)-62* ALK PHOS-92 TOT
BILI-1.0
___ 10:20PM LIPASE-1342*
___ 10:20PM ALBUMIN-4.5
___ 10:20PM WBC-17.7* RBC-4.66 HGB-12.1* HCT-36.4*
MCV-78* MCH-26.0* MCHC-33.2 RDW-16.6*
___ 10:20PM PLT COUNT-319
US RUQ:
1. Sludge in the gallbladder, without evidence of
cholelithiasis or cholecystitis.
2. Common bile duct measures 8 mm. Pancreatic duct is not seen.
3. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant fibrosis/cirrhosis cannot be
excluded on this study.
___ MRCP -- IMPRESSION: 1. Acute necrotizing pancreatitis
confined to the tail. No organized fluid collections. 2. Mild
intrahepatic bile duct prominence, and 9 mm CBD, without
evidence of stone or obstructing mass. 3. Gallbladder filled
with sludge. No MR evidence for acute cholecystitis. 4. Severe
hepatic steatosis.
Brief Hospital Course:
___ man w/PMHx poorly controlled HTN admitted with
pancreatitis, possibly due to biliary pathology (e.g. GB
sludge). Stable w/conservative therapy, gradually improving.
DETAILS BY PROBLEMS
Pancreatitis of unclear etiology with tachycardia, leukocytosis
- given the patient's labs and imaging, the ERCP team felt there
was no need for ERCP but they do recommend elective
cholecystectomy as an outpt -- will ask his PCP to refer him
when he has insurance again
- has a h/o of sig EtOH in the past, but denies recent --
steatosis is concerning, lipids unremark, viral hepatitis
studies neg
- pain control done with PO hydromorphone, pt will back down on
the medication in the upcoming few days as an outpatient.
Poorly controlled HTN, improved overall, suspect some elevation
still due to pain
- continue amlodipine, lisinopril, metoprolol
- advised the pt that his BP is not yet at goal, but as he has
not been on HTN medications since this ___ his baseline is
likely even higher. OK to d/c to home and will have continued
outpt BP medication titration.
Microcytic anemia, stable
- suspect ___ acute inflammation and hospital phlebotomy
- markedly elevated ferritin suspected ___ inflammation but
could be a sign of liver disease, may require more workup
- don't suspect iron or B12 deficiency
- can f/u as outpt about this
Active smoking
- recommend stopping smoking
Proteinuria, urine protein/Cr ratio 0.5
- suspect related to HTN
- plan further w/u as outpt PRN
Hyperglycemic to 200s here but hemoglobin A1c normal -- sugars
improved.
- suspect ___ inflammation of pancreatitis
- SSI for now -- hasn't need much and won't need to leave on
insulin
History of non-adherence
- hospitalized recently for hypertensive urgency/emergency
having seemingly not filled meds since ___ (according to
a ___ where he'd been before)
- needs more investigation
Depression/anxiety
- no longer on sertraline or gabapentin
Insurance issues
- spoke with SW and CM about this -- financial counseling spoke
with him -- insurance ends on ___
Transitional issues: noted above
OTHER INACTIVE PMHx
History of DVT/PE ___ -- per pt he thinks that it was from
going back and forth from ___ to ___ -- was tx'd
for 90 days with an anticoagulant
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q4H:PRN Pain
2. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily 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 as
needed for constipation Disp #*60 Capsule Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 3
hours as needed for pain Disp #*20 Tablet Refills:*0
5. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day as
needed for constipation Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pancreatitis of unclear etiology (possible due to
gallstones, sludge)
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for pancreatitis (inflammation of your
pancreas) that was of unclear cause. You were treated with IV
fluids and your pain improved. You underwent a MRI of your
liver and gallbladder which showed some fat in the liver
(steatosis) -- it's possible this is due to alcohol and we
recommend you cut down on alcohol. You were restarted on your
blood pressure medications and need to follow closely with your
primary care doctor. We also recommend you talk with your
doctor about having your gallbladder removed in case gallstones
or gallbladder sludge were the cause of your pancreatitis.
We also noted that there is protein in the urine. this is not
normal and needs to be checked again by your primary care
doctor. It may be that your kidneys are being damaged by high
blood pressure.
Followup Instructions:
___
|
10040149-DS-13 | 10,040,149 | 21,810,717 | DS | 13 | 2181-09-23 00:00:00 | 2181-10-06 10:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
aspirin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female history of hypertension, cholecystectomy,
hernia repair, hysterectomy, nephrectomy, transferred from
___ for bowel obstruction
seen on CT scan. Patient has had a day of diffuse abdominal
pain vomiting and diarrhea. No similar symptoms in past. No
fever, chest pain, shortness of breath, cough.
Past Medical History:
PMH:
Hypertension
UTI
Hypothyroidism
CAD
Pyelonephritis
AAA
PSH:
CABG
Cholecystectomy
Hernia repair
Hysterectomy
L nephrectomy
EVAR
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Physical Examination
Temp: 97.4 HR: 58 BP: 112/67 Resp: 20 O2 Sat: 94 Low
Constitutional: Elderly woman seated in bed, awake and alert,
speaking in full sentences, in no
acute distress
Head / Eyes: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular
muscles intact
ENT / Neck: Moist mucous membranes. NG tube in place.
Chest/Resp: Breathing comfortably on room air, speaking full
sentences. Mild scattered
rhonchi on auscultation without wheezes or crackles.
Cardiovascular: Regular Rate and Rhythm
GI / Abdominal: Soft, mildly distended, mild TTP throughout,
worst on left side of abdomen.
GU/Flank: No costovertebral angle tenderness
Musc/Extr/Back: No peripheral edema. No midline spinal TTP.
Skin: Warm and dry
Neuro: Speech fluent. PERRL. EOMI. Facial movements symmetric.
Moving all
extremities
Discharge Physical Exam:
VS: 97.5, 156/92, 55, 18, 94 Ra
Gen: A&O, intermittently confused
Pulm: LS w/ faint expiratory wheeze
CV: HRR
Abd: softly distended. mildly TTP over left side of abdomen (has
chronic pain here from ? hernia)
Ext: WWP . no edema
Pertinent Results:
___ 06:40AM BLOOD WBC-5.5 RBC-4.60 Hgb-12.6 Hct-40.4 MCV-88
MCH-27.4 MCHC-31.2* RDW-16.7* RDWSD-53.1* Plt ___
___ 06:58AM BLOOD WBC-4.0 RBC-4.39 Hgb-11.9 Hct-38.6 MCV-88
MCH-27.1 MCHC-30.8* RDW-16.2* RDWSD-51.8* Plt ___
___ 06:11AM BLOOD WBC-6.0 RBC-4.24 Hgb-11.4 Hct-37.7 MCV-89
MCH-26.9 MCHC-30.2* RDW-16.0* RDWSD-52.4* Plt ___
___ 08:45AM BLOOD WBC-4.8 RBC-4.30 Hgb-11.7 Hct-38.8 MCV-90
MCH-27.2 MCHC-30.2* RDW-16.2* RDWSD-53.7* Plt ___
___ 07:18AM BLOOD WBC-6.9 RBC-4.22 Hgb-11.4 Hct-37.5 MCV-89
MCH-27.0 MCHC-30.4* RDW-16.3* RDWSD-53.2* Plt ___
___ 05:25PM BLOOD WBC-6.2 RBC-4.35 Hgb-11.8 Hct-38.3 MCV-88
MCH-27.1 MCHC-30.8* RDW-16.3* RDWSD-52.7* Plt ___
___ 11:46AM BLOOD WBC-5.8 RBC-3.56* Hgb-9.6* Hct-32.5*
MCV-91 MCH-27.0 MCHC-29.5* RDW-16.5* RDWSD-55.5* Plt ___
___ 06:40AM BLOOD Glucose-86 UreaN-15 Creat-1.0 Na-140
K-4.9 Cl-102 HCO3-29 AnGap-9*
___ 06:58AM BLOOD Glucose-79 UreaN-13 Creat-1.3* Na-140
K-4.8 Cl-101 HCO3-29 AnGap-10
___ 06:11AM BLOOD Glucose-106* UreaN-9 Creat-0.8 Na-140
K-3.9 Cl-104 HCO3-26 AnGap-10
___ 08:45AM BLOOD Glucose-98 UreaN-10 Creat-1.0 Na-143
K-4.2 Cl-106 HCO3-25 AnGap-12
___ 07:18AM BLOOD Glucose-91 UreaN-12 Creat-0.9 Na-143
K-3.5 Cl-106 HCO3-28 AnGap-9*
___ 06:40AM BLOOD Calcium-8.8 Phos-2.4* Mg-2.0
___ 06:58AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.0
___ 06:11AM BLOOD Calcium-8.0* Phos-2.4* Mg-2.1
Imaging: OSH CT abdomen pelvis without contrast -
1. Distention of the stomach proximal and mid small bowel to the
level of a lumbar abdominal wall hernia above the left iliac
crest.
2. Status post endograft stenting of the infrarenal abdominal
aorta and common iliac arteries
___ ECG - Baseline artifact but probable sinus bradycardia with
atrio-ventricular conduction delay. Inferior infarction of
indeterminate age. Intraventricular conduction delay. Delayed R
wave transition. Non-specific ST segment changes. Left
ventricular hypertrophy. Compared to the previous tracing of
___ the overall findings are similar.
___ Abdomen - 1. Mild pulmonary edema. 2. Oral contrast has
progressed to the level of the proximal transverse colon
excluding obstruction. There remains mild distension of the
small and large bowel loops suggesting ileus.
Brief Hospital Course:
___ with history of hypertension, prior UTI, hypothyroidism,
cholecystectomy, hernia
repair, hysterectomy, and left nephrectomy, who presents as a
transfer from ___ with concern
for small bowel obstruction and incidental finding of UTI. The
patient was admitted for bowel rest, IV fluids, and close
monitoring of her abdominal exam. She was hemodynamically
stable. She was given antibiotics for the UTI. Nasogastric tube
was inserted for stomach decompression. Oral contrast was given
via the NGT. Eight hours after contrast had been given, an
abdominal x-ray showed that oral contrast has progressed to the
level of the proximal transverse colon, excluding obstruction.
On HD2, the NGT was removed.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay. Because the patient
was elderly and deconditioned, ___ evaluated the patient to
determine the safest disposition. They recommended she be
discharged to rehab. The patient was refusing rehab and
currently lived with one of her sons who she stated provided
assistance with her care.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with a walker, voiding without assistance,
having bowel movements, and denied pain. The patient was
discharged home with services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
Levothyroxine Sodium 75 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Levothyroxine Sodium 75 mcg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Small bowel obstruction
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 and were
found on CT scan to have a small bowel obstruction. You were
managed non-operatively with a nasogastric tube for stomach
decompression, bowel rest, IV fluids, and close monitoring of
your abdominal exam. Once your obstruction resolved, your diet
was advanced and you are now tolerating regular food and having
bowel movements. You are ready for discharge home to continue
your recovery. Please note the following:
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
Followup Instructions:
___
|
10040284-DS-5 | 10,040,284 | 26,059,791 | DS | 5 | 2144-01-23 00:00:00 | 2144-01-23 16:22:00 |
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, foreign body ingestion
Major Surgical or Invasive Procedure:
___: EGD with removal of foreign objects (magnets) and
clipping/injection of gastric ulcerations
History of Present Illness:
___ w PMH Schizophrenia, depression, PTSD and prior suicide
attempts, presenting with abdominal pain following magnet
ingestion. Pt recently discharged from ___ after presenting
on ___ with ingestion of 4 magnets.
The ingestion on ___ was with intent for self harm, so she was
admitted to the psychiatric unit, started on SSRI and mood
stabilizer and discharged on ___.
She presents to ___ today after reportedly swallowing three
magnets on ___. Says they were cylindrical, strong magnets
taken from an office where she works in ___. She developed
LUQ abdominal pain so she came to the ED.
Patient reports swallowing magnets so as to come to the
hospital and avoid her family, in a desire to save her family.
She states that she heard voices telling her to hurt her family
members, so she decided to swallow the magnets, in an attempt
for help from the medical community. Denies SI or HI; endorses
continued auditory hallucinations. She does not wish that her
family know about this.
Magnets were small, approx. 1x1cm; she swallowed them
separately with 30 minute interval between them. Reports
retrosternal pain initially after swallowing magnets. Today has
developed epigastric and LLQ pain, worse with movement. No
n/v/d. No bloody stool or melena
In the ED, initial vitals: 98.0 69 120/56 18 100% RA.
Physical exam significant for disorganized thought process
epigastric and LLQ pain with involuntary guarding, no rebound
tenderness.
- Labs were significant for normal CBC, BMP, urine toxicology.
UA + large blood, trace protein, trace ketones, 2 epithelial
cells.
- CXR significant for three connected oblong structures
projecting over the expected area of stomach.
- She received 2mg morphine and 1L NS.
- She was taking emergently for EGD for attempted magnetic
removal.
Upon arrival to the floor, she endorsed sore throat and mild
epigastric pain.
Past Medical History:
- PTSD
- Depression
- Dissociative Disorder
- Schizophrenia
- Multiple prior suicide attempts: clonazepam ingestion, magnet
ingestion
Social History:
___
Family History:
+ schizophrenia, alcoholism - father
Physical ___:
ADMISSION PHYSICAL:
=====================
VS: T 98.1, BP 102/47, HR 68, R 18, SpO2 100%/RA 68.6 kg
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Clear bilaterally without wheeze or rhonchi
COR: RRR (+)S1/S2 with faint grade I systolic murmur at
bilateral upper sternal borders
ABD: Soft, non-distended, mild TTP over epigastrium, normal
bowel sounds
EXTREM: Warm, well-perfused, no edema
NEURO: face symmetric, moving all extremities well
PSYCH: appropriate, denies SI, HI, AH, VH
DISCHARGE PHYSICAL:
===================
VITALS: 98 107/42 74 16 99% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated
RESP: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABD: +BS, soft, nondistended, ttp in LUQ without rebound
GU: no foley
EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
===================
___ 03:01PM BLOOD WBC-5.4 RBC-3.82* Hgb-11.6 Hct-34.4
MCV-90 MCH-30.4 MCHC-33.7 RDW-11.9 RDWSD-38.4 Plt ___
___ 03:01PM BLOOD Neuts-56.1 ___ Monos-4.8*
Eos-0.4* Baso-0.7 Im ___ AbsNeut-3.04 AbsLymp-2.05
AbsMono-0.26 AbsEos-0.02* AbsBaso-0.04
___ 03:01PM BLOOD Glucose-90 UreaN-6 Creat-0.6 Na-137 K-3.5
Cl-101 HCO3-27 AnGap-13
DISCHARGE LABS:
=================
___ 07:35AM BLOOD WBC-4.6 RBC-3.68* Hgb-11.1* Hct-33.8*
MCV-92 MCH-30.2 MCHC-32.8 RDW-11.9 RDWSD-39.7 Plt ___
IMAGING:
=============
CXR ___
No acute cardiopulmonary process. Three connected oblong
structures are seen projecting over the expected area of the
stomach, likely representing ingested magnets.
KUB ___
IMPRESSION:
3 cylindrical radiopaque densities vertically aligned end-to-end
with each other likely reflective of ingested magnets in the
left upper quadrant abdomen, possibly within the stomach. No
free intraperitoneal gas.
EGD ___:
Foreign body in the stomach (foreign body removal)
Ulcers in the stomach (injection, endoclip)
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ w PMH depression, ? schizophrenia, PTSD and prior suicide
attempts, presenting with abdominal pain following magnet
ingestion.
# Magnet ingestion: Presented with abdominal pain following
ingestion of 3 magnets which were seen on CXR and KUB. GI was
consulted and patient underwent EGD on ___ with removal of
magnets. Per patient, was not suicide attempt but rather was
trying to get away from her family. While she has a history of
prior episodes of magnet ingestion, psychiatric evaluation was
unrevealing for true SI/HI and her attempt was felt to be
related to an attempt to deal with ego dystonic thoughts related
towards her anger towards her family. As such, she did not meet
___ criteria and the patient was felt to need assistance
with housing outside of her current living situation. She was
maintained on a 1:1 sitter prior to discharge to avoid further
ingestions. Her abdominal pain was improved prior to discharge.
Patient was discharged with cab voucher to take her to ___
___ and was provided with clothes, a new cell phone,
outpatient psych resources and T passes prior to discharge.
# Gastric ulcers: Likely related to ingestion of magnets with
pinching of gastric lining s/p clipping and epi injection.
Patient was treated with 24 hours of IV pantoprazole BID and
then transitioned to PO pantoprazole prior to discharge. Her
diet was advanced to regular.
# Anemia: Normocytic anemia in young female. Could be due to
menstrual blood loss vs bleeding from gastric ulcers depending
on duration (ie caused by prior magnet ingestion). Stable during
this admission. Will require further work-up as outpatient if
persists.
# Depression: Patient with a history of ? schizophrenia,
depression, and recent admission at ___ following intentional
magnetic ingestion, representing with the same. As above, does
not appear to be true voices suggesting psychosis but rather her
own voice related to her anger at her current living situation.
She had no active SI/HI and given that presentation was not felt
to be true suicide attempt, she did not meet criteria for
___. She was started on aripiprazole (previously taking)
per psychiatry recommendation and continued on home fluoxetine,
trazodone and clonazepam. She had outpatient psychiatry
___ scheduled for ___ ___s access to the ___
women's program and was provided with the number for BEST on
discharge.
TRANSITIONAL ISSUES:
======================
[ ]Patient will benefit from ongoing psychiatric evaluation for
depression and medication management
[ ]Please have patient continue on BID PPI for at least one
month (through ___
[ ]Please repeat Hemoglobin and hematocrit at PCP ___ on
___. If persistent anemia, consider further work-up for
unexplained anemia
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. TraZODone 50 mg PO QHS
2. Fluoxetine 30 mg PO DAILY
3. ClonazePAM 1 mg PO BID:PRN anxiety
Discharge Medications:
1. ClonazePAM 1 mg PO BID:PRN anxiety
RX *clonazepam 1 mg 1 tablet by mouth twice a day Disp #*6
Tablet Refills:*0
2. Fluoxetine 30 mg PO DAILY
RX *fluoxetine 10 mg 3 tablets by mouth daily Disp #*45 Tablet
Refills:*0
3. TraZODone 50 mg PO QHS
RX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*15
Tablet Refills:*0
4. ARIPiprazole 10 mg PO DAILY
RX *aripiprazole 10 mg 1 tablet(s) by mouth Daily Disp #*15
Tablet Refills:*0
5. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet by mouth twice a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Foreign body (magnet) Ingestion
Gastric Ulcers
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital after swallowing several
magnets. You underwent a procedure called an endoscopy to remove
the magnets. The endoscopy showed several ulcerations (cuts)
from the magnets which were repaired. You were started on a new
medication called pantoprazole to help your stomach heal. It is
important that you take this medication as prescribed.
You were seen by psychiatry in the hospital who felt that you
were safe for discharge as you were not having thoughts of
hurting yourself or others. You were restarted on abilify and
continued on your other psychiatric medications. It is very
important that you ___ with your psychiatrist as scheduled
on ___ (see below). Additionally, please call
the partial hospital program for women at ___ HRI at
___ to set up an intake appointment.
Finally, you were seen by social work who helped to provide you
with resources for when you leave the hospital. If you find that
you need additional assistance when you leave the hospital, you
have several options:
1. ___ CSA in ___ for care coordination at
___.
2. ___ Emergency Services Team (BEST) for emergency mental
health concerns at ___
We wish you the best in your recovery.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
10040602-DS-17 | 10,040,602 | 25,984,377 | DS | 17 | 2189-06-17 00:00:00 | 2189-06-17 23:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with H/O cardiomyopathy (LVEF 30%), lung cancer s/p right
upper lobectomy, hypertension, and hyperlipidemia presented with
chest pain.
Patient reports acute onset of chest pain that woke him up from
sleep the morning of presentation at about 3A. He described the
pain as sharp and worse with inspiration. It had been constant
throughout the course of the day and notably not worse with
exertion. Pain was mainly across the ___ his chest, but he
also has the sensation that it was "traveling down my esophagus
and across the top of my back." There was no radiation down the
arm or to the jaw. He reported some limitation in his ability to
take a deep breath due to pain but no shortness of breath per
se. He denied palpitations or diaphoresis. Patient has never had
pain like this before. There was no significant improvement in
pain by leaning forward. He denied any recent URI. He did
recently travel to a resort in the ___. He denied
fevers, chills, abdominal pain, nausea, vomiting, diarrhea, or
urinary symptoms.
In the ED, initial vitals: HR 47 BP 112/54 RR 20 SaO2 99% on RA.
EKG showed new inferior T waver inversions. Labs/studies notable
for Hgb/Hct 12.7/38.0, WBC 9.3, plt 185, Na 140, K 4.5, BUN 36,
Cr 1.8, Troponin-T negative x2, NT-pro-BNP 970. D-Dimer 1108.
CXR showed that the heart size and mediastinum were stable with
unchanged vascular enlargement in the hila, but no evidence of
acute exacerbation of congestive heart failure. CTA showed no
evidence of pulmonary embolism or acute aortic abnormality, no
acute etiology identified for pleuritic chest pain, no focal
consolidation concerning for underlying infection. There was
enlargement of the pulmonary arterial system, consistent with
pulmonary arterial hypertension. There was an unchanged soft
tissue mass in the prevascular mediastinum, which has been
slowly growing since ___ and appears stable since ___, probably an encapsulated thymoma. Thickening the
mediastinal esophagus was unchanged compared ___ and
may be sequela of chronic esophageal inflammation. Patient was
given Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO, Donnatal
10 mL PO, Lidocaine Viscous 2% 10 mL PO, famotidine 20 mg IV,
Nitroglycerin infusion starting at 0.35 mcg/kg/min.
After arrival to the cardiology ward, the patient reported
persistent, pleuritic chest pain. He said the nitroglycerin gtt
might be helping marginally. He had been resting comfortably in
bed prior to being woken up to give the above history.
Past Medical History:
1. CAD RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
-Dilated cardiomyopathy attributed to PVC burden
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
-Lung cancer s/p lobectomy (no chemo/XRT)
-Nephrolithiasis
-Colonic polyps
-High-grade prostatic intraepithelial neoplasia
-Neuropathy
Social History:
___
Family History:
Mother with rheumatic heart disease, father with diabetes and
required open heart surgery.
Physical Exam:
On admission
GENERAL: Pleasant elderly white man in NAD
VS: T 98 BP 112/66 HR 65 RR 20 SaO2 99% on RA
HEENT: NCAT, mucous membranes moist
CV: RRR; no murmurs, rubs or gallops
PULM: CTAB
GI: Soft, non-tender, not distended, BS+
EXTREMITIES: warm and well perfused; no clubbing, cyanosis or
edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
At discharge
GENERAL: Pleasant elderly man in NAD
VS: 24 HR Data (last updated ___ @ ___ Temp: 98.3 (Tm
99.5), BP: 99/62 (99-145/62-83), HR: 48 (48-58), RR: 20 (___),
O2 sat: 96% (94-98), O2 delivery: RA
HEENT: NCAT, mucous membranes moist
CV: RRR; no murmurs, rubs or gallops
PULM: CTAB
GI: Soft, non-tender, not distended, BS+
EXTREMITIES: warm and well perfused; no clubbing, cyanosis or
edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
Pertinent Results:
___ 10:56AM BLOOD WBC-9.3 RBC-4.01* Hgb-12.7* Hct-38.0*
MCV-95 MCH-31.7 MCHC-33.4 RDW-12.9 RDWSD-44.4 Plt ___
___ 10:56AM BLOOD Neuts-74.1* Lymphs-12.9* Monos-11.6
Eos-0.9* Baso-0.3 Im ___ AbsNeut-6.88* AbsLymp-1.20
AbsMono-1.08* AbsEos-0.08 AbsBaso-0.03
___ 10:56AM BLOOD Glucose-111* UreaN-36* Creat-1.8* Na-140
K-4.5 Cl-100 HCO3-26 AnGap-14
___ 10:56AM BLOOD CRP-32.7*
___ 06:30AM BLOOD VitB12-691 Folate-19 Hapto-126
___ 10:56AM BLOOD proBNP-970*
___ 10:56AM BLOOD cTropnT-<0.01
___ 03:05PM BLOOD cTropnT-<0.01
___ 06:30AM BLOOD cTropnT-<0.01
DISCHARGE LABS
___ 05:50AM BLOOD WBC-5.5 RBC-3.83* Hgb-12.1* Hct-36.6*
MCV-96 MCH-31.6 MCHC-33.1 RDW-13.1 RDWSD-45.4 Plt ___
___ 05:50AM BLOOD Glucose-129* UreaN-23* Creat-1.5* Na-138
K-4.3 Cl-101 HCO3-25 AnGap-12
___ 05:50AM BLOOD Calcium-9.4 Phos-2.7 Mg-2.2
___ ECGs
ECG: stable anterior J point elevation, new inferior T wave
inversions, with subsequent widening of the QRS duration into a
not-quite-LBBB IVCD.
___ CXR
Heart size and mediastinum are stable in appearance. Vascular
enlargement in the hila is unchanged, with no evidence of acute
exacerbation of congestive heart failure on the radiograph.
Postsurgical changes in the right lung are stable. There is no
pleural effusion. There is no pneumothorax.
___ CTA Chest
HEART AND VASCULATURE: Pulmonary vasculature is well opacified
to the subsegmental level without filling defect to indicate a
pulmonary embolus. There is enlargement of the main, right main,
and left main pulmonary arteries, measuring up to 3.8, 3.1, and
2.8 cm, respectively. These findings are likely suggestive of
pulmonary arterial hypertension. 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.
AXILLA, HILA, AND MEDIASTINUM: Mediastinal esophagus appears
thickened throughout its course (series 2; image 21), similar
compared to prior and suggestive of underlying chronic
esophageal inflammation. Again seen in the mediastinum, along
the superior aspect of the left ventricle, adjacent to the main
pulmonary artery, there is a lobulated, homogeneous 3.4 x 2.2 cm
soft tissue density, which previously measured 3.5 x 2.0 cm.
This mass is been slowly growing since ___ and likely represent
an encapsulated thymoma. It appears to now abut the myocardium
over a couple of cm. There is no axillary lymphadenopathy. There
are prominent subcarinal and right hilar lymph nodes, which are
nonspecific.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Changes seen after right upper lobectomy. There
is bibasilar atelectasis, right greater than left, without focal
consolidation concerning for infection. Incidentally noted is an
azygos lobe. 4 mm nodule in the right upper lobe (series 3;
image 84) is unchanged compared to ___ and now stable
for 32 months. No additional concerning nodules are identified.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no
acute fracture.
IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic
abnormality. No acute etiology identified for pleuritic chest
pain. No focal consolidation concerning for underlying
infection. 2. Enlargement of the pulmonary arterial system,
consistent with pulmonary arterial hypertension. 3. Unchanged
soft tissue mass in the prevascular mediastinum, which has been
slowly growing since ___ and appears stable since ___. This is probably an encapsulated thymoma. 4. Thickening
the mediastinal esophagus is unchanged compared ___
and may be sequela of chronic esophageal inflammation. EGD could
be pursued on a nonurgent basis if clinically indicated.
___ Echocardiogram
The left atrial volume index is normal. There is normal left
ventricular wall thickness with a normal cavity size. There is
mild-moderate global left ventricular hypokinesis. The visually
estimated left ventricular ejection fraction is 35%. There is no
resting left ventricular outflow tract gradient. Normal right
ventricular cavity size with normal free wall motion. The aortic
sinus diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets appear structurally normal with no mitral
valve prolapse. There is mild [1+] mitral regurgitation. The
tricuspid valve leaflets appear structurally normal. There is
physiologic tricuspid regurgitation. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior TTE (images not available for review) of
___, the estimated PA systolic pressure is now increased.
Brief Hospital Course:
___ with H/O cardiomyopathy (LVEF 30%), lung cancer s/p right
upper lobectomy, hypertension, and hyperlipidemia presented with
chest pain. He had negative troponin-T x3. He was also found to
have esophagitis, with chest pain improved with initiation of
PPI and Aluminum-Magnesium Hydrox-Simethicone.
ACUTE ISSUES:
# Chest pain, esophagitis: Patient was admitted with acute onset
chest pain described as burning around esophagus, radiating
across shoulders and to lesser degree across chest, not classic
for ACS. ECG initially with some inferoapical T wave inversion
(non-specific) though no other changes suggestive of acute
ischemia, but troponin-T and CK-MB negative x3. Initial
treatment with nitroglycerin gtt without obvious improvement in
pain. CTA also negative after patient noted to recently have
been on relatively long plane flight and with elevated D-Dimer.
Patient reported no symptoms during recent trip to ___
___ but a lot of stress during the flight home. Most likely
etiologies of chest pain felt to be esophagitis (given thickened
mediastinal esophagus on CTA) vs pericarditis with elevated CRP.
Significant relief of chest pain with empiric treatment of
esophagitis with GI cocktail and pantoprazole, therefore
treatment of pericarditis not initiated. At time of discharge,
chest pain was almost completely gone, and patient only reported
faint sensation of burning around esophagus.
# Non-conducted P waves, bradycardia. ___ telemetry pause
with non-conducted P waves (2.5 sec longer QRS-free interval
than expected if single non-conducted PAC with apparent AV block
after a likely P wave vs artifact--failure of ventricular escape
and/or AV block). Patient does not recall what he was doing at
the time. Pause and tracing reviewed with several
electrophysiologists. As sinus node dysfunction isolated and
asymptomatic, no further intervention was felt warranted at
present. Patient mentioned that Dr. ___ mentioned
possibility of ICD (presumably primary prevention). Patient
discharged with outpatient EP F/U with Dr. ___. We
decreased home metoprolol succinate dose given occasional
bradycardia (HR ___.
# Dilated cardiomyopathy: LVEF 30% in ___ -> 44% on CMR in
___, presumed to be secondary to VEA burden. Per recent
cardiology note, "Initially started on metoprolol and lisinopril
with reduction in PVC burden to 15% and subsequently was
initiated on amiodarone therapy in ___ with most recent
Holter on ___ showing reduction VPC burden to 8% with
multiple morphologies." Continued home amiodarone. Decreased
dose of metoprolol, as above.
CHRONIC ISSUES:
# CKD stage 3 with ___: Cr on admission 1.8 (baseline 1.3-1.8)
downtrended to 1.5 this admission.
# Hypertension: Continued home hydralazine (once daily dosing
confirmed by patient), HCTZ, metoprolol.
# Hyperlipidemia: Continued home statin.
# Lung CA s/p right upper lobectomy (no chemo/XRT): Surveillance
imaging as outpatient.
# Primary prevention against CAD: Continued home aspirin,
statin, metoprolol.
TRANSITIONAL ISSUES:
====================
[ ] Follow up resolution of chest pain with GI cocktail and
pantoprazole.
[ ] Further workup of esophagitis, would recommend endoscopy
with Dr. ___.
[ ] Follow up of non-conducted P waves in clinic with Dr.
___ ICD for primary prevention.
[ ] He was noted to have left leg calf pain which is suspicious
for claudication and PAD, would recommend an outpatient ABI and
vascular medicine follow up to assess this.
[ ] Consider ETT-MIBI or R-MIBI (develops claudication after
walking 0.5 miles slowly, but useful to assess functional
capacity) if symptoms not improve with aggressive GI regimen.
[ ] Follow up of likely thymoma noted on CTA.
- New Meds: GI cocktail QID, pantoprazole 40 mg daily
- Stopped/Held Meds: None
- Changed Meds: Metoprolol succinate XL 50 mg -> 25 mg daily
- Follow-up appointments: PCP appointment with Dr. ___
appointment with Dr. ___ follow up with Dr.
___.
- Post-Discharge Follow-up Labs Needed: None
- Incidental Findings: Thymoma, left leg claudication
- Discharge weight: 94.8kg
- Discharge creatinine: 1.5
# CODE: full (presumed)
# CONTACT: ___ (wife) - ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Gabapentin 100 mg PO BID
3. HydrALAZINE 25 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Simvastatin 10 mg PO QPM
7. Aspirin 81 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
10. Multivitamin 50 Plus (multivitamin-minerals-lutein) oral
DAILY
11. selenium 200 mcg oral DAILY
12. Florastor (Saccharomyces boulardii) 250 mg oral DAILY
Discharge Medications:
1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID
RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL ___ mL
by mouth four times a day Disp #*1680 Milliliter Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 20 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
3. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*60 Tablet Refills:*0
4. Amiodarone 200 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Florastor (Saccharomyces boulardii) 250 mg oral DAILY
8. Gabapentin 100 mg PO BID
9. HydrALAZINE 25 mg PO DAILY
10. Hydrochlorothiazide 12.5 mg PO DAILY
11. Multivitamin 50 Plus (multivitamin-minerals-lutein) oral
DAILY
12. selenium 200 mcg oral DAILY
13. Simvastatin 10 mg PO QPM
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Chest pain
# Esophagitis
# Dilated cardiomyopathy/chronic left ventricular systolic heart
failure
# Non-conducted P waves consistent with asymptomatic sinus node
dysfunction
# Bradycardia
# Acute kidney injury on
# Chronic kidney disease, stage 3
# Normocytic anemia
# Left calf claudication consistent with peripheral arterial
disease
# Hypertension
# Hyperlipidemia
# Mediastinal mass
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 ___.
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because of chest pain.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were admitted to the hospital because you had chest pain.
- Lab tests of your blood found that your cardiac enzymes were
normal (not elevated), and you had electrocardiograms (EKGs)
that did not show a heart attack.
- You had an imaging test called a CT angiogram of your chest.
There was no sign of a blood clot in your lung (pulmonary
embolus) and no signs of aortic dissection. However, the CT
angiogram showed a mass in the mediastinum that is likely a
thymoma that should be followed up as an outpatient.
- The CTA showed thickening of your esophagus that could be a
sign of esophagitis (inflammation of the esophagus), which was
likely causing your chest pain.
- You were treated with a GI cocktail medication and a proton
pump inhibitor that helps to reduce acid in the stomach, and
your pain improved.
- You were noted to have slow heart rates and a pause on cardiac
telemetry monitoring. You should see your cardiologist Dr.
___ in clinic for follow up.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Continue to take the GI cocktail and proton pump inhibitor.
- Follow up with your gastroenterology doctor. We recommend
getting an endoscopy to look at your esophagus.
- You should get a test called an ankle-brachial index (ABI) as
an outpatient to work up your left calf tightness.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10040721-DS-2 | 10,040,721 | 27,632,777 | DS | 2 | 2176-04-13 00:00:00 | 2176-04-19 11:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Amoxicillin
Attending: ___
Chief Complaint:
Trauma: motor vehicle collusion
Major Surgical or Invasive Procedure:
___: s/p bilateral incision and drainage, arthrotomy,
wound closure
History of Present Illness:
Ms. ___ is a ___ year old female with MVC vs pole. Patient
brought in by medflight from scene. S/P car vs pole. Unknown of
she was restrained or not. Found next to her car. Significant
damage to vehicle. Steering wheel broken. As per medflight
report initially unconscious. Regained consciousness but became
agitated. Intubated by ALS prior to medflight arrival. Has
multiple abrasions on extremities.
Past Medical History:
PMH: Obesity
PSH: Gastric Bypass ___
Social History:
___
Family History:
NC
Physical Exam:
Admission Physical Exam:
Constitutional: intubated and sedated
HEENT: Pupils equal, round and reactive to light,
Normocephalic, atraumatic, Extraocular muscles intact
C collar in place
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
GU/Flank: no crepitus or stepoff
Extremities:
RUE/LUE with multiple superficial abrasions about elbows and
ecchymosis about R humeral shaft. No palpable step-offs or
crepitus is felt. No gross deformity. Able to range wrist,
elbow and shoulder without resistance.
LLE with 5cm laceration about lateral aspect of knee,
penetrating
deeply. Visible patellar tendon. Bleeding controlled. No
gross
crepitus about knee. Thigh compartment soft. Calf compartment
soft. Unable to assess neuro exam ___ intubated. palpable
dp/pt
pulses.
RLE with 7cm laceration about lateral aspect of knee,
penetrating
deeply. Visible muscle and tendons. Bleeding controlled. No
gross fracture or anatomic abnormality. R medial calf wound
approximately 2cm in length, with exposed fat. No gross
crepitus
or instability about tibia. Ankle range of motion without
resistance. unable to assess neuro exam ___ intubated.
palpable
dp/pt pulses.
Neuro: moving all extremities, intubated and sedated
Psych: as above
___: No petechiae
Physical examination upon discharge: ___:
Vital signs: t=97.5, hr=84, rr=20, bp=140/78, 97% room air
General: Tired appearing, ambulating with walker
CV: Ns1, s2, -s3, -s4
LUNGS: Clear
ABDOMEN: soft, non-tender
EXT: sutured laceration left knee, clean and dry, right knee
laceration mildly abraded with xeroform gauze and DSD, sutured
laceration right lower leg, ecchymosis right lower leg, mild
pedal edema bil.
NEURO: oriented x 3, speech clear, no tremors
Pertinent Results:
___ 06:15AM BLOOD WBC-5.8 RBC-3.35* Hgb-9.9* Hct-29.1*
MCV-87 MCH-29.7 MCHC-34.1 RDW-12.4 Plt ___
___ 12:00AM BLOOD Neuts-85.9* Lymphs-9.9* Monos-3.7 Eos-0.2
Baso-0.3
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-121* UreaN-5* Creat-0.4 Na-131*
K-3.9 Cl-96 HCO3-25 AnGap-14
___ 12:00AM BLOOD ALT-40 AST-82* AlkPhos-46 Amylase-25
TotBili-0.7
___ 12:00AM BLOOD Lipase-15
___ 06:15AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.9
___ 03:32AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:19PM BLOOD Lactate-1.9
Imaging:
CT ChestAbdomen/Pelvis:
IMPRESSION:
1. Suboptimal exam due to extensive streak artifact generated by
patient's
arms by her side. Within this limitation, no acute
intra-abdominal injury is
identified.
2. Small consolidations in the lung bases bilaterally, may
reflect
aspiration, atelectasis or infection in the appropriate setting.
Additionally, there are heterogeneous ground-glass opacities in
right upper
and middle lobes, which may reflect pulmonary contusions or
aspiration.
3. Large amount of fluid in the excluded portion of the stomach,
suggestive of
gastrogastric fistula.
4. Locule of gas seen just anterior to left pericardium, may
represent
extrapleural air.
Bilateral Tib/Fib Xrays
IMPRESSION:
1. No fracture or dislocation of knee joints. Extensive soft
tissue edema
and linear lucencies surrounding knee joints, likely correspond
to patient's
known lacerations.
2. Limited views of the ankles are suggestive of ankle
dislocation and/or
ligamentous injury. Dedicated ankle views may be obtained when
feasible.
Bilateral ___ CT:
CONCLUSION:
Overall, there is little evidence to suggest significant bony
trauma.
Extensive soft tissue trauma as described. Fragmentation in the
superolateral
left patella.
UGI SGL W/O KUB
FINDINGS: This exam was limited due to poor patient mobility
secondary to
pain. Limited AP and RPO projections were obtained. There is no
evidence of contrast extravasation after ingestion of
water-soluble Optiray contrast. There is no obstruction. This
study was not designed to evaluate for communication between the
alimentary tract and excluded stomach as was suggested on the
recent CT due to the large volume of fluid in the excluded
stomach.
IMPRESSION: No contrast leak
___: x-ray of right shoulder:
Possible nondisplaced fracture of the distal acromion given
history of trauma versus os acromiale. Limited assesment on
current radiographs. Correlate with direct palpation or CT for
definitive assesment.
Brief Hospital Course:
Patient presented to the emergency room via medflight after
being involved in a MVC. She was intubated at the scene for a
GCS of 3 and med-flighted here. Upon admission, she wa evaluated
by the acute care service. The patient was reportedly
intoxicated with a blood alcohol level of 261.
Upon admission, she underwent radiographic imaging and was
admitted to the intensive care unit for monitoring. Head and
c-spine x-rays were reported as normal. Extensive x-rays and
cat scans did not demonstrate any fractures or dislocations. She
was reported to have sustained billateral pulmonary contusions.
Her oxygen saturation was closely monitored. She was evaluated
by the Orthopedic service who washed out the lower extremity
lacerations and applied a wet to dry dressing. She was taken to
the operating room on HD #1 for a bilateral knee arthrotomy,
incision and drainage, and patella incision. Her operative
course was stable with a 50cc blood loss. She remained intubated
and returned to the intensive care unit for monitoring. She was
extubated shortly after and started on clear liquids. She
reported nausea with emesis after starting a diet. There was
concern for an anastomotic leak related to her history of
gastric bypass. An upper GI study was done which did not
demonstrate any extrasavation of contrast. Her nausea was
controlled with oral anti-emetics and slowly resolved. Patient
was transfered to the floor and evaluated by physcical therapy.
On HD #3, the patient reported right shoulder pain. Orthopedics
was consulted and an x-ray of the shoulder was done which showed
a possible non-displaced fracture of the distal acromion. A
sling was recommended for comfort and no surgical intervention
needed. Orthopedic reccomendations for full weight bearing
bilateral lower extremities with knee immobilizer to right knee.
Her vital signs have remained stable and she has been afebrile.
Her appetite was slowly improving and she was ambulating with
walker assistance. She has family support at home who will
provide her with assistance in ADL's. She is preparing for
discharge home with instructions to follow -up with orthopedics
and with the acute care service.
Medications on Admission:
1. OCP
2. MVI
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Ultram 50 mg Tablet Sig: One (1) Tablet PO four times a day.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Trauma: MVC:
bilateral knee lacerations
pulmonary contusion
R upper molar chipped
possible non-displaced fracture right distal acromion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the ___ General Surgery service after a
motor vehicle collision. You sustained bilateral lacerations to
your lower extremities witout evidence of fracture. Your
lacerations were closed and you were transfered to the floor for
general care, ___ evaluation and recovery. Orthopaedics also
evaluated you for your lower extremity injuries and will be
following you after discharge. You will be discharged with the
following instructions:
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 activity as tolerated per
physical therapy reccomendations and orthopaedic restrictions,
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.
As per previous instruction do not take NSAIDS given your
history of gastric bypass and continue any nutritional
supplements as instructed by your bariatric physican.
Followup Instructions:
___
|
10040884-DS-13 | 10,040,884 | 23,184,027 | DS | 13 | 2162-07-21 00:00:00 | 2162-07-23 02:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Cough, dyspnea, diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of metastatic melanoma (on Ipilimumab, last
dose 2 days ago) comes to the ED with cough and dyspnea on
ambulation. Patient had onset of symptoms after his infusion 2
days ago. Denies any fever, chills, chest pain or dyspnea at
rest. Endorses dyspnea with ambulation. Noted at clinic to have
ambulatory O2 sat drop to 87 %. In the ED: initial vitals: 97.6
63 99/53 18 99%. CXR: No acute process. Concern for PE, but
given renal insufficiency, CT not done. But likelihood very
high, D ___ ___, so heparin drip started in ED.
On the floor, patient endorses SOB on ambulation. Otherwise, no
fever, chills, nausea, vomiting. No palpitations. he reports
that for the last 2 days, he had loose Bms twice daily, which
has now resolved. No PMH of DVT or PE.
Past Medical History:
Past Medical History: Hypertension, hyperlipidemia, myocardial
infarction in ___ status post angioplasty, aortic stenosis. .
Past Surgical History: Status post appendectomy at age ___, two
TURP, Prior history of SCC and BCC with surgical removal
Oncologic history:
___: biopsy of right lower back skin lesion showed invasive
malignant melanoma, superficial spreading type, with a Breslow
thickness of 0.95 mm, ___ level IV with ulceration present.
Mitotic activity less than one per mm sq. He went on to have an
excisional biopsy of that area as well as a right iliac sentinel
lymph node biopsy. Margins were free of melanoma and Breslow
thickness was 1.1 mm. Four out of four lymph nodes were
negative for melanoma.
- ___ noticed a right groin mass thought to be a
hernia
- ___: excisional biopsy was consistent with malignant
melanoma. Immunohistochemical stains showed expression of
MART-1 and was S100 negative.
- ___: CT scan of his abdomen and pelvis showed right
inguinal iliac and retroperitoneal lymphadenopathy as well as
numerous metastatic disease in his liver.
- ___: Brain MRI negative for metastatic disease.
- BRAF wild-type
- ___: Week 1 Ipilimumab 3 mg/kg
- ___: Week 4 Ipilimumab 3 mg/kg
- ___: Week 7 Ipilimumab 3 mg/kg
- ___: developed a new rash, treated with prednisone 40 mg
daily, ___ with creatinine 2.1
- ___: Week 10 Ipilimumab delayed due to ___ and K+ 6.2;
prednisone decreased to 20 mg.
- ___: prednisone decreased to 10 mg x 4 days, then stop
Social History:
___
Family History:
He reports a sister with some type of cancer in her ___.
Otherwise, no family history of melanoma.
Physical Exam:
97.6 64 98/54 16 99% RA
GENERAL: Alert, oriented, ashen color.
HEENT: Anicteric, MMM, oropharynx is clear
NECK: No cervical, supraclavicular, or axillary LAD, no
thyromegaly
CV: Regular rate and rhythm, nl S1/S2, no murmurs, rubs or
gallops
PULM: Clear to auscultation bilaterally
ABD: Normoactive bowel sounds, soft, non-tender, non-distended,
no masses or hepatosplenomegaly
INGUINAL LYMPH NODES: Firm, fixed nodal mass on the right side,
appears unchanged without evidence of infection.
LIMBS: Trace peripheral edema of the lower extremities
bilaterally
Discharge exam:
VSS, O2 sat 98-100% on RA at rest and with ambulation
Skin: gray/bluish tinge on face, scalp
Pulm: clear lungs bilaterally
Pertinent Results:
___ 05:32PM ___
___ 05:05PM GLUCOSE-121* UREA N-24* CREAT-1.8* SODIUM-140
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-26 ANION GAP-16
___ 05:05PM WBC-5.4 RBC-4.38* HGB-12.2* HCT-37.6* MCV-86
MCH-27.8 MCHC-32.3 RDW-14.3
___ 05:05PM NEUTS-60.9 ___ MONOS-9.4 EOS-4.1*
BASOS-0.6
___ 05:05PM PLT COUNT-134*
___ 05:05PM ___ PTT-24.4* ___
Labs at discharge:
___ RDW Plt Ct
___ 14.2 128
GlucoseUreaN Creat Na KCl HCO3AnGap
114 30 1.7 138 ___ 13
TypeArterial:
pO2pCO2 pH ___ 7.47 22
O2 SatMetHgb
97 0
FINDINGS:
The heart size is normal. The aorta is mildly tortuous and
demonstrates
diffuse atherosclerotic calcifications. Mediastinal and hilar
contours
otherwise are unremarkable. Previously noted nodular opacity
within the
lingula on CT is not clearly demonstrated on the current study.
The lungs are
clear. No pleural effusion or pneumothorax is present. The
pulmonary
vascularity is normal. No acute osseous abnormalities are seen.
IMPRESSION:
No acute cardiopulmonary abnormality.
CT head:
FINDINGS: There is no evidence of acute hemorrhage, edema, mass
effect or
recent infarction. Prominence of the ventricles and sulci is
consistent with
age-related global atrophy. A hypodensity in the region of the
right basal
ganglia (2:9) is consistent with a prominent perivascular space.
No
concerning osseous lesion is seen. The mastoid air cells are
clear. There is
mucosal thickening of the left frontal sinus, right
frontoethmoidal recess,
left ethmoid air cells and sphenoid sinuses bilaterally.
IMPRESSION: No evidence of acute intracranial process. No
evidence of mass
or mass effect.
V/Q Scan:
INTERPRETATION:
Ventilation images obtained with Tc-99m aerosol in 8 views
demonstrate no
significant defects
Perfusion images in the same 8 views show no segmental defects
Chest x-ray shows no acute cardiopulmonary process
The above findings are consistent with a very low probability of
pulmonary
embolus.
IMPRESSION: Very low probability for acute pulmonary embolus.
Brief Hospital Course:
___ with history of metastatic melanoma (on Ipilimumab, last
dose 2 days ago) comes to the ED with cough and possible
hypoxia.
# Hypoxia: The acuity of symptoms, d Dimer of ___, pulmonary
embolism is highly likely. Given renal insufficiency, CTA would
not be a reasonable study. Continued heparin gtt until V/Q scan
returned very low probability for PE. Given bluish/gray
discoloration of skin, ruled out methemoglobinemia with ABG.
There was no evidence of hypoxia at rest or with ambulation.
Patient noted to have significant nasal congestion, and Flonase
was started empirically for symptomatic relief of cough.
# Metastatic melanoma- pt will follow up with his oncologists as
previously scheduled
# Diarrhea: ikely secondary to side effect from Ipilimumab.
Latter can cause diarrhea in around 30 % cases. Will watch for
now. Did not recur, did not check C diff PCR.
# HTN: Continued home dose Metoprolol.
# Hyperlipidemia: Continue Crestor.
# CAD: Stable. Continue Aspirin and Metoprolol. ACEI was stopped
recently due to history of hyperkalemia and low blood pressure.
# CKD: Likely secondary to HTN. Cr. remained at baseline.
# Full code
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 81 mg PO 2 tabs DAILY
2. Rosuvastatin Calcium 40 mg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
Discharge Medications:
1. Aspirin 162 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO BID
3. Rosuvastatin Calcium 40 mg PO DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
RX *Flonase 50 mcg 1 spray NU daily Disp #*1 Unit Refills:*0
5. Lisinopril 10 mg PO DAILY
not taking as prescribed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
possible hypoxia, eval for pulmonary embolus
metastatic melanoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after noted to have a low oxygen level at your
doctors ___. You presented to the hospital, and there was
concern for a possible blood clot in your lungs, and you
received a blood thinner. You underwent a lung scan that did
not show any evidence of blood clots, which is good news. Your
oxygen level was normal at rest and with walking, and your blood
oxygen level, determined with a blood test, was also normal.
The only medication change is the addition of Flonase, one spray
per nostril daily. This may help with your cough.
Please see below for your follow up appointments.
Followup Instructions:
___
|
10040984-DS-9 | 10,040,984 | 29,975,777 | DS | 9 | 2179-03-16 00:00:00 | 2179-03-16 15:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Incarcerated inguinal hernia and perforation of incarcerated
sigmoid colon with foreign body (toothpick).
Major Surgical or Invasive Procedure:
___
1. Exploratory laparotomy with sigmoid colectomy and
___ procedure.
2. Abdominal washout.
3. Reduction of incarcerated left inguinal hernia with
Bassini-type repair.
History of Present Illness:
Per Dr. ___ note as follows:
___ man with known
cirrhosis who presents with a two-day history of
incarceration of a known left inguinal hernia. He also has
not passed any flatus and is quite sick with an elevated
white count and redness over the hernia. He is brought
urgently to the operating room.
Past Medical History:
- prostate CA s/p prostatectomy in ___
- Saw a hematologist (Dr. ___ in ___ for a "blood
disorder" a few years ago, might have been related to his liver
disease
- GERD
- ETOH Abuse (per pt and wife quit ___ years ago)
- s/p L hip ORIF (pt fell and broke right hip while withdrawing
from EtOH a number of years ago)
- "liver disease," unclear if pt had actually been diagnosed
with cirrhosis
Social History:
___
Family History:
No FH of CAD or CA. A grandparent had DM.
Physical Exam:
___ 80 HR 136/81 RR18 98% RA
Gen: affable, elderly appearing gentleman
CV: RRR no obvious MRG
Pulm: post CTAB, anterior minor wheezes
Abd: soft, non tender non distend no guarding or rebound, infra
umbilical midline incision well healed no obvious facial defects
Left scrotm large, tender, non reducible with erythematous skin.
No ___ edema b/l
Labs:
141 ___
4.4 21 1.3
estGFR: 53
ALT: 42 AP: 136 Tbili: 1.4 Alb: 3.5
AST: 32 Lip: 19
11.0
23.1 500
32.3
Coags: pending
CXR: outside facility ___ without evidence of acute process
EKG: pending
OSH ___:
WBC 27k
Plts 644k
Cr 1.44
Tb 1.7
lactic acid ___
Pertinent Results:
Admission labs:
___ 04:07PM BLOOD WBC-23.1*# RBC-3.49* Hgb-11.0*# Hct-32.3*
MCV-93 MCH-31.5 MCHC-34.1 RDW-13.9 RDWSD-47.1* Plt ___
___ 04:07PM BLOOD Glucose-106* UreaN-30* Creat-1.3* Na-141
K-4.4 Cl-107 HCO3-21* AnGap-17
___ 04:07PM BLOOD ALT-42* AST-32 AlkPhos-136* TotBili-1.4
___ 11:59PM BLOOD Calcium-7.6* Phos-4.7* Mg-1.7
___ 04:07PM BLOOD Albumin-3.5
Discharge labs:
___ 06:14AM BLOOD WBC-8.3 RBC-3.37* Hgb-10.0* Hct-30.8*
MCV-91 MCH-29.7 MCHC-32.5 RDW-14.4 RDWSD-47.3* Plt ___
___ 04:53AM BLOOD ___ PTT-27.8 ___
___ 06:14AM BLOOD Glucose-130* UreaN-43* Creat-1.8* Na-135
K-4.8 Cl-100 HCO3-22 AnGap-18
___ 06:14AM BLOOD ALT-60* AST-50* AlkPhos-368* TotBili-0.5
___ 06:14AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.3
Brief Hospital Course:
On ___, he underwent exploratory laparotomy with sigmoid
colectomy and ___ procedure for perforation of incarcerated
sigmoid colon with foreign body (tooth pick), abdominal washout
and reduction of incarcerated left inguinal hernia with
Bassini-type repair. Other finders were peritonitis and
cirrhosis. Surgeon was Dr. ___. Please refer to
operative note for complete details.
Postop,urine output was low and IV fluid bolus was given with
improvement. He had a short run of VTach with normal EKG.
Metoprolol was given for tachycardia on ___. Overnnight on ___,
he had several rhythms (Tachy w/ new LBBB, inverted T waves).
Cardiology was consulted. Cardiology was consulted and
recommended ???? Cardiac enzymes were normal and lytes were
repleted.
The NG was removed on ___. He was started on sips and was
passing gas and stool thru ostomy on ___. Diet was advanced to a
regular diet. Dilaudid PCA was changed to oral dilaudid.
On ___, O2 desaturated to 80%. CXR was done showing stable left
opacity and right upper opacity. Lasix was started for pulmonary
edema. Heart rate was tachy with a new LBBB, inverted T waves.
Cardiology was consulted, troponin/ck cycled (wnl),and lytes
replaced. Metoprolol was started for rate control. TTE was
grossly unremarkable.
On ___, he had ascites leaking through the incision as well as
parastomal. Albumin and Lasix doses were given. Zosyn was
started while ascites leaking. On ___, Liver U/S
demonstrated cirrhosis, secondary evidence of portal HTN, and no
thrombus. LFTs increased mildly from admission and remained in
the same range.
Cardiac enzymes were cycled and negative. Metoprolol was given
with better control of heart rate. He had some SVT
initermittently on walks down hallway without symptoms. Lasix
and Spironolactone were decreased a couple times for creatinine
increase to 1.8 on ___ from 1.3-1.5. Creatinine remained at
1.8 Weight was 64kg (admission 74kg).
A Prevena wound vac was applied to the incision to control the
ascites leak with good response. Prevena vac was removed on
___. Incision remained clean and dry. Staples were left in
place to be removed by Dr. ___ in follow up appointment.
Zosyn was changed to Augmenting on ___ then discontinued on
___ when he was discharged to rehab ___). He remained
afebrile.
Nutritional intake was poor despite nutritional supplements.
Kcal count was low (325) and a feeding tube was placed. Osmolite
1.5 was started and rate increased to goal of 60ml/hour
continuous. He tolerated this just fine.
___ evaluated and worked with him noting deconditioning and
weakness. Rehab was recommended. ___ in ___ offered
a bed and he was discharged in stable condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. LevETIRAcetam 250 mg PO BID
3. Omeprazole Dose is Unknown PO DAILY
4. Aspirin Dose is Unknown PO Frequency is Unknown
5. Vitamin D 800 UNIT PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Ranitidine 150 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Acetylcysteine 20% ___ mL NEB Q4H:PRN thick secretions
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
5. Furosemide 10 mg PO DAILY
6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
7. Glucose Gel 15 g PO PRN hypoglycemia protocol
8. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN Wheezing
10. Metoprolol Tartrate 12.5 mg PO Q6H
Hold for SBP <95 Hold for HR <60
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Senna 8.6 mg PO BID:PRN constipation
13. Spironolactone 25 mg PO DAILY
14. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
15. Aspirin 81 mg PO DAILY
16. Docusate Sodium 100 mg PO BID
hold for loose stool
17. LevETIRAcetam 250 mg PO BID
18. Ranitidine 150 mg PO QHS
19. HELD- Vitamin D 800 UNIT PO DAILY This medication was held.
Do not restart Vitamin D until discussed with PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Incarcerated inguinal hernia.
Perforation of incarcerated sigmoid colon with foreign body
(toothpick)
Peritonitis
Cirrhosis
ETOH Cirrhosis
SVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You will be transferring to ___ Rehab in ___
Please call Dr. ___ office at ___ for fever
of 101 or greater, chills, nausea, vomiting, diarrhea,
constipation, inability to tolerate food, fluids or medications,
yellowing of skin or eyes, increased abdominal pain, incisional
redness, drainage or bleeding, discoloration of stoma,
constipation, dizziness or weakness, decreased urine output or
dark, cloudy urine, swelling of abdomen or ankles, or any other
concerning symptoms.
You may shower, but no tub baths
No heavy lifting/straining (nothing heavier than 10 pounds)
Tube feedings have been started for malnutrition.
Followup Instructions:
___
|
10041312-DS-20 | 10,041,312 | 26,413,298 | DS | 20 | 2169-10-30 00:00:00 | 2169-10-30 10:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
codeine / erythromycin base / cephalasporin / Motrin
Attending: ___.
Chief Complaint:
RUQ abdominal pain
Major Surgical or Invasive Procedure:
___: ___ aspiration of perihepatic fluid collection
___: ___ drainage of perihepatic fluid collection, drain
placement
___: ___ drainage of perihepatic fluid collection,
replacement of drain; percutaneous cholecystostomy tube
History of Present Illness:
___ COPD, CHF (EF 40%) was recently treated for acute
cholecystitis with a cholecystostomy at beginning of ___ at
___ here with recurrent right upper quadrant pain. She was
transferred to ___ from ___ after being found hypotensive
and hypoxic at rehab. She responded to 1L of fluid and was
started on levaquin and flagyl. She reports having right upper
quadrant pain that has been on going but progressive in nature.
Her percutaneous cholecystostomy was accidentally removed over
the weekend and she saw Dr. ___ in clinic on the ___ who
wanted to discuss an interval cholecystectomy with the family.
Of note she was discharged from rehab yesterday and last night
she felt weak and slid to the floor. She denies any LOC, or head
strike. The fire department did come and help her back to bed.
The following morning she was taken to the rehab who found her
to
be hypotensive which prompted the transfer.
She reports some nausea and has a decreased appetite. She denies
any post prandial pain, diarrhea, vomiting, constipation, back
pain, headaches, dysuria, cough, chest pain, shortness of
breath,
rashes. She is reporting some left foot pain that seems to be
chronic and was evaluated by her PCP.
Past Medical History:
MHx: COPD- not on home O2, CHF/CMO, CKDIII, CAD, HTN, HLD,
Cognitive dysfunction, Obesity, GERD Hypercoagulable
state-family
unsure-no history of clots, OA, asthma, gastric polyps,
diverticulosis history of falls,
SHx: ___
Family History:
Non-contributory
Physical Exam:
At admission:
97.2 86 105/55 16 96%
General: Comfortable, obsese
HEENT: anicteric sclera
___: regular rhythm
Pulm: clear bilaterally
Abdomen: soft, TTP RUQ
Ext: WWP, moves all extremities
At discharge:
97.9 82 128/81 20 92RA
General: NAD
HEENT: EOMI, MMM, anicteric sclera
Cardiac: RRR
Pulm: non-labored breathing, on room air
Abdomen: soft, NT, ND, RUQ ___ drains x2 with bilious fluid in
bag
Ext: no edema
Neuro: A&Ox2
Psych: appropriate mood, appropriate affect
Pertinent Results:
-Ultrasound guided drainage of perihepatic collection (___):
IMPRESSION:
1. Technically successful ultrasound guided diagnostic
paracentesis.
2. 0.45 L of fluid were removed.
-Abdominal Ultrasound (___):
IMPRESSION:
1. Reaccumulation of perihepatic ascites appears overall similar
to the images obtained prior to ultrasound-guided paracentesis 1
day prior. There is a more loculated portion measuring 5.6 x
2.0 x 5.0 cm in the midline upper abdomen which appears to be
connected to the perihepatic ascites
2. Cholelithiasis.
-Ultrasound guided drainage of perihepatic collection (___):
IMPRESSION:
1. Technically successful US-guided placement of ___
pigtail catheter into the right upper quadrant fluid collection.
2. 160 cc of dark green bilious fluid was removed.
-Abdominal Ultrasound (___):
IMPRESSION:
Perihepatic fluid again identified and a small right pleural
effusion is
noted. Despite effort the right upper quadrant drain could not
be identified with ultrasound. The CT is recommended for
further evaluation.
CT INTERVENTIONAL PROCEDURE (___):
IMPRESSION:
1. Successful CT-guided placement of ___ pigtail catheter
into the
perihepatic collection. Samples were sent for microbiology
evaluation.
2. Successful CT-guided ___ percutaneous cholecystostomy tube
placement.
___ Drainage (___):
-Tbili 55
-Gram stain: no organisms, no PMNs
-Culture: rare GPCs
Urine Culture (___):
-Preliminary: gram negative rods (>100k CFU),
speciation/sensitivity pending
Brief Hospital Course:
Ms. ___ presented to the ___ ED from ___ on ___
after CT scan showed a perihepatic abscess following accidental
removal of her percutaneous cholecystostomy tube 1 week ago. She
was admitted and started on IV antibiotics (Cipro/Flagyl). She
was kept NPO and ___ was consulted. INR was 1.7 and she was given
1 unit of FFP prior to ___ procedure. She underwent US-guided
drainage of a perihepatic fluid collection on ___. Fluid
drained was non-purulent and bilious, concerning for a bile
leak. She underwent repeat abdominal ultrasound on ___ that
showed reaccumulation and she returned to ___ on ___ for
placement of an ___ drain. Drain output was initially good, but
became minimal on ___. She underwent another ultrasound on
___ which again showed unchanged perihepatic fluid
collection with drain unable to be visualized in the collection.
She returned to ___ on ___ for replacement of the perihepatic
___ drain and was as placement of percutaneous cholecystostomy
tube.
Diet was advanced to regular on ___ and she was transitioned
to oral antibiotics which she tolerated well. Foley was removed
on ___ and patient voided spontaneously without issue. Urine
was noted to be concentrated and foul smelling on ___ and a
sample was sent for UA and culture. At time of discharge,
preliminary culture data showed >100k CFU of gram negative rods.
She was already on ciprofloxacin for bile leak and continues on
this at the time of discharge for a total 5 day course (stop
date ___. Speciation and sensitivity were pending at time
of discharge, and the rehab facility will be contacted to make
appropriate changes if final culture data shows resistance to
ciprofloxacin.
She was discharged to rehab on ___. At the time of discharge
she ambulating with assistance, voiding spontaneously,
tolerating a regular diet, and pain was well controlled with
oral medications. She was discharged with instructions to follow
up in the ___ with Dr. ___ on ___ at 10:30
am.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. amLODIPine 2.5 mg PO DAILY
9. Gabapentin 300 mg PO TID
10. Simvastatin 20 mg PO QPM
11. TraZODone 50 mg PO QHS
12. Acetaminophen 650 mg PO BID:PRN Pain - Mild
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*5 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*7 Tablet Refills:*0
3. Acetaminophen 650 mg PO BID:PRN Pain - Mild
4. amLODIPine 2.5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Gabapentin 300 mg PO TID
8. Lisinopril 20 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Simvastatin 20 mg PO QPM
13. TraZODone 50 mg PO QHS
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
perihepatic fluid collection
bile leak s/p cholecystostomy tube
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (___
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for drainage of a perihepatic fluid
collection that developed after your percutaneous
cholecystostomy tube fell out. You were also noted to have a
urinary tract infection while you were here, for which you have
been prescribed antibiotics. You have recovered well and are now
ready for discharge. Please follow the recommendations below to
ensure a speedy and uneventful recovery.
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may climb stairs.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- You may start some light exercise when you feel comfortable.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
YOUR BOWELS:
- Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
If you experience any of the folloiwng, 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.
Thank you for allowing us to participate in your medical care.
Sincerely,
Your ___ Surgery Team
Followup Instructions:
___
|
10041429-DS-8 | 10,041,429 | 28,466,281 | DS | 8 | 2114-03-12 00:00:00 | 2114-03-12 12:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Vicodin
Attending: ___.
Chief Complaint:
recurrent low back pain post mvc and right foot paresthesias and
weakness
Major Surgical or Invasive Procedure:
L4-S1 Decompression/Fusion
History of Present Illness:
___ female PMHx lumbar spinal stenosis, chronic low back pain s/p
multiple surgeries on her lumbar spine including several
microdiscectomies (___ @ ___, ___ @___) s/p L4,L5
laminectomies ___ ___ @ ___ who had been
doing relatively well over the past ___ years until she was
involved in a high energy MVC ___ following which she had
recurrent severe low back pain and also esophageal injury
currently being worked up. Since this past ___ she noted
that her right foot was unable to dorsiflex and had decreased
sensation and paresthesias - this has resulted in several falls
over the past week. She had planned follow-up with Dr. ___
___ this upcoming ___ but became concerned due to these
falls and did not feel safe to wait any longer for evaluation.
Went to ___, transferred to ___ due to lack of
spine consult availability at ___. Denies saddle
anesthesia, denies bowel/bladder changes. IMAGING:MRI of the
lumbar spine demonstrates diffuse post-surgical changes
including superficial seroma. Multiple lumbar disc herniations
most prominent at L4/5-right lateral disc.
Past Medical History:
PMH/PSH:
Multiple lumbar spine surgeries
s/p MVC ___
Social History:
___
Family History:
Single mother, works but not currently working after MVC.
Physical Exam:
PHYSICAL EXAMINATION:
Vitals: AVSS
General: Well-appearing female in no acute distress.
Spine exam:
Surgical wounds well healed over lumbar spine, no erythema.
Vascular
Radial: L2+, R2+
DPR: L2+, R2+
Motor-
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 2 3
-Sensory:
Sensory UE
C5 (Ax) R nl, L nl
C6 (MC) R nl, L nl
C7 (Mid finger) R nl, L nl
C8 (MACN) R nl, L nl
T1 (MBCN) R nl, L nl
T2-L2 Trunk R nl, L nl
Sensory ___
L2 (Groin): R nl, L nl
L3 (Leg) R nl, L nl
L4 (Knee) R decreased sensation, L nl
L5 (Grt Toe): R decreased sensation, L nl
S1 (Sm toe): R decreased sensation, L nl
S2 (Post Thigh): R nl, L nl
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 0
___: neg
Babinski: downgoing
Clonus: none
Perianal sensation: intact
Rectal tone: intact
LABS: Pending
Pertinent Results:
___ 11:03AM BLOOD WBC-7.3 RBC-3.01* Hgb-8.3* Hct-26.9*
MCV-89 MCH-27.6 MCHC-30.9* RDW-15.6* RDWSD-50.6* Plt ___
___ 10:33AM BLOOD WBC-6.6 RBC-3.09* Hgb-8.7* Hct-27.3*
MCV-88 MCH-28.2 MCHC-31.9* RDW-15.0 RDWSD-48.6* Plt ___
___ 07:30AM BLOOD WBC-7.0# RBC-3.33* Hgb-9.2* Hct-29.4*
MCV-88 MCH-27.6 MCHC-31.3* RDW-15.2 RDWSD-48.9* Plt ___
___ 01:35PM BLOOD Neuts-81.9* Lymphs-13.5* Monos-3.6*
Eos-0.2* Baso-0.6 Im ___ AbsNeut-3.82# AbsLymp-0.63*
AbsMono-0.17* AbsEos-0.01* AbsBaso-0.03
___ 08:00AM BLOOD Neuts-54.5 ___ Monos-6.5 Eos-3.5
Baso-0.8 Im ___ AbsNeut-2.17 AbsLymp-1.37 AbsMono-0.26
AbsEos-0.14 AbsBaso-0.03
___ 11:03AM BLOOD Plt ___
___ 10:33AM BLOOD Plt ___
___ 07:30AM BLOOD Plt ___
___ 01:35PM BLOOD ___ PTT-27.5 ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD ___ PTT-27.8 ___
___ 11:03AM BLOOD Glucose-122* UreaN-7 Creat-0.6 Na-136
K-3.9 Cl-103 HCO3-22 AnGap-15
___ 10:33AM BLOOD Glucose-153* UreaN-7 Creat-0.4 Na-137
K-4.3 Cl-104 HCO3-22 AnGap-15
___ 07:30AM BLOOD Glucose-99 UreaN-12 Creat-0.6 Na-136
K-3.9 Cl-103 HCO3-25 AnGap-12
___ 10:33AM BLOOD Calcium-8.5 Phos-4.1 Mg-1.8
___ 07:30AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.9
___ 03:01PM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as
tolerated.Foley was removed on POD#2. Physical therapy and
Occupational therapy were consulted for mobilization OOB to
ambulate and ADL's.Hospital course was otherwise unremarkable.On
the day of discharge the patient was afebrile with stable vital
signs, comfortable on oral pain control and tolerating a regular
diet.
Medications on Admission:
Clonazepam
Gabapentin
Mirtazapine
Omeprazole
Sertraline
Discharge Medications:
1. Diazepam 5 mg PO Q6H:PRN muscle spasms
may cause drowsiness
RX *diazepam 5 mg 1 tab by mouth every eight (8) hours Disp #*60
Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
please take with narcotic pain medications
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth three
times a day Disp #*90 Capsule Refills:*0
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
please do not operate heavy machinery, drink alcohol or drive
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*90 Tablet Refills:*0
4. TraMADol 50 mg PO BID:PRN BREAKTHROUGH PAIN
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*90 Tablet Refills:*0
5. ClonazePAM 1 mg PO QID
6. Gabapentin 300 mg PO TID
7. Mirtazapine 7.5 mg PO QHS
8. Omeprazole 20 mg PO DAILY
9. Sertraline 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Lumbar spondylosis and stenosis and scoliosis.
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:
Lumbar Decompression With Fusion:
You have undergone the following operation: Lumbar Decompression
With Fusion
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit or stand more than~45 minutes without getting up and
walking around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Diet: Eat a normal healthy diet.You may have
some constipation after surgery.You have been given medication
to help with this issue.
Brace:You may have been given a brace.If you
have been given a brace,this brace is to be worn when you are
walking.You may take it off when sitting in a chair or while
lying in bed.
Wound Care:Remove the dressing in 2 days.If the
incision is draining cover it with a new sterile dressing.If it
is dry then you can leave the incision open to the air.Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower.Do not soak the incision in a
bath or pool.If the incision starts draining at anytime after
surgery, do not get the incision wet.Cover it with a sterile
dressing.Call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions,so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___ 2.We are not allowed to call in or fax narcotic
prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your
incision,take baseline X-rays and answer any questions.We may at
that time start physical therapy
We will then see you at 6 weeks from the day of
the operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
1)Weight bearing as tolerated.2)Gait,balance training.3)No
lifting >10 lbs.4)No significant bending/twisting.
Treatments Frequency:
Remove the dressing in 2 days.If the incision is draining cover
it with a new sterile dressing.If it is dry then you can leave
the incision open to the air.Once the incision is completely dry
(usually ___ days after the operation) you may take a shower.Do
not soak the incision in a bath or pool.If the incision starts
draining at anytime after surgery,do not get the incision
wet.Cover it with a sterile dressing.Call the office.
Followup Instructions:
___
|
10041429-DS-9 | 10,041,429 | 20,403,729 | DS | 9 | 2114-04-05 00:00:00 | 2114-04-05 16:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Vicodin
Attending: ___.
Chief Complaint:
Abdominal pain, fever
Major Surgical or Invasive Procedure:
Laparoscopic adjustable gastric band and port
removal.
History of Present Illness:
Ms. ___ is a ___ s/p laparoscopic gastric band at ___
in ___ who presented with LLQ abdominal pain. She has a recent
history of a motor vehicle accident on ___ with exacerbation
in lumbar pain, and underwent L4-S1 3 part laminectomy and
instrumented fusion ___ and was discharged from the
hospital on ___. She was recovering well after her procedure,
but presented to the ED on ___ for fever up to 103 at home.
She has been having LLQ pain since her spinal surgery. She
reports that she has been having occasional food intolerance and
difficult swallowing for the past 5 months, with occasional
heartburn but no regurgitation. Her symptoms have gradually
worsened during the
past 5 months. She reports occasional nausea, no vomiting, no
constipation or diarrhea.
She has lost 200 pounds after the lap band procedure, her preop
weight was 365 and now it is 165lbs.
Upon arrival to the ED they performed a CT scan, which
demonstrated a large fluid collection in the soft tissues
posterior to the lumbar fusion (?seroma/ abscess) and a moderate
hiatal hernia and slipped lap band.
Past Medical History:
PMH/PSH:
Multiple lumbar spine surgeries
s/p MVC ___
Social History:
___
Family History:
Single mother, works but not currently working after ___.
Physical Exam:
Vitals:
T=98.2F; BP=96/60mmHg; HR=76x'; RR=18x'; O2 Sat=98% Ra
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic.
CARDIAC: Regular rate and rhythm, no murmurs/rubs/gallops.
LUNGS: No respiratory distress. Clear to auscultation
bilaterally. No wheezes, rhonchi or rales.
ABDOMEN: Decreased bowel sounds, non distended, expectedly
tender diffusely. No peritoneal signs. Dressings appear clean,
dry, and intact
EXTREMITIES: No clubbing, cyanosis, or edema.
Pertinent Results:
___ 05:08AM BLOOD Hct-30.3*
___ 12:30AM BLOOD WBC-5.1 RBC-3.19* Hgb-8.2* Hct-26.7*
MCV-84 MCH-25.7* MCHC-30.7* RDW-15.1 RDWSD-46.1 Plt ___
___ 12:30AM BLOOD Neuts-71.1* Lymphs-18.9* Monos-8.4
Eos-0.6* Baso-0.8 Im ___ AbsNeut-3.65 AbsLymp-0.97*
AbsMono-0.43 AbsEos-0.03* AbsBaso-0.04
___ 12:30AM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-138
K-3.8 Cl-102 HCO3-24 AnGap-16
___ 12:30AM BLOOD CRP-38.0*
CT abdomen/pelvis w/contrast ___
1. Large fluid collection in the soft tissues posterior to the
lumbar fusion surgical bed could represent abscess or post
operative seroma.
2. Moderate hiatal hernia and increased stomach above the band
consistent with slipped lap band.
Brief Hospital Course:
Ms. ___ is a ___ who is status post laparoscopic gastric
band placed at an outside hospital (___). She presented to the
ED on ___ with a history of many months of dysphagia
to solids, progressive to liquids over the last day or so.
We removed all the fluid from her band with no improvement of
symptoms. Her CT scan, demonstrated
prolapse. We discussed risks, benefits, alternatives. She
understood and consented to have the band removed.
She underwent laparoscopic gastric band removal on ___
without complications. Her postoperative hematocrit was stable.
Of note, she underwent L4-S1 3 partial laminectomy and
instrumented fusion recently and is currently followed by her
spine surgeon, who is managing her pain medications. We have
given her a prescription for Dilaudid tablets (#10) that should
suffice until her next appointment with Dr. ___ spinal
surgeon) on ___ at 9:30AM.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. ClonazePAM 1 mg PO QID
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 300 mg PO TID
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
5. Omeprazole 20 mg PO DAILY
6. Sertraline 100 mg PO DAILY
7. Diazepam 5 mg PO Q6H:PRN muscle spasms
8. Mirtazapine 7.5 mg PO QHS
9. TraMADol 50 mg PO BID:PRN BREAKTHROUGH PAIN
Discharge Medications:
1. Diazepam 5 mg PO Q6H:PRN muscle spasms
2. Docusate Sodium 100 mg PO BID
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*10 Tablet Refills:*0
4. TraMADol 50 mg PO BID:PRN BREAKTHROUGH PAIN
5. ClonazePAM 1 mg PO QID
6. Gabapentin 300 mg PO TID
7. Mirtazapine 7.5 mg PO QHS
8. Omeprazole 20 mg PO DAILY
9. Sertraline 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Laparoscopic adjustable gastric band prolapse.
2. Dysphagia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You have undergone removal of your adjustable gastric band,
recovered in the hospital and are now preparing for discharge to
home with the following instructions:
Discharge Instructions: Please call your surgeon or return to
the Emergency Department if you develop a fever greater than 101
F, shaking chills, chest pain, difficulty breathing, pain with
breathing, cough, a rapid heartbeat, dizziness, severe abdominal
pain, pain unrelieved by your pain medication, a change in the
nature or severity of your pain, severe nausea, vomiting,
abdominal bloating, severe diarrhea, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness,
swelling from your incisions, or any other symptoms which are
concerning to you.
Diet: Stay on Stage IV diet until your follow up appointment;
please refer to your work book for detailed instructions. Do not
self- advance your diet and avoid drinking with a straw or
chewing gum. To avoid dehydration, remember to sip small amounts
of fluid frequently throughout the day to reach a goal of
approximately ___ mL per day. Please note the following signs
of dehydration: dry mouth, rapid heartbeat, feeling dizzy or
faint, dark colored urine, infrequent urination.
Medication Instructions:
Please refer to the medication list provided with your discharge
paperwork for detailed instruction regarding your home and newly
prescribed medications.
Some of the new medications you will be taking include:
Pain medication: You will receive a prescription for Dilaudid
tablets that should last you until your appointment with Dr.
___.
Constipation: This is a common side effect of opioid pain
medication. If you experience constipation, please reduce or
eliminate opioid pain medication. You may trial 2 ounces of
light prune juice and/or a stool softener (i.e. crushed docusate
sodium tablets), twice daily until you resume a normal bowel
pattern. Please stop taking this medication if you develop
loose stools. Please do not begin taking laxatives including
until you have discussed it with your nurse or surgeon.
You must not use NSAIDS (non-steroidal anti-inflammatory drugs).
Examples include, but are not limited to Aleve, Arthrotec,
aspirin, Bufferin, diclofenac, Ecotrin, etodolac, ibuprofen,
Indocin, indomethacin, Feldene, ketorolac, meclofenamate,
meloxicam, Midol, Motrin, nambumetone, Naprosyn, Naproxen,
Nuprin, oxaprozin, Piroxicam, Relafen, Toradol and Voltaren.
These agents may cause bleeding and ulcers in your digestive
system. If you are unclear whether a medication is considered an
NSAID, please ask call your nurse or ask your pharmacist.
Activity:
You should continue walking frequently throughout the day right
after surgery; you may climb stairs.
You may resume moderate exercise at your discretion, but avoid
performing abdominal exercises or lifting items greater than10
to 15 pounds for six weeks.
Wound Care:
You may remove any remaining gauze from over your incisions.
You will have thin paper strips (Steri-Strips) over your
incision; please, remove any remaining Steri-Strip seven to 10
days after surgery.
You may shower 48 hours following your surgery; avoid scrubbing
your incisions and gently pat them dry. Avoid tub baths or
swimming until cleared by your surgeon.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Please call the doctor if you have increased pain, swelling,
redness, cloudy, bloody or foul smelling drainage from the
incision sites.
Avoid direct sun exposure to the incision area for up to 24
months.
Do not use any ointments on the incision unless you were told
otherwise.
Followup Instructions:
___
|
10041690-DS-8 | 10,041,690 | 23,389,330 | DS | 8 | 2139-11-24 00:00:00 | 2139-11-26 10:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / escitalopram / lisinopril / aspirin / latex /
hydrochlorothiazide
Attending: ___.
Chief Complaint:
Hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with hypertension,
hypothyroidism and anxiety presenting with hyponatremia found on
outside labs.
For approximately the past 10 days she has not been feeling
herself. Over this time frame she has had a headache, dizziness,
general weakness and bilateral tinnitus. Notably in the end of
___ she has a diarrheal illness, which her son had at the
same time. She recovered from this spontaneously. She went to an
urgent care on ___ and was given HCTZ 25mg BID for
hypertension. She took a single dose of this medication on ___
in the evening.
She then presented to her primary care physician ___ ___ for
hypertension and had a chem panel drawn in this setting. Her
sodium resulted as 118 and she was called to come to the ED. Her
last sodium check prior to this was about 3 months prior and was
normal at 135.
Of note, she describes an incident about ___ years ago when she
was very weak after a diarrheal illness and collapsed. She was
admitted to the hospital at that time reportedly because of
severe hyponatremia.
Ms. ___ reports she typically has about 4 cups of tea
every morning and then ___ bottles of water later in the day.
Overall she eats a fairly mixed diet.
She has not had chest pain, vomiting, diarrhea, fevers, chills.
She endorses some anorexia.
In the ED,
- Initial Vitals: T97.8, HR 75, BP 178/89, RR 16, O2 100% RA
- Exam:
Physical
General: well-appearing
HEENT: MMM, neck supple
Lungs: CTAB, normal work of breathing
Heart: RRR, normal S1/S2, no murmurs
Abd: soft, nontener, nondistended
Skin: WWP, cap refill <2 sec
Ext: no edema, ecchymosis
Neuro: CN II-XII grossly intact, ___ strength and sensation to
light touch throughout
Her initial sodium was 121 on presentation. She received 1L NS
for this and overcorrected to 130. She then received DDAVP 2mcg
and her sodium dropped to 126 before coming to the floor.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
- Osteoporosis
- Anxiety
- HTN
- Hypothyroidism
- Sciatica
Social History:
___
Family History:
No known family history of electrolyte derangement
Physical Exam:
============================
ADMISSION PHYSICAL EXAMINATION
============================
VS: T98.7, HR 81, BP 142/87, RR 16, ___ 98% RA
GEN: Sitting up in bed and speaking with me. Somewhat anxious.
EYES: Pupils equal and reactive. No icterus or injection
HENNT: Moist mucous membranes.
CV: S1/S2 regular with no murmurs, rubs or S3/S4.
RESP: Clear bilaterally, no respiratory distress.
GI: Soft, non-tender, non-distended.
EXT: Warm extremities, no lower extremity edema.
SKIN: Warm, dry. Bruising on L dorsum of hand.
NEURO: CN II-XII normal, ___ strength in upper and lower
extremities.
PSYCH: Anxious appearing.
============================
DISCHARGE PHYSICAL EXAMINATION
VS: 24 HR Data (last updated ___ @ 749)
Temp: 98.1 (Tm 98.3), BP: 155/87 (132-155/83-87), HR: 70
(67-70), RR: 18 (___), O2 sat: 99% (97-99), O2 delivery: Ra\
GEN: Ambulating around room/hall, NAD
EYES: Pupils equal and reactive. No icterus or injection
HENNT: Moist mucous membranes. No CLAD
CV: S1/S2 regular with no murmurs, rubs or S3/S4.
RESP: Clear bilaterally, no respiratory distress.
GI: Soft, non-tender, non-distended.
EXT: Warm extremities, no lower extremity edema.
SKIN: Warm, dry.
NEURO: CN II-XII normal, ___ strength in upper and lower
extremities.
PSYCH: Mildly anxious appearing.
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 04:30PM BLOOD WBC-6.7 RBC-4.31 Hgb-13.6 Hct-37.8 MCV-88
MCH-31.6 MCHC-36.0 RDW-11.1 RDWSD-35.6 Plt ___
___ 04:30PM BLOOD UreaN-8 Creat-0.4 Na-118* K-3.6 Cl-81*
HCO3-24 AnGap-13
___ 12:59AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.2
==========================================
DISCHARGE AND PERTINENT LABORATORY STUDIES
==========================================
___ 10:26AM BLOOD Na-122* K-3.2*
___ 02:12PM BLOOD Na-127*
___ 04:22PM BLOOD Na-130*
___ 04:48PM BLOOD Na-126*
___ 06:28PM BLOOD Na-125* K-3.8
___ 09:27PM BLOOD Na-127*
___ 01:12AM BLOOD Na-126*
___ 04:36AM BLOOD Na-126*
___ 08:29AM BLOOD Na-124*
___ 01:08PM BLOOD Na-125*
___ 04:35PM BLOOD Na-130*
___ 11:52PM BLOOD Na-126*
___ 07:07AM BLOOD Na-127*
===========================
REPORTS AND IMAGING STUDIES
===========================
___ CXR
FINDINGS: The lungs are hyperexpanded. There is no focal
consolidation, pleural effusion or pneumothorax identified. The
size of the cardiomediastinal silhouette is within normal
limits. The bony thorax is grossly intact.
IMPRESSION: No acute cardiopulmonary abnormality.
============
MICROBIOLOGY
============
URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
Brief Hospital Course:
ASSESSMENT/PLAN:
___ w/ HTN, hypothyroidism, and anxiety p/w hyponatremia that is
likely multifactorial iso recent HCTZ use and excessive water
intake in relation to solute intake.
#Hyponatremia:
10 days of constitutional symptoms prompting PCP visit and lab
testing revealing hyponatremia to 118. Likely multifactorial in
the setting of poor solute intake, high water intake, recent
HCTZ use. ___ have been precipitated by diarrheal illness 3
weeks ago. She seems prone to this with a similar episode about
___ years ago. Received a total of 2 doses of DDAVP while in the
ICU. Sodium improved with 1L/day fluid restriction; however, by
day of discharge it had not fully normalized and urine osms had
increased to 458 from 121, raising the possibility of an
additional underlying process such as SIADH. Discharged home on
fluid restriction per renal recommendation with PCP ___ in two
days for sodium check. HCTZ added to allergy list. Discharge Na
131 by serum, 129 by whole blood. Plan for repeat labs on ___
with results faxed to PCP and nephrology. PCP received ___ warm
hand off on patient.
#HTN: On metop XL 25 TID at home, which is an unusual regimen.
Appears that patient feels some sense of reassurance by taking
this medication more frequently. We therefore changed her
metoprolol succ to metop tartrate 25 tid. Added amlodipine 5mg
daily for blood pressure control.
Chronic Issues
#Anxiety: Continued home alprazolam
#GERD: Continued Maalox, ranitidine
Transitional Issues:
[] ___ blood sodium, consider SIADH if not normalized
[] Patient was taking metoprolol XL 25 TID at home. We changed
this to metop tartrate 25 tid.
[] HCTZ added to allergy list, would use caution with diuretics
in this patient given 2x episodes of hyponatremia
[] ___ blood pressures on amlodipine 5mg initiated on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Metoprolol Succinate XL 25 mg PO TID
3. ALPRAZolam 0.25 mg PO TID:PRN anxiety
4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
5. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Metoprolol Tartrate 25 mg PO TID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
4. ALPRAZolam 0.25 mg PO TID:PRN anxiety
5. Levothyroxine Sodium 50 mcg PO DAILY
6.Outpatient Lab Work
E87.1
Please obtain chem 7, fax results to ___ attention ___
___ MD
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:
Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted because you had a low sodium level in your
blood. The medical term for this condition is 'hyponatremia'.
What was done for me while I was in the hospital?
Your blood's sodium level was increased to a near-normal level
by managing your body's fluid level.
Your blood sodium level did not completely normalize, and we
made an appointment for you with your PCP to follow up on this
issue as an outpatient in the next ___ days.
What should I do when I leave the hospital?
Limit your fluid intake to no more than 1 liter per day, until
you see your PCP.
Make sure to attend your scheduled PCP appointment, which should
be scheduled for ___ days from your discharge from the hospital.
Please make sure to get labs drawn on ___. The results will
be faxed to your doctors.
We started you on amlodipine which is blood pressure medication
in place of HCTZ.
Please take all of your medications as prescribed.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10041894-DS-9 | 10,041,894 | 29,235,759 | DS | 9 | 2140-12-09 00:00:00 | 2140-12-12 14:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
TEE
History of Present Illness:
Mr. ___ is a ___ y/o man with a PMH of AFib on warfarin,
bioprosthetic AVR/MVR, gout, HTN, and HLD, who was transferred
from ___ for ___ and anemia. He has been having
fatigue, back pain and intermittent fevers for the past five
weeks up to ___ (most recently AM of ___. Notes a 10 lb weight
loss over this time. 2 weeks ago he saw his PCP for these fevers
as well as cough, who felt that his presentation was consistent
with community-acquired pneumonia, for which he received a
five-day course of azithromycin with some relief. He
subsequently received a one week course of levofloxacin.
Yesterday, he returned to his PCP because he was having sacral
pain for the past three weeks. This sacral pain was previously
treated with cyclobenzaprine and orphenadrine. Denied any
trauma. In conjunction with these fevers, his PCP was concerned
for pyelonephritis, and he was sent to the ED at ___.
There, a CT chest/abd/pelvis was performed. CT chest had no
acute abnormality. The abdomen and pelvis scan showed
cardiomegaly, mild splenomegaly, degenerative spine changes, and
severe prostate enlargement. Labs at ___ were notable
for: WBC 22, H/H 10.1/29, plt 116, bands 4, Na 128, K 4.5, BUN
41, Cr 2.08, trop .08, lactate 1.1, CRP 21, INR 4.35. EKG: AFib
91, LAD, QTc 471, TWI III Blood cultures grew GPC in pairs and
chains. He received IV fluids, vancomycin, and Zosyn, and he was
transferred to ___.
In the ___ ED, initial vitals: T 99.6 P 80 BP 116/74 RR 16 O2
96% RA
- Exam notable for PE: dry mucous membranes, CTAB, ___,
abdomen soft, NT, ND, no CVAT, no midline spine tenderness.
Brown, weakly positive guaiac stool.
- Labs were notable for:
Chemistries:
132 100 44
-------------< 115
4.7 20 1.8
CBC:
8.5
16.0 >---< 96
25.1
DIFF: N:84 Band:7 ___ M:7 E:0 Bas:0 Nrbc: 1 Absneut: 14.56
Abslymp: 0.32 Absmono: 1.12 Abseos: 0.00 Absbaso: 0.00
Coags:
___: 78.3 PTT: 46.1 INR: 6.9
Trop-T: <0.01
Lactate:1.2
UA: WBC 68, many bacteria, large leuks, negative nitrites, large
blood, trace ketones
- Patient was given:
___ 00:56 IVF 1000 mL NS 500 mL
___ 02:19 IV Pantoprazole Started 8 mg/hr
___ 02:19 IV Phytonadione 2.5 mg
___ 02:39 IV Gentamicin 350 mg
___ 02:39 IVF 1000 mL NS 1000 mL
- Consults: none
On arrival to the MICU, he reported L flank pain and sacral
pain. He denied chest pain, shortness of breath. He has
previously had fevers and chills, which had subsequently
resolved. Denied nausea, vomiting, lightheadedness, dizziness,
dysuria, hematuria, melena, or hematochezia. Denied sick
contacts.
Review of systems:
- as above, otherwise a 10 point review of systems was negative
Past Medical History:
atrial fibrillation on warfarin
- severe aortic stenosis s/p #23 ___ pericardial
valve (___)
- severe mitral regurgitation s/p #33 ___ porcine valve
(___)
- gout
- hypertension
- hyperlipidemia
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 97.6F BP 106/51 mmHg P 70 RR 22 O2 97% 2L O2
General: Pleasant, elderly man appearing his stated age in NAD.
HEENT: PERRL; EOMs intact. Dry mucous membranes. OP clear.
Neck: Supple, neck veins flat. No JVD.
CV: Irregularly irregular. III/VI systolic murmur; no rubs or
gallops.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, non-tender, non-distended. NABS.
Back: Point tenderness to palpation over sacrum.
Ext: Warm and well-perfused. Lone splinter hemorrhage on L
thumb. No ___ nodes. 2+ DP pulses. No edema.
Neuro: A&Ox3; CNs II-XII grossly intact. Distal sensation intact
to light touch.
DISCHARGE PHYSICAL EXAM:
=========================
Vital Signs: 99.0 121/64 74 18 94%RA
GEN: Alert, NAD
HEENT: NC/AT
CV: irreg, ___ systolic murmur
PULM: CTA B, bilateral rales in the lower lung fields
GI: S/NT/ND, BS present
EXT: no calf tenderness ___ edema
NEURO: A&Ox3
Pertinent Results:
Admission Labs:
___ 12:15AM BLOOD WBC-16.0* RBC-2.73* Hgb-8.5* Hct-25.1*
MCV-92 MCH-31.1 MCHC-33.9 RDW-14.2 RDWSD-47.6* Plt Ct-96*
___ 12:15AM BLOOD Neuts-84* Bands-7* Lymphs-2* Monos-7
Eos-0 Baso-0 ___ Myelos-0 NRBC-1* AbsNeut-14.56*
AbsLymp-0.32* AbsMono-1.12* AbsEos-0.00* AbsBaso-0.00*
___ 12:15AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
___ 12:15AM BLOOD ___ PTT-46.1* ___
___ 06:12AM BLOOD ___
___ 06:12AM BLOOD Ret Aut-1.1 Abs Ret-0.03
___ 12:15AM BLOOD Glucose-115* UreaN-44* Creat-1.8* Na-132*
K-4.7 Cl-100 HCO3-20* AnGap-17
___ 06:12AM BLOOD ALT-31 AST-40 LD(LDH)-356* AlkPhos-135*
TotBili-0.6
___ 12:15AM BLOOD cTropnT-<0.01
___ 06:12AM BLOOD Albumin-2.5* Calcium-7.6* Phos-4.4 Mg-2.0
Iron-14*
___ 06:12AM BLOOD calTIBC-146* Hapto-278* Ferritn-1144*
TRF-112*
___ 12:18AM BLOOD Lactate-1.2
Discharge Labs:
___ 05:42AM BLOOD WBC-14.1* RBC-2.79* Hgb-8.7* Hct-26.0*
MCV-93 MCH-31.2 MCHC-33.5 RDW-14.3 RDWSD-48.4* Plt ___
___ 05:42AM BLOOD ___ PTT-40.6* ___
___ 05:42AM BLOOD Glucose-107* UreaN-21* Creat-1.0 Na-133
K-3.9 Cl-100 HCO3-23 AnGap-14
___ 05:42AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.8
___ 01:00AM URINE Color-Yellow Appear-Hazy Sp ___
___ 01:00AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 01:00AM URINE RBC-131* WBC-68* Bacteri-MANY Yeast-NONE
Epi-<1 TransE-<1
Blood Cx x 4 negative, OSH blood cx growing strep pneuma
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
==========
___ EKG: Probable atrial fibrillation. Compared to the
previous
tracing no change.
___ TTE:
The left atrium is markedly dilated. The right atrium is
markedly dilated. The estimated right atrial pressure is at
least 15 mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). The
right ventricular cavity is moderately dilated with borderline
normal free wall function. [Intrinsic right ventricular systolic
function is likely more depressed given the severity of
tricuspid regurgitation.] There is abnormal septal
motion/position. A bioprosthetic aortic valve prosthesis is
present. The aortic valve prosthesis appears well seated, with
normal leaflet/disc motion and transvalvular gradients. No
masses or vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. A bioprosthetic mitral valve prosthesis
is present. The prosthetic mitral valve leaflets appear
thickened in some views. The gradients across the prosthesis are
likley mildly elevated (not knowing what type of prosthesis this
is). No masses or vegetations are seen on the mitral valve, but
cannot be fully excluded due to suboptimal image quality. No
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is mild 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.
IMPRESSION: Marked biatrial enlargement. Normal left ventricular
systolic function. Moderately dilated right ventricle with
borderline normal free wall motion (intrinsically depressed due
to volume of tricuspid regurgitation). Well seated aortic valve
bioprosthesis with normal gradients and no evidence of
endocarditis. Mildly increased gradients across the mitral valve
bioprosthesis without definitive vegetation. Moderate to severe
tricuspid regurgitation with at least mild pulmonary
hypertension (likely higher given increased RA pressures). No
mobile masses on the tricuspid valve.
No prior echos for comparison. If there is a high clinical
suspicion for endocarditis, TTE cannot exclude with two
bioprosthetic valves.
___ TEE:
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch and the descending
thoracic aorta to 38 cm from the incisors. A bioprosthetic
aortic valve prosthesis is present. The aortic valve prosthesis
leaflets appear to move normally. No masses or vegetations are
seen on the aortic valve. No aortic valve abscess is seen. No
aortic regurgitation is seen. A bioprosthetic mitral valve
prosthesis is present. The motion of the mitral valve prosthetic
leaflets appears normal. There is a highly mobile echodensity on
the anterior leaflet of the bioprosthetic mitral valve,
measuring 0.5 cm x 0.4 cm, most consistent with a small
vegetation. No mitral valve abscess is seen. Trivial mitral
regurgitation is seen. There is no abscess of the tricuspid
valve. The tricuspid regurgitation jet is eccentric and may be
underestimated. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Well-seated mitral valve bioprosthesis with small
vegetation on the anterior leaflet and trivial mitral
regurgitation. Well-seated aortic valve bioprosthesis with no
vegetation and no aortic regurgitation. Normal global
biventricular systolic function.
CXR - IMPRESSION:
No previous images. There is been placement of a left
subclavian PICC line that extends to the lower portion of the
SVC. There is substantial enlargement of the cardiac silhouette
in a patient with intact midline sternal wires. No definite
vascular congestion. Mild blunting of the left costophrenic
angle with opacification at the left base suggests small pleural
effusion and atelectatic changes.
MRI L Spine (___) - IMPRESSION:
1. Due to patient discomfort postcontrast imaging and
multiplanar, multisequence imaging of the sacrum were not
performed.
2. L2-L3 and L3-L4 severe spinal canal stenosis which crowds the
central nerve roots and compresses the traversing L3 and L4
nerve roots in the subarticular zones.
3. L5-S1 subarticular zone stenosis which contacts the
traversing S1 nerve
roots.
4. Edema at L3-L4 articulating endplates with fluid signal
within the intervertebral disc space, likely representing
degenerative type ___ ___ change. No specific findings for
infection, without cortical dehiscence, epidural fluid, or
paraspinal soft tissue edema. Recommend clinical correlation.
If there is high suspicion for infection, consider follow-up
postcontrast imaging to assess for interval change.
MRI Pelvis (___) - IMPRESSION:
1. Punctate foci of high T2 signal are seen along the inferior
edge of both SI joints. The appearance is not typical for
infectious or inflammatory sacroiliitis. Otherwise, the
sacroiliac joints are within normal limits.
2. No evidence of osteomyelitis or abscess formation.
3. Diffuse soft tissue edema including small amount of pelvic
free fluid, an atypical finding in a male.
4. Focal edema and enhancement in the left gluteus muscle near
the coccyx could represent a focal area of phlegmon. The
differential diagnosis could include an site of prior
intramuscular injection.
5. Please see separate report of L-spine MRI performed on ___.
MRI L Spine (___) - IMPRESSION:
No enhancement to support discitis, osteomyelitis. No epidural
or prevertebral fluid collection.
Brief Hospital Course:
Mr. ___ is a ___ y/o man with a PMH of AFib on warfarin,
AVR/MVR, gout, HTN, and HLD, who was transferred from
___ for ___ and anemia, found to have strep pneumo
bacteremia / endocarditis.
#Strep pneumococcus bacteremia / endocarditis: Strep pneumo in
___ bottles from ___. TEE showed small mitral valve veg.
Now narrowed to CTX with ID input. No further positive blood
cultures on labs here. Will continue CTX for total of 6-week
course. Discharged home with services for home infusion via
___.
# Lower back pain: Initial concern for epidural abscess v.
osteomyelitis in light of bacteremia. CT torso at ___
negative for fluid collection. MRI performed here without
evidence of infection.
#Coagulopathy. INR of 6.9 on admission; most likely appears to
have been ___ concomitant usage of azithromycin, levofloxacin,
and warfarin. He received 2.5 mg Vitamin Kx1 in ED, with INR
downtrended to 2 and warfarin was resumed. However, INR trended
back up, once again likely ___ abx. Coumadin was held at
discharged with plans for INR recheck on Modnay ___. This was
communicated with pt's PCP's office.
#Thrombocytopenia: His platelets were at nadir of 77-97, and may
have been acute response to infection vs. medication
side-effect. There were no signs of bleeding. Plts were trending
back up at discharge.
#Acute Kidney Injury: Patient's creatinine initially was 2.1,
likely pre-renal injury improved with fluid resuscitation.
#Atrial Fibrillation: Goal INR 2.0-3.0, warfarin held on
discharge as above.
#Concern for GI bleeding: Patient's hemoglobin was 8.5 on
admission from 10.2 at OSH. His serial H/H remained stable since
his transfer to ___. He had a weakly guaiac positive, stool
but was at high risk of bleeding given coagulopathy with
elevated INR. Patient's initial hypotension appeared to be
likely hypovolemic and vasodilatory from infection, with no
evidence of an active bleed. He was initially on an IV proton
pump inhibitor transitioned to oral form.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Simvastatin 40 mg PO QPM
4. Warfarin 4 mg PO DAILY16
5. Aspirin 81 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Simvastatin 40 mg PO QPM
5. Allopurinol ___ mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. CefTRIAXone 2 gm IV Q 24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams IV q 24
hours Disp #*38 Intravenous Bag Refills:*0
8. Outpatient Lab Work
Weekly labs: CBC with differential, BUN, Cr, AST, ALT, Total
Bili, ALK PHOS, ESR/CRP. RESULTS SHOULD BE SENT TO ___
CLINIC - FAX: ___
9. Outpatient Lab Work
Please check INR on ___. Results should be faxed to Dr.
___ (Fax: ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Endocarditis
Bacteremia
Acute Kidney Injury
Coagulopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred here with an fevers, an infection in your
heart valve, as well as a blood stream infection. You were seen
by our infectious diseases team, and you were started on
antibiotics. You will continue the IV antibiotics for 6 weeks
total.
Of note, you also underwent an MRI of your lower back given your
back pain. This did not show any evidence of infection.
As we discussed on ___, your INR (Coumadin level) is very
high. Please hold your Coumadin on ___ and ___. Please
call your PCP's office on ___ morning to have your INR
checked and Coumadin dose adjusted accordingly.
Followup Instructions:
___
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Subsets and Splits